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Library of Congress Cataloging-in-Publication Data
Names: Steele, Scott R. (Surgeon), editor. | Cleveland Clinic Foundation.

Title: Cleveland Clinic illustrated tips and tricks in colon and rectal surgery / [edited by] Scott R.
Steele.
Other titles: Illustrated tips and tricks in colon and rectal surgery
Description: Philadelphia : Lippincott Williams & Wilkins, [2021] |
Includes bibliographical references and index. | Summary: “Tips and
Tricks in Surgery will be a series of books that offer the sort of
wisdom attending surgeons pass on to residents or fellows about how to
perform surgery (it is patterned after the series being developed in the
orthopaedic surgery program). Keith Lillemoe, chair of surgery at MGH,
is the series editor. Each volume will cover one area of surgery and
will be written by faculty and residents of a single institution
renowned for its work in that area”–Provided by publisher.
Identifiers: LCCN 2019033892 | ISBN 9781975108250 (paperback) | eISBN: 9781975108816
Subjects: MESH: Colon–surgery | Rectum–surgery | Colorectal Surgery–methods
Classification: LCC RD543.C57 | NLM WI 650 | DDC 617.5/547—dc23
LC record available at https://lccn.loc.gov/2019033892
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shop.lww.com
“The opportunity to work with excellent people … the ability to work in a
collegial fashion . . . and to witness the gradual growth of the specialty.”
—Victor W. Fazio, MB, BS, FRACS, FACS (2012)
Contents
Contributors
Foreword
Preface
IN THE OPERATING ROOM AND ANATOMY
1• Anatomy of the Colon, Rectum, and Anus

Richard L. Drake, Jennifer M. McBride, Michelle D. Inkster,
and James S. Wu
2• Tools of the Trade: Retractors, Scopes, Probes, and More
David Liska
3• Principles of Operative Positioning
Daniel R. Fish
4• Advanced Endoluminal Surgery: Endoscopic Mucosal
Resection and Endoscopic Submucosal Dissection
Emre Gorgun
5• Combined Endoscopic and Laparoscopic Surgery
Emre Gorgun
6• Interventional Inflammatory Bowel Disease: Endoscopic
Management of Complex Inflammatory Bowel Disease
Bo Shen
7• Office Endoscopy
James Church
ANORECTAL DISEASE
8• Hemorrhoidectomy
Massarat Zutshi
9• Anal Fissures: Lateral Internal Sphincterotomy
James S. Wu
10 • Anoplasty for Anal Stenosis
Michael A. Valente
11 • Anorectal Abscess
Vladimir Bolshinsky and Joseph Trunzo
12 • Complex Anorectal Fistulas
Vladimir Bolshinsky and Stefan D. Holubar
13 • Hidradenitis Suppurativa
Anuradha R. Bhama and Scott R. Steele
14 • Rectovaginal Fistula
Tracy Hull
15 • Rectourethral Fistulas
Nicholas Hauser, Hadley Wood, and Kenneth Angermeier
16 • Crohn Anorectal Disease
James Church
17 • Pilonidal Disease Excise versus Flap: Technical Tips
Anuradha R. Bhama and Scott R. Steele
18 • Anal Intraepithelial Neoplasia: Performing High-
Resolution Anoscopy
Michelle D. Inkster, Eric D. Willis, and James S. Wu
THE ABDOMEN
19 • Anastomotic Construction Techniques

Matthew F. Kalady
20 • Complicated Anastomoses: Turnbull-Cutait
Sherief Shawki
21 • Left Colectomy
Michael A. Valente
22 • Right Colectomy
Peter Mark Neary, Sherief Shawki, and Conor P. Delaney
23 • Approaching the Transverse Colon
N. Arjun Jeganathan and Jeremy M. Lipman
24 • The Difficult Splenic Flexure
Sherief Shawki
25 • Cytoreductive Surgery and Hyperthermic Intraperitoneal
Chemotherapy
Anthony Costales and Robert DeBernardo
26 • Desmoids
James Church
27 • Enterocutaneous Fistula
Michael A. Valente
THE PELVIS
28 • Intraoperative Radiation Therapy for Colorectal Cancer

Sudha R. Amarnath
29 • Local Excision of Rectal Neoplasia
Anuradha R. Bhama, David Maron, and Scott R. Steele
30 • Approaching Presacral Tumors
Christy Cauley and Michael A. Valente
31 • Proctectomy from Above
James P. Tiernan and Conor P. Delaney
32 • Transanal Total Mesorectal Excision
Sherief Shawki, Dana Sands, and Matthew F. Kalady
33 • GYN-Onc Considerations for Complex and Multivisceral
Colorectal Disease
Mariam AlHilli and Robert DeBernardo
34 • Spinal and Orthopedic Considerations for Advanced
Multivisceral Colorectal Cancer
Lukas M. Nystrom and Nathan W. Mesko
35 • Intraoperative Urology Consultation
Hadley Wood and Kenneth Angermeier
TECHNICAL TIPS FOR SPECIFIC SITUATIONS
36 • Complex Diverticular Disease: Colovaginal and

Colovesicle Fistula Repair
Michelle F. DeLeon, Steven D. Wexner, and Bradley J.
Champagne
37 • Large Bowel Obstruction
David M. Schwartzberg and David Liska
38 • Endometriosis
Mariam AlHilli and Hermann Kessler
39 • Trauma of the Colon, Rectum, and Anus
Eric K. Johnson and Scott R. Steele
40 • Ileal Pouch-Anal Anastomosis
Tracy Hull
41 • Crohn Disease: Surgical Management
David M. Schwartzberg and Stefan D. Holubar
42 • Colorectal Cancer: Management of Stage IV Disease
Mohammad Ali Abbass and Bradley J. Champagne
43 • Construction of Intestinal Stomas
Hermann Kessler, Mariane G. M. Camargo, and Eric G.
Weiss
44 • The Difficult Stoma
Hermann Kessler and Mariane G. M. Camargo
45 • Complex Abdominal Wall Reconstruction and Parastomal
Hernia Repair after Colorectal Surgery
Charlotte Horne and Ajita Prabhu
46 • Kock Pouch (K-pouch)
Sherief Shawki
PELVIC FLOOR DISORDERS
47 • Rectal Prolapse
Tracy Hull and Giovanna da Silva Southwick
48 • Ventral Rectopexy
Sherief Shawki
49 • Sacral Neuromodulation and Sphincteroplasty for Fecal
Incontinence
Lisa C. Hickman and Cecile A. Ferrando
50 • Vertical Rectus Abdominis Myocutaneous Flaps, Gluteal
Flaps, and Plastic Surgery Reconstruction in Colorectal
Surgery
Emre Gorgun and Raymond Isakov
51 • Complex Abdominal Wall Reconstruction Following
Colorectal Surgery
Clayton C. Petro and Michael J. Rosen
52 • Constipation
Tracy Hull
53 • Botox of the Pelvic Floor and Acupuncture
Massarat Zutshi
54 • Perineal Proctectomy
Amy Lightner
Index
Contributors
Mohammad Ali Abbass, MD

Colorectal Surgery Fellow
Cleveland Clinic Foundation
Cleveland, Ohio
Mariam AlHilli, MD
Assistant Professor of Surgery, Cleveland Clinic Lerner College of Medicine
Division of Gynecologic Oncology, Department of Obstetrics and
Gynecology
Cleveland Clinic
Cleveland, Ohio
Sudha R. Amarnath, MD
Assistant Professor
Department of Radiation Oncology
Cleveland, Ohio
Kenneth Angermeier, MD, FACS

Professor of Surgery (Urology)
Cleveland Clinic Lerner College of Medicine of Case Western Reserve
University
Director, Center for Genitourinary
Reconstruction
Glickman Urological and Kidney Institute
Cleveland Clinic
Cleveland, Ohio
Anuradha R. Bhama, MD, FACS, FASCRS

Department of Colorectal Surgery
Cleveland, Ohio
Vladimir Bolshinsky, MBBS, FRACS

Clinical Associate
Digestive Disease & Surgery Institute
Cleveland Clinic
Cleveland, Ohio
Mariane G. M. Camargo, MD
Research Fellow
Cleveland Clinic
Cleveland, Ohio
Christy Cauley, MD
Fellow, Colorectal Surgery
Cleveland Clinic
Cleveland, Ohio
Bradley J. Champagne, FACS, FASCRS

Chairman of Surgery, Fairview Hospital
Director of Services, DDSI West Region
Professor of Surgery, Cleveland Clinic Lerner
School of Medicine
Medical Director of Fairview Ambulatory
Surgery Center
Fairview Hospital
Cleveland, Ohio
James Church, MBChB, FRACS

Staff Surgeon
Department of Colon and Rectal Surgery
Cleveland, Ohio
Anthony Costales, MD
Department of Obstetrics and Gynecology
OB/GYN and Women’s Health Institute
Cleveland Clinic
Cleveland, Ohio
Robert DeBernardo, MD
Associate Professor of Surgery Lerner College of Medicine
Director of Peritoneal Malignancy Program
Division of Gynecologic Oncology
Cleveland Clinic
Cleveland, Ohio
Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS (Hon),

FRCSI (Hon)
Chairman, Digestive Disease and Surgery
Institute
Victor W. Fazio MD Endowed Chair in Colorectal Surgery
Professor of Surgery, Cleveland Clinic Lerner
College of Medicine
Cleveland Clinic
Cleveland, Ohio
Michelle F. DeLeon, MD
Digestive Disease and Surgery Institute
Cleveland, Ohio
Richard L. Drake, PhD

Director of Anatomy and Professor of Surgery
University
Cleveland, Ohio
Cecile A. Ferrando, MD
Assistant Professor of Surgery
Women’s Health Institute
Cleveland Clinic
Cleveland, Ohio
Daniel R. Fish, MD, MS

Clinical Associate Staff
Cleveland Clinic
Cleveland, Ohio
Emre Gorgun, MD, FACS, FASCRS

Staff Surgeon
Colorectal Surgery
Krause-Lieberman Chair in Laparoscopic Colorectal Surgery
Cleveland Clinic, Digestive Disease Institute
Cleveland, Ohio
Nicholas Hauser, MD
Assistant Professor
Department of Urology
University of Miami Miller School of Medicine
Miami, Florida
Lisa C. Hickman, MD
Section of Urogynecology and Reconstructive Pelvic Surgery
Obstetrics, Gynecology & Women’s Health Institute
Cleveland, Ohio
Stefan D. Holubar, MD, MS

Director of Research
Cleveland Clinic
Cleveland Ohio
Charlotte Horne, MD
Fellow, Abdominal Wall Reconstruction
Department of Surgery
Cleveland Clinic
Cleveland, Ohio
Tracy Hull, MD
Professor of Surgery
The Cleveland Clinic Foundation
Cleveland, Ohio
Michelle D. Inkster, PhD, MD

Staff Gastroenterologist
DDSI Institute
Cleveland Clinic
Cleveland, Ohio
Raymond Isakov, MD
Cleveland Clinic Lerner College of Medicine
Associate Program Director, Plastic Surgery Residency
Cleveland Clinic
Cleveland, Ohio
N. Arjun Jeganathan, MD
Cleveland Clinic
Cleveland, Ohio
Eric K. Johnson, MD, FACS, FASCRS

of Case Western Reserve University
Cleveland, Ohio
Matthew F. Kalady, MD
Professor and Vice-Chairman
James Church, MD, and Edward DeBartolo Jr.
Family Chair in Colorectal Surgery
Co-Director, Comprehensive Colorectal
Cancer Program
Digestive Disease Institute
Cleveland Clinic
Cleveland, Ohio
Hermann Kessler, MD, PhD

Cleveland Clinic
Cleveland, Ohio
Ian Lavery, MD
Staff Colorectal Surgeon
Cleveland Clinic
Cleveland, Ohio
Amy Lightner, MD, FACS, FASCRS

Associate Professor of Surgery, Cleveland Clinic
Lerner College of Medicine of Case Western
Reserve University
Staff Surgeon
Cleveland Clinic
Cleveland, Ohio
Jeremy M. Lipman, FACS, FASCRS

Associate Professor of Surgery
University
Cleveland Clinic
Cleveland, Ohio
David Liska, MD, FACS, FASCRS

Department of Colorectal Surgery, Digestive
Disease & Surgery Institute
Department of Cancer Biology, Lerner Research
Institute
Cleveland Clinic
Cleveland, Ohio
David Maron, MD, MBA

Vice Chairman
Cleveland Clinic Florida
Weston, Florida
Jennifer M. McBride, PhD

Director of Virtual Anatomy Education
Cleveland, Ohio
Nathan W. Mesko, MD
Assistant Professor, Center Director
Musculoskeletal Oncology
Department of Orthopaedic Surgery
Cleveland Clinic
Cleveland, Ohio
Peter Mark Neary, MD

Professor of Surgical Oncology
University Hospital Waterford/University
College Cork
Waterford, Ireland
Lukas M. Nystrom, MD
Staff Surgeon
Orthopaedic and Rheumatologic Institute
Cleveland Clinic
Cleveland, Ohio
Clayton C. Petro, MD
Staff Surgeon, Hernia Surgery Section
Cleveland Clinic
Cleveland, Ohio
Ajita Prabhu, MD, FACS

Assistant Program Director, General Surgery
Residency, Cleveland Clinic
Quality Institute Officer, Digestive Diseases and Surgery Institute
Cleveland Clinic Center for Abdominal Core Health
Cleveland Clinic
Cleveland, Ohio
Michael J. Rosen, MD
Cleveland Clinic
Cleveland, Ohio
Dana Sands, MD
Staff Surgeon
Director of the Colorectal Physiology Center
at Cleveland Clinic Florida
Weston, Florida
David M. Schwartzberg, MD
Cleveland Clinic
Cleveland, Ohio
Sherief Shawki, MD
Staff Colon and Rectal Surgery
Cleveland Clinic Lerner Medical School of Medicine
Cleveland, Ohio
Bo Shen, MD
Professor of Medicine and The Ed and Joey Story Endowed Chair
Department of Gastroenterology/Hepatology/Nutrition
Cleveland Clinic
Cleveland, Ohio
Giovanna da Silva Southwick, MD

Staff Surgeon
Weston, Florida
Scott R. Steele, MD, MBA

University
Rupert B. Turnbull MD Endowed Chair in Colorectal Surgery
Chairman, Department of Colorectal Surgery
Cleveland Clinic
Cleveland, Ohio
James P. Tiernan, PhD, MD

Consultant in Colorectal Surgery
John Goligher Colorectal Unit
Leeds, England
Joseph Trunzo, MD, FACS, FASCRS

Fairview Hospital
Cleveland Clinic
Cleveland, Ohio
Michael A. Valente, DO, FACS, FASCRS

Program Director, Colorectal Surgery Residency
Cleveland Clinic
Cleveland, Ohio
Eric G. Weiss, MD, DIO

Chairman of Graduate
Medical Education
Residency Program Director
Colorectal Surgery Fellowship
Director of Surgical Endoscopy
Weston, Florida
Steven D. Wexner, MD, PhD (Hon), FACS, FRCS (Eng), FRCS (ED),
FRCSI (Hon), Hon FRCS (Glasg)
Director, Digestive Disease Center
Chair, Department of Colorectal Surgery
Weston, Florida
Clinical Professor of Surgery, Cleveland Clinic
Lerner College of Medicine of Case Western
Reserve University
Cleveland, Ohio
Clinical Affiliate Professor of Surgery, Charles E.
Schmidt College of Medicine, Florida Atlantic University
Boca Raton, Florida
Clinical Professor, Herbert Wertheim
College of Medicine, Florida International University
Miami, Florida
Professor of Surgery, The Ohio State University
Wexner College of Medicine
Columbus, Ohio
Affiliate Professor, Department of Surgery,
University of South Florida Morsani College of Medicine
Tampa, Florida
Honorary Professor, Division of Surgery
and Interventional Science, Department
of Targeted Intervention, University College London
London, England
Eric D. Willis, MD
Staff Pathologist
RMH Pathology Associates
OhioHealth
Columbus, Ohio
Hadley Wood, MD
Associate Professor
Glickman Urological and Kidney Institute
Cleveland Clinic
Cleveland, Ohio
James S. Wu, PhD, MD

Staff Surgeon
Digestive Diseases and Surgery Institute
Cleveland Clinic
Cleveland, Ohio
Massarat Zutshi, MD
Staff Colorectal Surgeon
Cleveland Clinic
Cleveland, Ohio
Foreword
It’s an honor to be a part of the storied tradition of surgical giants who have
mentored us previously, incredible colleagues here today, and the leaders that
will follow for generations. May this volume portray some of the tips and
tricks of the “Cleveland Clinic Way” for caring for patients with colorectal
disease.
Scott R. Steele, MD, MBA

Chairman
Cleveland Clinic
Cleveland, Ohio
Editor: Scott R. Steele, MD, MBA
Associate Editors: James Church, MBChB, FRACS,

Conor P. Delaney, MD,
Tracy Hull, MD,
Matthew F. Kalady, MD
Preface
In this era of evidence-based medicine, most of our clinical decisions are data
driven … and that is as it should be. However, patients constantly remind us
of the infinite variations in human biology, and these reminders influence our
care in ways that often cannot be measured. Data can only take us so far in
the practice of colorectal surgery, and there is ample room for augmenting
our practice with clinical acumen. Many of the diseases we treat present and
evolve in ways that are not covered by the usual textbook or by the latest
review article. We are left wondering how to nuance care to obtain the best
outcomes. We seek advice from our more experienced partners and
sometimes we call our mentors to ask for their input. In this book, the editors
have put together a series of chapters addressing colorectal diseases as if the
authors had been asked to comment on a difficult case. This volume is a
distillation of the clinical wisdom that has been built up over years of practice
at the busiest colorectal department in the world.
In writing this book, the authors want to provide an easily accessible,
understandable volume that makes phone calls to mentors and text messages
to experts less common. Our authors have combined the wisdom they
acquired from their own mentors with their personal clinical experience to
complement the knowledge found in textbooks, reviews, and experimental
studies. They describe the ways in which they dealt with tricky, dangerous,
and unusual situations, to provide tips and techniques that you can use when
faced with similar circumstances. Many of the tips described in this book are
derived from a previous generation of experts, with advice that filters down
over the years, constantly changing as understanding of disease and choices
of medications and operative techniques expand, but based on the sound
principles that have built a dynasty here in Cleveland. This is an unusual
book, but an intensely practical one. We trust that you find it to be so.
James Church, MBChB, FRACS

Ian Lavery, MD
Cleveland, Ohio
PART I
In The Operating Room and Anatomy
Chapter 1
Anatomy of the Colon, Rectum, and
Anus
RICHARD L. DRAKE
JENNIFER M. MCBRIDE
MICHELLE D. INKSTER
JAMES S. WU
Surgical Anatomy, properly understood, implies not merely relation

of parts, but such an acquaintance of the position, function and
relations of the structures entering into the formation of any region, as
may assist in the diagnosis and treatment of the injuries and diseases
occurring in it; or in certain cases to judge how far operative
interference is warrantable, and guide us, if it be, in planning and
performing the operation.
Edward Bellamy, FRCS
The Student’s Guide to Surgical Anatomy, 1885
Attributed to Professor Spence
The intestinal tract begins at the duodenum and ends at the anus.
Peritoneum
The intestines are enveloped variably in peritoneum (Fig. 1-1). In his 1903
syllabus of surgical anatomy, Thomas describes the peritoneum as follows:
Peritoneum. The peritoneum is a closed serous sac, having no external

communication, except in the female through the Fallopian tubes. It
intervenes between the abdominal wall and the viscera, which are
intraperitoneal only in the sense that they invaginate the posterior
layer. The viscera are held in position by the folds of peritoneum or
mesenteries thus formed. They may have a complete covering, except
where the two layers of these folds meet, as in the case of the ileum
and jejunum, the transverse colon, stomach and spleen. Often a viscus
is only partly covered, as in the case of the kidney, bladder, ascending
and descending colon.
Small Intestine
The small intestine consists of the duodenum, jejunum, and ileum (Fig. 1-2)
and is open, except at its beginning (pylorus) and at its end (ileocecal valve).
FIGURE 1-1 The peritoneum is a sac that covers the intestines, either completely or
partially. Except for its first part, the duodenum is retroperitoneal. The jejunum, ileum,
transverse colon, and sigmoid colon are covered by peritoneum and suspended on a
mesentery. The ascending colon, the descending colon, and the rectum are partly covered.
Duodenum
The term “duodenum” is derived from the Latin duodenum digitorum (space
of 12 digits) because its length is about the breadth of 12 fingerbreadths. The
duodenum is the first section of the small intestine and, except for the first
part, is retroperitoneal. It is C-shaped and formed around the head of the
pancreas (Fig. 1-3).
FIGURE 1-2 The small intestine is shown with its location relative to the large intestine.
FIGURE 1-3 The duodenum is located in close proximity to the pancreas, hepatobiliary
system, vena cava, portal vein, vertebral column, aorta, superior mesenteric vessels, urinary
system, and the colon.
The duodenum is divided into four parts (Fig. 1-4) as follows.

FIGURE 1-4 The duodenum and its relationship to the biliary system, vena cava, portal
vein, and superior mesenteric artery/vein. The pancreas has been removed.
The superior or first part begins at the pyloric sphincter and ends in the
area of the neck of the gallbladder. It lies anterior to the bile duct,
gastroduodenal artery, portal vein, and inferior vena cava.
The descending or second part passes from the neck of the gallbladder to
the inferior edge of vertebra L3. It is anterior to the medial portion of the
right kidney and just lateral to the head of the pancreas. Associated with
this part are the major duodenal papilla and minor duodenal papilla.
The inferior or third part passes anterior to the inferior vena cava,
abdominal aorta, and vertebral column, and its anterior surface is crossed
by the superior mesenteric artery and vein.
The ascending or fourth part is to the left of the abdominal aorta and
passes upward, ending at the duodenojejunal junction. The ligament of
Treitz (suspensory muscle/ligament of the duodenum) is associated with
this junction.
The arterial supply to the duodenum is from the gastroduodenal artery, the
supraduodenal artery, duodenal branches from the anterior and posterior
superior pancreaticoduodenal arteries, duodenal branches from the anterior
and posterior inferior pancreaticoduodenal arteries, and the first jejunal
branch from the superior mesenteric artery (Fig. 1-5).
FIGURE 1-5 Details of the arterial supply to the duodenum.
Jejunum and Ileum

The jejunum and the ileum are completely covered by peritoneum and
connected to the posterior abdominal wall by a mesentery. They travel from
the left upper quadrant to the right lower quadrant.
Jejunum
The word “jejunum” is derived from the Latin ieiunum or “empty” because it
is often found empty on dissections. The jejunum follows the duodenum and
represents about two-fifths of the small intestine. The arterial supply to this
portion of the small intestine consists of jejunal arteries that are branches of
the superior mesenteric artery (Fig. 1-6). Venous drainage is via the superior
mesenteric vein.
FIGURE 1-6 The jejunum and ileum are intraperitoneal structures that travel from the left
upper quadrant to the right lower quadrant and suspended on a mesentery. The vascular
supply is from the superior mesenteric artery and vein.
Ileum
The word “ileum” is derived from the Latin ilia for “groin” or “flank.” The
ileum is the final portion of the small intestine and represents about three-
fifths of this structure (Fig. 1-6). The ileum joins the large intestine at the
junction of the cecum and the ascending colon. The arterial supply to this
portion of the small intestine consists of ileal arteries from the superior
mesenteric artery and an ileal branch from the ileocolic artery.
Large Intestine
The large intestine begins as the cecum in the lower right quadrant and
continues superiorly as the ascending colon with the right colic flexure
(hepatic flexure) inferior to the liver. Continuing to the left, the transverse
colon turns inferiorly at the left colic flexure (splenic flexure). It continues
inferiorly as the descending colon and enters the lower abdomen as the
sigmoid colon. It continues into the pelvic cavity as the rectum and anal canal
(Fig. 1-7). The colon has three taeniae coli and haustra (taenia means ribbon
or tape; haustrum means pouch). The taeniae coli are three longitudinal bands
of smooth muscle that are on the outside of the colon and are part of the
longitudinal muscles. The appendices epiploicae are small pouches of
peritoneum filled with fat and along the colon and upper part of the rectum.
There are three taeniae: the mesocolic, the free, and the omental. When the
taenia contracts, haustra, or bulges, form. The taenia converge at the
appendiceal orifice in the cecum. At the rectosigmoid colon, they spread out
to become the longitudinal muscle layer of the rectum. The ascending and
transverse colons are perfused by the superior mesenteric artery. The left
colon, sigmoid colon, and rectum are perfused by the inferior mesenteric
artery (Fig. 1-8). Venous drainage is from the inferior mesenteric veins, the
splenic vein, and the portal vein (Fig. 1-9). The lymphatic drainage follows
the vascular supply. The large intestine and its relationships to neighboring
structures are shown in Figure 1-10.
FIGURE 1-7 The colon and its relation to the terminal ileum and the anorectum.
FIGURE 1-8 The terminal ileum, right colon, and transverse colon receive their blood
supply from the superior mesenteric artery. The left colon and sigmoid colon are perfused by
the inferior mesenteric artery. The watershed region between the superior and inferior
mesenteric circulations is at the splenic flexure. The marginal artery at the splenic flexure (of
Drummond)18 connects the superior and inferior circulations.
FIGURE 1-9 The venous drainage of the colon is via the superior and inferior mesenteric
veins. The inferior mesenteric vein merges with the splenic vein. The splenic vein merges with
the superior mesenteric vein to form the portal vein.
FIGURE 1-10 The colon and its relations to the pelvis, liver, spleen, diaphragm, and rib
cage.
FIGURE 1-11 Midline sagittal view of the (A) male pelvis and (B) and female pelvis. The
male pelvis is narrow compared to that of the female. Anteriorly, the prostate is found in the
male; the vagina is found in the female.
Cecum and Appendix

The word “cecum” is derived from the Latin intestinum caecum or “blind
gut.” The first part of the large intestine, in the lower right quadrant, inferior
to the ileocecal opening, is the cecum. Attached inferiorly to the cecum is the
appendix, located at the confluence of the taeniae coli. The cecum is covered
by peritoneum and is mobile.
Ascending Colon
The ascending colon continues superiorly to the right colic flexure just
inferior to the liver. Although in most cases, it has no mesentery and is fixed
to the posterior abdominal wall, in some cases, it has its own mesentery.
Immediately lateral to the ascending colon is the right paracolic gutter. The
arterial supply to the ascending colon consists of the colic branch of the
ileocolic artery (from the superior mesenteric artery). The origin of the right
colic artery variably arises from the superior mesenteric artery, the ileocolic
artery, or the right branch of the middle colic artery (MCA).
Transverse Colon
Beginning at the right colic flexure and continuing to the left colic flexure is
the transverse colon. This structure is intraperitoneal and suspended from the
posterior abdominal wall by the transverse mesocolon. The arterial supply to
the transverse colon is the right colic artery and MCA from the superior
mesenteric artery and left colic artery from the inferior mesenteric artery.
Variant origin of the MCA from the gastroduodenal artery has been reported.
Descending Colon
Beginning at the left colic flexure and extending to the area of the crest of the
ileum is the descending colon (Fig. 1-12). In most cases, it also has no
mesentery and is fixed, to varying degrees, to the posterior abdominal wall.
As was the case with the ascending colon, lateral to the descending colon is
the left paracolic gutter. The arterial supply to the descending colon is the left
colic artery from the inferior mesenteric artery.
FIGURE 1-12 The anus. There are two anal sphincters. The internal sphincter is an
extension of the rectal smooth muscle. The external sphincter is an extension of the levator
ani. The anus receives blood from the superior, middle, and inferior rectal arteries. The lining
of the anus involves four epithelia. The columnar epithelium of the gut joins the anal
transitional zone at the anorectal line. Within the anal transitional zone are the internal
hemorrhoids, located beneath the columns and sinuses of Morgagni. The distal border of the
anal transitional zone is the dentate line, aka pectinate line, so named for its toothlike or
scalloped (pectinate) appearance. Inferior to the dentate line is the pecten, hairless
nonkeratinized squamous epithelium. The pecten joins perianal skin (with hair) at the anal
verge.
Sigmoid Colon
The origin of the word “sigmoid” is from the 18th letter of the Greek
alphabet “Σ,σ” and the Latin “S.” Near the crest of the ileum, the sigmoid
colon begins (Fig. 1-12). It continues inferiorly until the mesentery is lost,
usually anterior to vertebra S3. This marks the beginning of the rectum. The
sigmoid colon is attached where it begins and ends, but is mobile throughout
its length being suspended by the sigmoid mesocolon. Important structures
posterior to the sigmoid colon and the sigmoid mesocolon include the left
external and internal iliac vessels, left gonadal vessels, left ureter, and the
roots of the sacral plexus. The arterial supply to the sigmoid colon consists of
several sigmoidal arteries from the inferior mesenteric artery (Fig. 1-8).
Rectum
The word “rectum” is derived from the Latin intestinum rectum or “straight
intestine.” The retroperitoneal rectum extends from the sigmoid colon to the
anal canal with the rectosigmoid junction defined as either the level of
vertebrae S3 or at the end of the sigmoid mesocolon (Fig. 1-11A and B). The
arterial supply to the rectum consists of the superior rectal artery from the
inferior mesenteric artery, middle rectal artery from the internal iliac artery,
and inferior rectal artery from the internal pudendal artery, a branch of the
inferior iliac artery.
Anus
The word “anus” is derived from the Latin anus or “ring.” The anal canal is
the final portion of the large intestine. It begins at the terminal end of the
rectal ampulla as it passes through the pelvic floor. The anal canal ends as the
anus after it has passed through the perineum. The arterial supply to the anal
canal consists primarily of the inferior rectal artery from the internal
pudendal artery, a branch of the inferior iliac artery (Fig. 1-12).
Suggested Readings
Bellamy E. The Student’s Guide to Surgical Anatomy. 3rd ed. London, England: J. & A. Churchill;
1885:vi. In his introduction, Dr. Bellamy attributed this quote to Professor Spence.
Drake RL, Vogl AW, Mitchell AWM, Tibbitts R, Richardson P. Gray’s Atlas of Anatomy.
Philadelphia, PA: Churchville Livingstone; 2007.
Drake RL, Vogl AW, Mitchell AWM. Gray’s Anatomy for Students. 3rd ed. Philadelphia, PA:
Churchville Livingstone/Elsevier; 2014.
Etymonline. Anus. Available at: https://www.etymonline.com/word/anus. Accessed May 26, 2018.
Etymonline. Caecum. Available at: https://www.etymonline.com/word/caecum. Accessed May 26,
2018.
Etymonline. Duodenum. Available at: https://www.etymonline.com/word/duodenum. Accessed May
26, 2018.
Etymonline. Ileum. Available at: https://www.etymonline.com/word/ileum. Accessed May 26, 2018.
Etymonline. Jejunum. Available at: https://www.etymonline.com/word/jejunum. Accessed May 26,
2018.
Etymonline. Rectum. Available at: https://www.etymonline.com/word/rectum. Accessed May 26,
2018.
Garćia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomy. Implications for
laparoscopic surgery. Dis Colon Rectum. 1996;39:906-911.
Gray H. Anatomy of the Human Body. 20th ed. Thoroughly revised and re-edited by Lewis WH.
Philadelphia, PA: Lea & Febiger; 1918:1157-1158.
Haywood M. Molyneux C, Mahadevan V, Lloyd J, Srinivasaiah, N. The right colic artery: an
anatomical demonstration and its relevance in the laparoscopic era. Ann R Coll Surg Engl.
2016;98:560-563.
Indrajit G, Ansuman R, Pallab B. Variant origin of the middle colic artery from the gastroduodenal
artery. Int J Anat Var. 2013;6:13-17.
Thomas TT. A Syllabus of Surgical Anatomy. 2nd ed. College Agency of U.P., F. W. S. Langmaid,
M.D., Philadelphia, copyright 1903, pp. 100-101, 127. This content is DRM free.
Treitz W. Ueber einen neuen Muskel am Duodenum des Menschen, über elastische Sehnen, under
einige andere anatomische Verhältnisse. Vierteljahrsschrift Praktisch Heilkund (Prague).
1853;37:113-144.
Chapter 2
Tools of the Trade: Retractors, Scopes,
Probes, and More
DAVID LISKA
Outpatient Office Equipment
General Equipment (Fig. 2-1)

FIGURE 2-1 Examination room.
Desk and computer with access to electronic medical record and imaging
studies
Chairs for patient and companion
Curtain for privacy during examination
Poster with illustration of gastrointestinal anatomy
Sink
Sharps container
Used instrument containers
Examination light
Examination table with ability to examine patient in different positions
(Fig. 2-2)
Seated
FIGURE 2-2 Colorectal tables.
Supine
Sims
Knee-chest (ie, Kraske)
Lithotomy
Office Procedures
Anoscopy and proctoscopy (Figs. 2-3 and 2-4)
Light source
FIGURE 2-3 Light, anoscopes, and proctoscopes.
FIGURE 2-4 Anoscopes and rigid proctoscopes.
Reusable anoscopes (eg, Hirschman) of different lengths and diameters

Reusable proctoscopes (different sizes) with insufflator
Hemorrhoid rubber band ligation
Suction ligator or McGivney ligator with atraumatic hemorrhoid
grasping forceps (Fig. 2-5)
FIGURE 2-5 Hemorrhoid banding equipment.
Instruments for simple incision and drainage procedures and assessment of

anal fistula (Fig. 2-6)
Sterile prep packs (iodine based)
FIGURE 2-6 Anorectal abscess and fistula set.
Local anesthetic (eg, lidocaine, bupivacaine)

Syringes and needles
Scalpels
Scissors
Forceps
Fistula probes
Culture swabs
Suction
Mushroom catheters
Silastic setons
Sutures
Flexible endoscopy
Endoscopy tower (Fig. 2-7)
FIGURE 2-7 Flexible endoscopy equipment and tower.
Flexible sigmoidoscopes (Fig. 2-8)

FIGURE 2-8 Flexible endoscopes.
Ileoscopes for endoscopic assessment of ileostomy or continent ileal

pouch
Biopsy forceps and snares
Electrosurgical generator for cautery
Specimen cups
Suction
Syringes for irrigation
Pelvic Floor Evaluation
Endorectal and endoanal ultrasonography system (Fig. 2-9)
FIGURE 2-9 Endorectal ultrasound.
Anorectal manometry system (Fig. 2-10)

FIGURE 2-10 Anorectal manometry equipment.
Operating Room Equipment
Minor Anorectal Procedures

CCF Dr. Lavery fistula set (Fig. 2-11)
FIGURE 2-11 Dr. Lavery fistula set.
Two clamps, Hemostatic, straight, 6 in

One clamp, Kelly, 6 in
One clamp, Tonsil, 7½ in
Two clamps, Allis, 6½ in
One clamp, Munion, right angle, 7 in
One needle holder, Mayo Hegar, 6¼ in
One scissor, Mayo, suture, straight, 6¾ in
One scissor, Reynolds, tenotomy
One forceps, Rat tooth 6 in
One retractor, Hill-Ferguson, small, lighted
One retractor, Hill-Ferguson, medium lighted
One cable, Fiberoptic, w/adaptor
One probe, w/grooved director
One probe, Lacrimal, w/needle eye
One probe, Fistula, heavy, wing tip
One probe, Fistula, light, wing tip
Five probes, Lacrimal, 5½ in, #00-8
One handle, Knife, #7, 6½ in
Seven curettes, Mastoid, #0-6
Anoscopy, Proctoscopy, and Transanal Procedures

Hill-Ferguson retractors (S, M, L)
Hirschman anoscopes
Fansler anoscope (Fig. 2-12E)
FIGURE 2-12 A. Dilators; B. Snare; C. Biopsy forceps; D. Pratt anoscope; E. Fansler

anoscope; F. Operating anoscope; G. Rigid proctoscope.
Pratt bivalve retractor (Fig. 2-12D)

Rigid proctoscope (Fig. 2-12G)
Operating (Salvati) proctoscope (Fig. 2-12F)
Dilators
Bougie dilators (Fig. 2-12A)
Hegar dilators
Frankfeldt diathermy snare (Fig. 2-12B)
Punch biopsy forceps (Fig. 2-12C)
Transanal Minimally Invasive Surgery (Fig. 2-13)

FIGURE 2-13 Transanal surgery setup.
GelPOINT Path Transanal Access Platform (Applied Medical, Rancho

Santa Margarita, CA)
AirSeal Access Port and Insufflation System (Surgiquest, Milford, CT)
Lone Star Retractor (Cooper Surgical, Trumbull, CT)
Laparoscopic instrument set
Transanal Endoscopic Microsurgery (Fig. 2-14)

FIGURE 2-14 Operating proctoscope.
Wolf or Storz Transanal Endoscopic Microsurgery (TEM) Instrument

System with pressure-controlled CO2 insufflation
TEM instrument set
Retractors
Self-Retaining Retractors
Balfour retractor with C-arm (Fig. 2-15)
FIGURE 2-15 Abdominal retractor.
Weitlaner retractor
Bookwalter retractor
Omni retractor
Dual-ring wound protector (Fig. 2-16)
FIGURE 2-16 Wound protector.
Lighted Pelvic Retractors (Fig. 2-17)

FIGURE 2-17 Abdominal handheld retractors.
Fazio (Figs. 2-17C and 2-18)

FIGURE 2-18 Abdominal retractors.
Britetrac (Fig. 2-17A)

St. Mark (Fig. 2-17B)
Deaver (Fig. 2-17D)
Sweetheart (Fig. 2-17E)
Deep Pelvic Instruments (Fig. 2-19)

FIGURE 2-19 Clamps, scissors, and forceps.
Clamp, Kelly, extra-long, 14 in (Fig. 2-19A)

Clamp, Tonsil, extra-long, 9½ in (Fig. 2-19B)
Clamp, Allis, extra-long, 10 in (Fig. 2-19C)
Scissors, Metzenbaum, curved, 11 in (Fig. 2-19D)
Scissors, Jones DuBois, 10½ in (Fig. 2-19E)
Scissors, Harrington, 11 in (Fig. 2-19F)
Forceps, Gerald, extra-long, 12 in (Fig. 2-19G)
Forceps, DeBakey, 9 in (Fig. 2-19H)
Forceps, Russian, 10 in (Fig. 2-19I)
Sponge stick, straight, long, 9¾ in
Needle holder, Crile Wood, diamond jaw, 10 ⅜ in
Staplers (Fig. 2-20)

FIGURE 2-20 Mechanical staplers.
GIA 80 (Fig. 2-20A)

TA 60 (Fig. 2-20B)
Endo GIA 60 (Fig. 2-20C)
PI 30 (Fig. 2-20D)
EEA 31 (Fig. 2-20E)
Suggested Reading
Steele SR, Hull T, Read TE, Saclarides T, Senagore A, Whitlow C, eds. The ASCRS Textbook of Colon
and Rectal Surgery. 3rd ed. New York, NY: Springer Publishing; 2016.
Chapter 3
Principles of Operative Positioning
DANIEL FISH
Perioperative Considerations
Positioning should be aimed at maximizing surgical access and ease, while
minimizing risk of positioning-related injuries.
When required, patient position can always be modified during a surgical
procedure, often without compromising the sterile field significantly.
Nonetheless, optimal efficiency and sterility are achieved with good
preoperative planning and positioning from the start of the operation.
A well-coordinated team can enact major position changes (eg, flip from
supine to prone for an abdominoperineal resection) on a routine basis
without incurring significant delays.
SUPINE POSITIONING
Most often used for open procedures where anal access is extremely
unlikely to be needed—ileostomy closure, ileostomy creation, open right
hemicolectomy, and open small bowel surgery—or for patients after
previous anorectal resection with permanent anal closure.
Most commonly used with legs strapped and arms out, although it can be
combined with adjunctive techniques such as arm tucking or a chest strap
(see later).
Supine position bears little risk of positioning-related injuries and is often
the default position whenever surgically appropriate.
Equipment
Leg and arm belts, straps, or tape/towels
Folded blankets or foam pads
Pneumatic compression devices for bilateral lower legs
Technique
Arms should be abducted <90 degrees on padded arm boards in neutral
position, with straps loosely across the forearms.
Legs can be supported with a pillow under the knees to maintain mild
flexion and with padding under the heels to prevent pressure ulcers, with a
belt or strap across the thighs snuggly.
Legs and chest should be covered with blankets or warmed air devices to
maintain body temperature.
LITHOTOMY POSITION
Lithotomy, or separation of the legs, is one of the most commonly used
positions in colorectal surgery as it offers readily available access to the
perineum.
Should be considered for any surgery where access to the anus is needed,
including perianal surgery, transanal surgery, intraoperative colonoscopy,
transanal stapling (eg, end-to-end anastomosis stapler), coloanal
anastomosis, or retraction maneuvers via the rectum or the vagina.
Should also be considered for any surgery where standing between the
legs could be useful (eg, laparoscopic right, transverse, left, or subtotal
colectomy or flexure mobilizations).
Different leg retraction devices and positions pose varying levels of risk of
nerve, joint, and compartment injuries to the legs, as well as exacerbating
back pain in patients with radiculopathy. These are all minimized through
proper positioning and padding.
Compartment syndrome is an unusual, but well-described, risk of
lithotomy position. It is thought to relate to decreased perfusion to the leg
compartments and seems to correlate with obesity and weight of the
extremity, the severity of angle of elevation, and overall time spent in
lithotomy position. For patients at risk, legs can be changed in or out of
lithotomy position as needed during a procedure without major breaks in
sterile technique.
Lithotomy is frequently combined with maneuvers that complement
laparoscopy (eg, arm tuck), Trendelenburg position (eg, chest strap), or
anal or rectal preparation techniques (eg, rectal washout, anal everting
sutures).
Warmed air devices or blankets should be applied to the chest to help
maintain body temperature, as the lower body cannot be blanketed.
Equipment
Operating room (OR) table with removable leg portion (preferable) or leg
portion that can fold downward to 90 degrees
Leg stirrups of choice (see individual sections) with attachment brackets
Foam padding
Folded blanket as needed to prop sacrum
Technique
Place lower extremity pneumatic compression devices.
Once the airway is secured, move the patient down on bed to have anus
beyond the edge of the body portion of the bed, while ensuring proper
padding on the sacral area.
Attach leg supports of choice (see specific lithotomy types), placing both
legs in supports simultaneously to minimize spinal torsion.
Remove/lower the leg portion of bed, or spread the legs if utilizing a split-
leg table (see split-leg lithotomy).
Readjust body/pelvis on the bed as needed to optimize the position of
perineum (Fig. 3-1).
FIGURE 3-1 Lithotomy position with “hangover” of the sacrum for anal access.
For procedures requiring minimal or no anal or perineal access (eg,

laparoscopic right hemicolectomy for a tattooed lesion), positioning the
pelvis such that sacrum/coccyx are fully supported correlates with the lowest
risk of pressure-related injury.
For procedures requiring anal access for surgery, intubation, or stapling,
the anus should hang slightly off the edge of the bed (∼2-7 cm) to facilitate
the perineal portion of the procedure.
For procedures requiring access to the perineum posterior to the anus, the
anus should hang further off of the bed (∼5-15 cm) to allow exposure of the
entire operative field. The perineum can be further exposed by propping the
pelvis up with a folded blanket placed under the sacrum.
If the patient is anticipated to be in significant Trendelenburg especially for
extended periods, prepare for ∼2-7 cm of slippage toward the head of the bed
that will likely occur.
LITHOTOMY WITH CANDY CANE STIRRUPS

Provides little support for the joints of the legs and should only be used for
short cases (eg, <30 minutes in length), such as colonoscopy or perianal
procedures.
Pneumatic compression devices may still be used, despite the short
duration of the case and lighter degree of anesthesia.
Equipment
Bed attachment brackets (Fig. 3-2)
FIGURE 3-2 Brackets attached to the side of the bed, allowing for proper angle
attachment of the candy cane stirrups.
Candy cane bars with two-strap foot stirrups attached
Technique
Place brackets on the lowest portion on side rail of body portion of the
table and then secure candy cane bars so that they are orthogonal to the
plane of the bed (Fig. 3-3).
FIGURE 3-3 Candy cane stirrups in place.
Simultaneously lift both legs, flexing hips and knees to minimize

unhealthy abduction/adduction at knee and ankle joints, and place the feet
in stirrups such that one strap cradles fore- to midfoot and one strap
cradles heel (Fig. 3-4).
FIGURE 3-4 Proper positioning of the stirrup on the heel and midfoot, avoiding
pressure on the Achilles tendon.
If the knees or ankles are excessively torqued, the angle of the candy canes
at their bed attachment may be modified to bring them into good position
(Fig. 3-5).
FIGURE 3-5 Adjustment of the angle of the stirrups at the bed to bring legs and hips
into proper alignment.
LITHOTOMY WITH BOOT-TYPE STIRRUPS (EG, YELLOWFINS)
Boot-type stirrups provide better support for the joints of the legs and are
preferable to candy canes for cases >30 minutes in length.
Peroneal nerve injury is the most common positioning injury associated
with boot-type stirrups, resulting in a sensory neuropathy without motor
deficit, and utilizing proper technique is aimed at avoidance of pressure on
the lateral aspect of the tibial head to avoid this injury.
Pressure on the popliteal fossa should be avoided by rotating the boot
toward the floor such that the foot is flat in the bottom of the boot
(“standing in the stirrup”), taking pressure off of the posterior calf. Also
avoid stirrup boots that reach too high posteriorly into the popliteal fossa.
The leg can be moved up and down as needed during the case. Keeping
the knee low (close to in line with the hip) helps avoid interference with
laparoscopy in the upper abdominal field or with a low abdominal
incision. On the contrary, elevating the foot as high as possible provides
maximal access to the posterior perineum. The leg should be tested in all
anticipated positions prior to draping and inspected for safety in each.
When combining arm tucking with boot lithotomy, protection of the hands
using padding is essential to aid in prevention of traumatic finger injury
during movement of stirrups (see arm tucking).
Equipment
Bed attachment brackets
Right and left stirrups
Foam padding torn into two small squares and two large squares
Technique
Place brackets on the lowest portion of side rail of body portion of the
table and then secure boot-type stirrups firmly (Fig. 3-6).
FIGURE 3-6 Bracket for boot-type stirrups on the table near the table break.
Adjust the boots to be lying parallel and adjacent to leg portion of the bed
and move boots up on bars to position closest to hips, with boot toes
facing forward and soles of feet orthogonal to the bed. Boots should be
just slightly loosened on the bars so that they can be manipulated easily
but without unintentional slippage (Fig. 3-7).
FIGURE 3-7 Placing the legs into the boot-type stirrups.
Move the legs simultaneously into stirrups and remove/lower the foot of
the bed, as described earlier.
Place a large piece of foam padding between the lateral aspect of the
knee/lower leg and the stirrup, and place a small piece of foam padding
between the tubing of the pneumatic compression devices and the patient’s
foot to minimize pressure (Fig. 3-8).
FIGURE 3-8 Foam padding on the lateral aspect and by the pneumatic compression
device connection.
While standing at the end of the stirrup and supporting the leg with one’s
body, moderately loosen one stirrup boot and position it with the
following principles:
The foot, knee, and opposite shoulder should form a line.
There should be minimal to no pressure on the lateral knee/lower leg to
avoid peroneal nerve injury.
The plantar foot should sit flat in the bottom of the stirrup, and the
weight of the leg should be resting on this portion of the foot, not on
the posterior calf (Fig. 3-9).
FIGURE 3-9 Proper position of the heel in the boot-type stirrup.
The knee should be neutrally rotated, not outwardly or inwardly (Fig.

3-10).
FIGURE 3-10 Appropriate knee positioning in boot-type stirrups.
The knee should be flexed, but not excessively as to interfere with

surgery. The distance between the heel and the table should be
customized for each patient’s leg length (Fig. 3-11).
FIGURE 3-11 Knee flexion in boot-type stirrups.
A fully extended knee is at risk for overextension during surgery. If

significant Trendelenburg position is anticipated, prepare for ∼2-7 cm of
slippage cephalad that may cause knee and hip extension.
LITHOTOMY WITH SPLIT-LEG TABLE
Split-leg table provides enhanced support for the legs more similar to
supine position, minimizing risk of nerve, joint, or compartment injury
relative to other forms of lithotomy.
On the downside, split-leg positioning provides more limited access to the
anus and perineum.
This position should be considered for surgery where standing between the
legs could be useful, but where access to the anus is not likely to be
necessary (eg, laparoscopic right/transverse colectomy or left or total
colectomy with end ostomy).
Transanal stapling or colonoscopy is not impossible in this position, just
more difficult.
Split leg keeps the knee close to the level of the hip, which helps to avoid
interference with laparoscopic instruments pointed toward the upper
quadrants.
Split-leg table does not intrinsically secure the legs, and straps/wraps
should be placed to secure the patient if any significant table tilt is
anticipated.
It may not be possible to attach split legs to a table without a removable
leg portion.
Equipment
Split-leg table stirrups with included brackets ×2 (right and left)
Foam padding to place under the knees
Straps or tape/towels to secure the legs
Technique
Before the patient is placed on the table, place the split-leg brackets on the
lowest portion of side rail of body portion of the table and secure firmly.
The cephalad adjustment knob on the bracket secures the foot board to the
bed. The posterior facing adjustment knob allows abduction/adduction of
the hip and includes a guide for A, B, and C positions. The caudal
adjustment knob allows for hip flexion and extension (Fig. 3-12).
FIGURE 3-12 Brackets for the split leg.
If the patient is already on a standard table, have your assistant hold both
legs in the air while replacing the leg/foot of the bed with split legs. Rotate
the legs to position in parallel with bed (A position).
Once patient is moved down into position on the table, rotate and secure
legs simultaneously and equally in medium (Fig. 3-13) or severe split (Fig.
3-14) position as needed.
FIGURE 3-13 Positioning of the legs in the split-leg table.
FIGURE 3-14 “B” position on a split-leg table positioning.
Slightly elevate both legs ∼10 degrees using the caudal adjustment knobs
to avoid hip overextension. Place cylindrical or rolled piece of foam under
each knee to slightly flex knee, preventing knee overextension. Pad the
heel/ankle to decrease pressure points.
Secure each leg to split-leg table at two points, on the thigh above the knee
and on the leg below the knee, using straps or towels and tape (Fig. 3-15).
FIGURE 3-15 Padding and securing the leg in the split-leg table.
ARM TUCKING
Arm tucking allows increased flexibility for the surgical team to stand
adjacent to the patient.
The ability to stand at the shoulder is frequently useful for procedures such
as laparoscopic colon and rectal surgery, and arm tucking should be
performed routinely. For some procedures where the surgeon anticipates
working nearly exclusively on one side of the abdomen, the arm on the
opposite side should be tucked to allow two operators on that side, but the
arm on the same side of the dissection field can potentially be left out (eg,
tuck the left arm and leave the right arm out for laparoscopic right
hemicolectomy).
Arm tucking has the risk of nerve, joint, or compartment injury and limits
anesthesia from accessing the arms during the procedure for intravenous
access, blood pressure monitoring, or other procedures.
Equipment
Folded or doubled sheet with anterior and posterior leaves; Cleveland
Clinic arm sheet is two pieces sewn together with two vertical seams
Gauze padding for IVs and foam padding for stirrups
Arm sleds as needed
Technique
The folded sheet should be placed across the bed such that two leaves of
sheet protrude ∼12-18 in on either side of patient and the patient lies on
top of this sheet (Figs. 3-16 and 3-17).
FIGURE 3-16 Initial positioning of the sheet on the bed.

FIGURE 3-17 Two leaves of the sheet separated.
IVs and other devices on the arm should be padded away from skin with
gauze to prevent skin ulcerations.
While holding the patient’s hand and arm in position such that the thumb
is facing upward and arm is fully extended, the upper leaf of drape is held
up in the air by an assistant across the table. The lower leaf is wrapped
over the top of the arm and around it medially and posteriorly to snuggly
support the arm. Reconfirm the thumb facing upward (Fig. 3-18).
FIGURE 3-18 Positioning of the lower sheet and arm/hand.
The upper sheet is then wrapped tightly over the arm and tucked
underneath the arm and patient’s body until the arm is firmly fixed in
place. Check again that the thumb is up (Fig. 3-19).
FIGURE 3-19 Positioning of the upper sheet.
The arm should now be securely fixed and supported by the wrap and the
table and not require further support (Fig. 3-20).
FIGURE 3-20 Final positioning of the arm tucked.
In patients with wider girth, an insufficient amount of table may remain

laterally so as to preclude stable arm fixation. In this case, a padded arm
sled can be introduced to further reinforce the arm. This should be at the
level of the elbow or below, with the lower end passing beneath the table
pad, and should be pushed in as much as possible so as not to interfere
with comfortable stance of the surgeon, while taking care not to
overextend the elbow (Fig. 3-21).
FIGURE 3-21 Addition of arm sleds.
If the patient is in lithotomy position, a piece of foam padding is placed

between the hand and the stirrup bracket to protect the hand from pressure
injury (Fig. 3-22).
FIGURE 3-22 Arm tuck in a lithotomy position with extra foam to protect the hand.
CHEST STRAP
Strapping the chest helps to secure the patient to the bed.
Chest straps should be used if anticipating significant bed tilt to the left or
right, or if significant Trendelenburg is required to prevent slippage on the
bed and keep the perineum exposed.
Generally, this should not (and typically does not) impact the ability to
ventilate.
Equipment
Protective towel
Chest strap, Velcro, or long role of thick, wide tape
Technique
Refold towel to make a long, narrow band and lay across the lower chest
roughly lower than the level of the nipples, so as not to interfere with the
surgical field.
Place the strap across the chest and anchor it to bed; or if using tape, tape
circumferentially around patient and bed 3-4 times (Fig. 3-23).
FIGURE 3-23 Chest strap utilizing towel and tape. Also note the hand position and
protection.
May place a patient warming device on top of or above this strap.

If desired, check ventilation at this stage, prior to preparation and draping
the patient; if the strap is causing interference, reposition with the
anesthesiologist’s hand on top of chest while strapping/taping to ensure
sufficient laxity—although loosening may increase slippage.
PRONE (IE, KRASKE) POSITIONING
Also referred to as “Kraske” positioning (though this more specifically
refers to prone jackknife), prone positioning allows improved exposure of
the posterior perineum, gluteal cleft, and anterior anal canal.
Allows more ergonomic positioning for the surgeon to operate on or
around the anus and improves exposure for assistants.
Prone position allows restricted access to the airway and usually requires a
patient to be endotracheally intubated, although laryngeal mask may be
feasible.
The risk of upper extremity injury/neuropraxia exists with prone
positioning. Arms are usually positioned with hands above the head on
arm boards, and care should be taken to avoid shoulder dislocation on
rotation of the arms into this position. The ulnar nerve at the elbow should
not be compressed and should be protected with padding. Chest rolls
should not place undue pressure on the arms, such as to limit perfusion.
Anterior abdominal incisions or an ostomy are not contraindications to the
prone position, although hard structures such as tubes should be padded to
prevent pressure ulceration.
Equipment
Patient stretcher positioned adjacent to operating table
Padded arm boards ×2
Large transverse pelvic roll; can be constructed by large wrap of
blankets/pillow, usually at least 20 cm in diameter
Two medium longitudinal chest rolls; rolled blankets and/or fluid bags can
be used, usually at least 7 cm in diameter
Foam padding ×2 or pillows for knees
Stack of blankets ×2 to support head and feet; foam head support
Straps or tape rolls/towels to secure patient to a table
Wide tape and benzoin adhesive for buttock taping, as needed
Technique
The patient should have an airway placed and secured and other facial and
neck protective measures (eg, eyes, teeth, lines) in place while the patient
is in stretcher. A Foley catheter is placed at this time, as needed.
OR table padding is set up—stack of blankets and foam for head support,
two longitudinal chest rolls stretching from clavicle to anterior superior
iliac spine, padded arm board on the side of table away from stretcher,
rotated cephalad, large transverse pelvic roll, padding for knees, and stack
of blankets for feet. If additional jackknife flexure of the bed is
anticipated, ensure that padding is set up for that flexure point (Fig. 3-24).
FIGURE 3-24 Bed setup for the prone position.
The patient stretcher should be elevated above OR table and locked in

place immediately next to the OR table. With the patient’s arms at their
side, flip patient onto the table with six personnel working as a team—one
or more anesthesia personnel controlling head, one person
elevating/rotating the feet and attending to the urethral catheter, two on
stretcher side flipping patient over onto the table, and two on table side
with arms outstretched who receive patient as they flip over and lift/adjust
the patient into proper position as needed (Fig. 3-25).
FIGURE 3-25 Positioning prior to flip to the prone position.
Move the stretcher away and place second padded arm board in matching
position.
Carefully rotate the patient’s arms down to the floor and then up onto arm
boards, taking care not to dislocate the shoulder by rotating the arm too far
posteriorly. Ensure the elbow is either free or padded to avoid pressure on
the ulnar nerve where it passes just medial to the olecranon process (Fig.
3-26).
FIGURE 3-26 The position of the shoulder once in position.
Check sites of potential pressure and alleviate as needed—elbows, knees,

and feet may require additional support. The penis should point downward
toward the feet and should not be under excess pressure, with care taken to
pad the catheter tubing where it lies against the skin to prevent skin
ulceration.
Place a strap or belt across thighs; place additional securing straps on chest
and arms if table tilt anticipated.
Flex the bed as needed for jackknife positioning. Recheck security and
pressure points after flexing.
Buttocks may be taped apart to allow additional anal or gluteal cleft
exposure.
If hirsute, shave buttocks in areas where tape will be applied, usually a
few centimeters to either side of center of planned operative field.
Paint benzoin or another adhesive in a longitudinal stripe on each buttock.
Place the end of tape roll within center of adhesive area, pointing at and a
few centimeters from center of operative field. While one person firmly
holds this tape end in place, another pulls roll of tape tautly down and
slightly cephalad and affixes tape strip to the side and bottom of bed with
generous contact area. Repeat on other buttock. Place a second stripe of
tape if needed as support.
Place a short longitudinal piece of tape orthogonally over retracting piece
and incorporating stripe of adhesive to reinforce security of retracting tape
(Figs. 3-27 and 3-28).
FIGURE 3-27 Tape secured to the buttocks.

FIGURE 3-28 Final positioning with tape in the prone position.
RECTAL IRRIGATION
Irrigation can be instilled with a rectal catheter, which can be clamped to
keep irrigation in the rectum at the outset of surgery, or can be left in after
drainage to further evacuate air or liquid from the colon during the
operation.
Water or saline irrigation can be used to remove fecal matter from an
insufficiently cleared rectum for purposes of colonoscopy or transanal
maneuvers.
Iodine rectal irrigation can be used in an effort to decrease pelvic
infections.
40% alcohol solution irrigation (ie, Turnbull’s solution) can be used in an
effort to decrease pelvic cancer recurrences.
Equipment
34Fr Pezzer (ie, mushroom) catheter (Fig. 3-29)
FIGURE 3-29 Pezzer catheter.
Lubricant
40-cm rod or jumbo cotton-tip applicator
Collection bag
Gauze
Applicator(s) of choice, depending on source of irrigation
Bulb syringe with bulb removed for bottled irrigation solution
Irrigation tubing for bagged irrigation
Technique
With lubricant applied and rod or applicator inserted into the catheter end,
apply tension to straighten catheter tip and gently insert the catheter into
the rectum (Figs. 3-30 and 3-31). Remove the rod/applicator and gently
tug catheter down so tip sits upon anorectal ring, occluding the anus.
FIGURE 3-30 Rod inserted into the tip of the catheter.
FIGURE 3-31 Inserting the catheter into the rectum.

If using irrigation washout from a bag, place the bag on a high pole and
spike with tubing (Fig. 3-32). Insert the tubing end into catheter and instill
a few hundred milliliters at a time, alternately emptying rectum through
the catheter, until irrigation returns clear (Fig. 3-33).
FIGURE 3-32 Irrigation fluid.

FIGURE 3-33 Return of rectal irrigation.
If using solution from a bottle, insert a bulb syringe into the end of
catheter and remove the bulb. Holding syringe upright and above the level
of the patient to act as a funnel, pour solution into the catheter until the
liquid level begins to rise in the syringe, indicating good fill and fluid
pressure (Fig. 3-34). If planning to keep fluid in the rectum for
sterilization, place a large clamp across the catheter such that it will not
pull the catheter out by gravity. This clamp can be removed mid-procedure
to release the fluid (Fig. 3-35).
FIGURE 3-34 Rectal irrigation from a bottle. Note that the level of the tube is above
the patient.
FIGURE 3-35 Clamp placed across the tube.

Place a bag over the end of the catheter to collect fluid during the case and
then tie gauze around the bag and catheter near the anus (Fig. 3-36). Then
tuck the gauze ends under the buttocks. The catheter and bag can be
removed during the surgery as needed.
FIGURE 3-36 Bag applied to the rectal tube to collect drainage.
Suggested Reading
Chapter 4
Advanced Endoluminal Surgery:
Endoscopic Mucosal Resection and
Endoscopic Submucosal Dissection
EMRE GORGUN
ENDOSCOPIC MUCOSAL RESECTION
Procedure can be performed in regular endoscopy suites under sedation or
in the operating room under general anesthesia.
The patient should be positioned based on the location of the lesion.
Position the lesion at 6 o’clock (ie, inferior midline).
The colonoscope is introduced, and a standard colonoscopic examination
is first performed to evaluate for other pathology.
Equipment
Colonoscope/endoscope
Methylene blue or indigo carmine dye mixed with local anesthesia
Eleview or other premixed solution (as desired)
Select snares, baskets, and injection needles for the colonoscope
Bipolar/monopolar unit
Endoscopic clips
Specimen trap
Technique
After standard colonoscopic examination, locate the lesion for endoscopic
resection.
Methylene blue or indigo carmine dye is added to the injectate to establish
better visualization between the lesion and the normal mucosa (Fig. 4-1).
FIGURE 4-1 Hypromellose solution that can be used to prepare the injectate.
Alternatively, premixed solutions such as Eleview can be used.

After locating the lesion, the special injectate is injected between the
mucosa and the submucosa.
Start injecting from the area that is difficult to access (typically start from
oral/proximal site). Adjust needle tip to be tangent to the lesion.
Solution is injected circumferentially around the lesion with a 2-mm
margin.
Be dynamic while injecting and adjust depth and amount of the injection
based on visual cues (Fig. 4-2).
FIGURE 4-2 Injection is started circumferentially around the lesion and continued until
adequate mucosal elevation is observed.
Injections are finalized when the lesion is adequately elevated and is

suitable for resection.
Select the snare size and shape according to the lesion dimensions (Fig. 4-
3).
FIGURE 4-3 There are various snare types available based on size and shape.
Appropriate snare should be selected based on lesion characteristics.
Snare removal can be done piecemeal or en bloc based on the size and
location of the lesion.
Start snaring from the edge that is difficult to access. Incorporate 2-3 mm
of normal mucosal margin when resecting.
Open the snare fully before aiming the lesion and position the snare on top
of the lesion (Fig. 4-4).
FIGURE 4-4 After injection is completed, locate the snare on top of the lesion and
then include the lesion in the snare and close the snare.
After including the lesion in the snare that will be resected, hold the snare
parallel and tilt, close the snare tightly.
During snare removal, perform additional injections when necessary. This
may be required if the injectate diffuses, or if additional lift and
demarcation of the lesion, are required.
Repeat until the lesion is completely removed.
After each snaring, clean the resected area with normal saline and
visualize the site for any defects or remaining lesions.
Use snare-tip coagulation or coagulation forceps to establish hemostasis
and reduce adenoma recurrence (Fig. 4-5).
FIGURE 4-5 Close the snare and resect the lesion in a piecemeal manner.
See Video 4-1 for example of endoscopic mucosal resection (EMR).
PEARLS AND PITFALLS
During injection, be dynamic. Start injecting and slowly withdraw the

needle.
Avoid excessive injectate as this can block the view during snaring.
If the lesion is not lifting (ie, the nonlifting sign), terminate the
procedure or consider endoscopic submucosal dissection (ESD) in
selected cases, as this may indicate submucosal fibrosis due to
underlying scarring or a lesion with high risk of malignancy.
Alternatively, a lesion with nonlifting sign may require advanced
surgical resection.
Use endoscopic hemoclips or coagrasper if coagulation does not suffice
to establish hemostasis.
Make sure majority of the pieces are collected through the suction
channel and a specimen trap is used; or alternatively, if there are larger
pieces, utilize a Roth Net or other endoscopic baskets.
ENDOSCOPIC SUBMUCOSAL DISSECTION
The procedure can be performed in regular endoscopy suites under
sedation or in the operating room under general anesthesia.
During the early learning curve with ESD, consider performing the cases
in the operating room setting with laparoscopy as backup as needed.
Decide the place you will perform the procedure based on the possibility
of creating a full-thickness defect and the general condition of the patient.
Previously resected and scarred lesions are typically stuck to the muscular
layer and may be impossible to enter the submucosal plane.
Observe the patient for at least 4 hours after the procedure, but be prepared
to keep a patient overnight if any concerns.
Having a height-adjustable examination bed is vital for the comfort and
ergonomics of the endoscopist.
The endoscopist typically stands on the right side of the patient in the
endoscopy suite or in between the legs in the operating room and performs
a standard colonoscopy prior to the procedure.
Leave the leg extension of the operating table in place and slide the patient
on the table way down while patient legs are suited in Yellowfins. This
will allow the bottom portion of the operating table to support the part of
the colonoscope that is not inserted—providing stability.
Change the patient position according to the location of the lesion and
apply abdominal pressure, when necessary, for better visualization.
Aim for the lesion to be at 6 o’clock (ie, midline inferior) during the
procedure.
For both EMR and ESD, different injectates are available.
In our practice, we use 100 mL hydroxyethyl starch and 1 mL of 0.1%
adrenaline solution; however, a variety of solutions are available and can
be used to prepare the injectate.
Methylene blue or indigo carmine dye is added to the injectate to establish
better visualization.
Alternatively, injectates that contain glycerol, hyaluronic acid, albumin
solutions, and sterile saline can be used, based on the availability and cost.
Hypromellose can be preferred as an inexpensive alternative when diluted
6-8 times with sterile saline.
Premixed recently Food and Drug Administration–approved solutions,
such as Eleview, can also be used alternatively.
Equipment
Colonoscope
Methylene blue or indigo carmine dye mixed with local anesthesia
Eleview or other premixed solution (as desired)
Select snares, baskets, and injection needles for the colonoscope
Bipolar/monopolar unit
100 mL hydroxyethyl starch and 1 mL of 0.1% adrenaline solution
DualKnife (Olympus America Inc., Center Valley, PA) or HookKnife
(Olympus America Inc., Center Valley, PA)
Available platforms such as DiLumen or ORISE
Available over-the-scope clips or endoscopic hemoclips
Technique (Fig. 4-6)

FIGURE 4-6 Overview of endoscopic submucosal dissection.
Injection
Determine your injection technique based on the location and shape of the
lesion.
If the polyp is situated on a fold, primary injection site should be along the
far aspect (oral site) of the lesion to avoid it falling forward into view.
100 mL hydroxyethyl starch and 1 mL of 0.1% adrenaline solution or a
readily mixed solution is injected into the submucosa with an injection
needle.
Advance the injection needle, aiming it tangential to the mucosa of the
lesion (Fig. 4-7).
FIGURE 4-7 Advance the injection needle and start injecting the solution. Reposition
and repeat injections for lesions located on difficult locations such as folds.
The assistant helps to advance the needle into the mucosal–submucosal

area to create the submucosal cushion.
Start the injection and observe the lesion for mucosal elevation.
Inadequate elevation can be due to entry into incorrect plane.
Reposition the injection needle and inject again.
Continue injecting the solution to the submucosal space while
withdrawing the needle (Fig. 4-8).
FIGURE 4-8 Steps of endoscopic submucosal dissection. A. Marking; B. Staining; C.
Incision; D. Dissection; E. Collection; F. Hemostasis
Dissection
After achieving the submucosal cushion, start the dissection by delineating
the borders of the lesion with circumferential incision.
DualKnife (Olympus America Inc., Center Valley, PA) or HookKnife
(Olympus America Inc., Center Valley, PA) can be used for dissection
(Fig. 4-9).
FIGURE 4-9 After adequate injection is completed, dissection is started with
circumferential incision. Partially completed incision with DualKnife can be seen on the
lower right of the image.
After incising the first half of the lesion, deepen your dissection into the
submucosal space.
After deep submucosal dissection is completed for the initial half,
continue circumferentially and dissect the lesion using the submucosal
plane with the guidance of blue dye. During this stage, distal disposable
cap aids to create traction–countertraction (Fig. 4-10).
FIGURE 4-10 After circumferential incision, submucosal dissection is carried with the
guidance of the blue dye to ensure correct plane. Distal disposable cap is used for secure
dissection.
When available, platforms such as DiLumen or ORISE can be used to

create a stable therapeutic zone.
These platforms can also be used to achieve retraction (Fig. 4-11).
FIGURE 4-11 ORISE platform (A), balloon-assisted retraction with DiLumen (B), and
clipping lesion to the bowel wall (C) can be used to achieve retraction.
After excising each portion, clean the field and obtain good visualization
of the dissection field and establish hemostasis.
Always keep your dissection instrument tangential to the submucosa to
prevent advancement of dissection to the muscular layer.
Continue incision and submucosal dissection until you dissect the lesion
completely.
When necessary, apply a hybrid method to complete dissection with
snaring for large lesions or lesions in a difficult dissection (Fig. 4-12).
FIGURE 4-12 Endoscopic submucosal dissection enables en bloc removal of the
lesion.
Use coagulation forceps to establish hemostasis and stop any minor

hemorrhage.
Use endoscopic hemoclips if any defects can be observed in the field
deeper than submucosa.
Over-the-scope clips can also be used for larger defects (Fig. 4-13).
FIGURE 4-13 Endoscopic hemoclips (A) or over-the-scope clip (B) can be used to
close the defect after endoscopic submucosal dissection.
See Video 4-2 for example of ESD.

Postoperative Care
Most EMR patients can be safely discharged the day of the procedure.
ESD patients are admitted under observation for 24 hours.
No extended perioperative antibiotics are typically needed.
Diet is advanced routinely directly following the procedure, except in full-
thickness resections that typically started on clears and then advanced
once confirmed stable.
Follow-up on the pathology is critically important to determine
surveillance strategies or, in the case of malignancy, potential formal
resection.
Suggested Readings
Benlice C, Gorgun E. Endoscopic mucosal dissection. In: Lee SW, Ross HM, Rivadeneira DE, Steele
SR, Feingold DL, eds. Advanced Colonoscopy and Endoluminal Surgery. Cham, Switzerland:
Springer Publishing; 2017:159-169.
Gamaledin M, Benlice C, Delaney CP, Steele S, Gorgun E. Management of the colorectal polyp
referred for resection: a case-matched comparison of advanced endoscopic surgery and
laparoscopic colectomy. Surgery. 2018;163(3):522-527.
Gorgun E, Benlice C, Abbas MA, Steele S. Experience in colon sparing surgery in North America:
advanced endoscopic approaches for complex colorectal lesions. Surg Endosc.
2018;32(7):3114-3121.
Chapter 5
Combined Endoscopic and
Laparoscopic Surgery
EMRE GORGUN
Combined endoscopic and laparoscopic surgery (CELS) enables
mobilization of the colon to provide ease in colonoscopic dissection and
removal of colon lesions, and synchronized visualization of the colonic
wall after lesion removal and prompt closure of full-thickness defects,
when necessary.
CELS can be used for large benign lesions or lesions that are located in
areas that make the endoscopic resection difficult (ie, flexures and folds).
CELS can also be preferred in lesions where endoscopic resection was
attempted multiple times and scarred. These lesions have a higher risk of
full-thickness defect during removal and may require minimally invasive
approaches for repair.
Benign lesions and lesions with high-grade dysplasia can also be removed
using CELS (Fig. 5-1).
FIGURE 5-1 Operating room setup for combined endoscopic laparoscopic surgery.
The operating room should be equipped with a colonoscope, most

importantly with CO2 insufflation for the colonoscopy unit.
Two monitors should be placed depending on the surgeon’s position to
allow for visualization of the endoscopic portion and abdominal portion.
An experienced assistant or an attending physician should be present to
perform either the laparoscopic or the colonoscopic part of the procedure
and aid the primary surgeon accordingly (Fig. 5-2).
FIGURE 5-2 Two monitors are placed depending on the surgeon’s position. It is
important that both the colonoscopy and laparoscopy monitor are visible by the operating
team.
Equipment
Adult colonoscope
CO2 insufflation unit
Assorted snares, baskets, and irrigation for the colonoscope
Bipolar and monopolar endoscopic energy unit
10- and 5-mm abdominal trocars
Standard laparoscopic abdominal colectomy set with bowel graspers
(atraumatic)
Endovascular gastrointestinal anastomosis or other mechanical staplers
Technique
Under general anesthesia, stabilize the patient on the operating table and
place orogastric tube and Foley catheter.
Choose a pediatric or adult colonoscope to use.
Start by introducing the colonoscope to locate the lesion. If lesion is
amenable to endoscopic removal, it can be removed at this stage without
further need for laparoscopy.
If the lesion shows nonlifting sign or displays signs of malignancy, the
lesion can biopsied intraoperatively for frozen sections, and CELS or
formal oncological resection should be performed.
If polyp can’t be removed using endoscopic approach only, proceed with
laparoscopy (Fig. 5-3).
FIGURE 5-3 Simultaneous combined approach with colonoscopy and laparoscopy
enables the surgeon to view and manipulate the bowel accordingly.
Make a periumbilical incision and enter the fascia with sharp dissection.
Use a 10-12 mm balloon port and start insufflation.
Insert two or three 5-mm trocars, depending on the location of the lesion.
For lesions located in the left colon, enter the trocars in the right lower
quadrant and suprapubically.
For lesions in the right colon and ileocecal valve, enter the trocars on the
left lower quadrant and suprapubically.
Enter a separate 5-12-mm port if stapling is necessary or use 5-mm scope
and utilize the supraumbilical trocar for stapling.
After locating the lesion using colonoscopy, use transillumination or
endoscopic manipulation to locate the lesion laparoscopically.
Mobilize the colon laterally if the lesion is retroperitoneal.
Mobilize the colon if the lesion is located on a difficult-to-reach area.
Lift the polyp using an injection solution.
After lifting the mucosa from the submucosa and creating a cushion for
snaring/dissection, align the snare on top of the lesion.
Use the laparoscopic instruments to manipulate the colon wall (Video 5-
1), and after making sure the lesion is completely included in the snare,
proceed with snaring the lesion.
Observe the serosa after snaring with laparoscopic camera for thermal
injury or any defects.
If a defect is observed, place sutures and close the defect laparoscopically.
If the lesion is difficult to remove due to scarring or underlying fibrosis,
proceed with full-thickness CELS (Fig. 5-4).
FIGURE 5-4 After endoscopic lesion removal is completed, laparoscopy can be used
to suture the defects.
Use laparoscopic hot scissors to create a defect in the bowel wall up to the
submucosal layer.
Following this, manipulate the lesion to fall into the colonic lumen and
proceed with snaring.
Prior to snaring, close the defect laparoscopically by suturing and continue
with snaring endoscopically.
Combined Wedge Resection

If the lesion is located on the cecum (or in any colon segment and not
amenable for snare resection), wedge resection can be performed
laparoscopically.
Attention should be paid not to occlude the lumen, ileocecal valve, or
appendiceal orifice. This can be assessed via the passage of the scope
through the lumen and direct visualization of the aforementioned structure.
Enter an additional 5-12 mm trocar if necessary to insert stapler (Fig. 5-5).
FIGURE 5-5 Stapler can be used to complete full-thickness combined endoscopic and
laparoscopic surgery for lesions not amenable for endoscopic resection, and simultaneous
scoping can be used to assess the passage and ensure that lumen is not occluded
during/after resection.
Insert the stapler and simultaneously coordinate with endoscopy to place

the stapler across the bowel, ensuring adequate margins (Fig. 5-6).
FIGURE 5-6 For lesions located on difficult-to-reach areas such as the cecum, wedge
resection can be performed to remove the lesion.
After stapling, observe the colon wall for defects and repair if any defect is
present.
Check for hemostasis in the abdomen and terminate the procedure.
PEARLS AND PITFALLS
The CO2 colonoscope is critical for this procedure. Normal air

colonoscopy will dilate the bowel too much and prevent visualization
from the abdominal side.
Position the patient for a combined procedure, and prep the patient’s
abdomen for a formal resection.
Should the combined approach not be feasible, ensure that both the
patient and your staff are prepared to undergo a standard resection at
that time.
Postoperative Care
We typically admit patients following CELS for operation.
Patients may resume routine enhanced recovery care pathways following
CELS.
Avoidance of nasogastric tube
Early urinary catheter removal
Early diet initiation
Venous thromboembolism chemoprophylaxis (may consider holding
pending specifics on the procedure and patient risk)
Early ambulation
Multimodality, narcotic-sparing, pain control
Suggested Readings
Gorgun E, Benlice C. En bloc resection of a 5-cm flat ascending colon lesion with endoscopic
submucosal dissection combined with laparoscopy. Dis Colon Rectum. 2016;59(12):1230.
Gorgun E, Benlice C, Abbas MA, Steele S. Experience in colon sparing surgery in North America:
advanced endoscopic approaches for complex colorectal lesions. Surg Endosc.
2018;32(7):3114-3121.
Chapter 6
Interventional Inflammatory Bowel
Disease: Endoscopic Management of
Complex Inflammatory Bowel Disease
BO SHEN
ENDOSCOPIC BALLOON DILATION OF STRICTURES
Stricture is a common complication of inflammatory bowel disease (IBD),
including Crohn disease (CD) and ulcerative colitis.
Strictures may result from the chronic process of inflammation and tissue
repair of underlying disease, as well as tissue healing of inflammation
from medical therapy, the concurrent use of nonsteroidal anti-
inflammatory drugs, or surgery-associated ischemia.
Strictures in IBD can be classified as follows: (1) primary (ie, disease
associated) versus secondary (eg, anastomotic), based on etiology (Figs. 6-
1 and 6-2); (2) short (<4 cm) versus long (≥4 cm), based on the length; (3)
inflammatory versus fibrostenotic versus mixed; and benign versus
malignant, based on histology; (4) mild versus moderate versus severe,
based on the degree; (5) various locations, such as ileocolonic anastomosis
(Fig. 6-2) and strictureplasty site (Fig. 6-3); and (6) associated conditions
(eg, fistula, abscess, malignancy).
FIGURE 6-1 A and B. Endoscopic balloon dilation of tight ileocecal valve stricture.
FIGURE 6-2 A and B. Endoscopic balloon dilation of ileocolonic anastomosis

stricture.
FIGURE 6-3 A and B. Endoscopic balloon dilation of stricture at the strictureplasty

site.
Endoscopic balloon dilation (EBD) has evolved into a main treatment
modality of IBD and non–IBD-associated strictures.
EBD can have associated complications, including bowel perforation and
excessive bleeding.
IBD patients on systemic corticosteroids have a higher risk for procedure-
associated bowel perforation. EBD procedure should be avoided or
postponed for those patients.
A high-quality bowel preparation is important for safe and successful
EBD.
Preprocedural abdominal imaging should be obtained and carefully
reviewed, which will help provide a road-map for the endoscopic
intervention.
It is important to review any previous operative notes (since a number of
patients have had some form of surgery in the past) and endoscopy notes
prior to the current endoscopy procedure.
Surgical backup should be readily available, if a perforation occurs.
Equipment
Adult colonoscope, pediatric colonoscope, or gastroscope utilizing CO2
Through-the-scope (TTS) wires and balloons of various sizes (typically
5.5 and 8.0 cm in length)
Energy system to provide for coagulation/fulguration along with
appropriate graspers and biopsy/ball-tip electrodes (Fig. 6-4)
FIGURE 6-4 Endoscopic ball-tip electrode used for hemostasis.
Suction, electrocautery, and irrigation devices
Technique
EBD can be performed in an outpatient setting with or without
fluoroscopic guidance.
EBD can be performed with patients utilizing conscious sedation alone in
most cases.
EBD can be performed via adult colonoscope, pediatric colonoscope, or
gastroscope, depending on the degree and location of stricture.
Patients are placed in the left lateral decubitus position. This provides
access to the perineum and avoids potential respiratory issues with the
prone position.
During the index endoscopy, any strictures should be biopsied to rule out
malignancy.
The endoscopist should make an attempt to traverse encountered stricture,
even when encountering some resistance. Ultrathin endoscopes may be
used to traverse the stricture and observe the bowel segment proximal to
the stricture.
The passage of scope through the stricture will allow for observation of
the bowel anatomy at the proximal side of the stricture and the
characterization of length, nature, and degree of the stricture.
EBD can be performed in a retrograde (ie, passage of scope through
stricture, introduction of the balloon, then pulling scope back, followed by
insufflation of balloon) or an antegrade manner. Retrograde EBD is
preferred to antegrade EBD.
For strictures that are not traversable, antegrade EBD may be performed.
A wire exchange technique is recommended during antegrade EBD to
reduce the risk of bowel perforation.
The wire should be pushed out from the tip of the balloon during
insufflation to reduce barotrauma from the tip of a forward-slipped
balloon.
For the treatment of an IBD-associated stricture, the targeted balloon size
is set from 15 to 20 mm, depending on the location, degree, length, and
shape of the stricture.
There are two commonly used balloons, 5.5 and 8.0 cm, in length. The
short balloon is equipped with a guidewire.
The duration of balloon insufflation is around 5 seconds.
A second look of stricture and bowel segment proximal to the stricture
after EBD is often performed to observe efficacy of the treatment, to
ensure no excessive bleeding or perforation, and/or to perform a rescuing
procedure (such as clipping of bleeding vessel or perforation) as needed.
In addition, passage of the endoscope through dilated stricture has been
used to measure “technical success” of EBD.
The role of intralesional injection of long acting corticosteroids after EBD
in keeping the lumen patent and avoidance of restricturing is controversial.
Patients are observed in the endoscopy recovery suite for at least 30
minutes. An excessive pain, bloating, or unstable vital sign should
immediately trigger further evaluation, such as plain abdominal series to
rule out a perforation.
PEARLS AND PITFALLS
Minimum air insufflation during procedure should be a routine practice.

Insufflation of carbon dioxide, rather than room air, is recommended.
Postprocedural bloating with trapped gas in the bowel is common,
resulting from air or carbon dioxide insufflation, use of sedatives during
procedure, or loss of bowel volume from prior bowel resection. A
nasogastric tube can be placed via anus or stoma to decompress the
bowel.
An ulcerated stricture is not a contraindication for balloon dilation.
The main concern for repeat EBD has been the risk for perforation.
Always keep a backup rescuing plan (such as clipping of bleeding
vessel or perforation) in mind and be ready.
Primary stricture with prestenotic luminal dilation typically responds
poorly to EBD. Early surgical intervention is preferred.
EBD is not recommended for a long stricture (>4 cm), angulated
stricture, multiple strictures, or stricture associated with fistula and
abscess, due to poor response and the high risk for perforation.
ENDOSCOPIC STRICTUROTOMY
Endoscopic stricturotomy with a needle knife or isolated-tip knife has
emerged as a valid endoscopic treatment option.
Endoscopic stricturotomy is more effective than EBD, particularly for
short (<3 cm) fibrostenotic stricture. The procedure can be performed in
both primary and anastomotic strictures (Figs. 6-5 and 6-6).
FIGURE 6-5 Endoscopic stricturotomy. A. Colonic stricture from Crohn disease. B.
Needle knife was used. C. Radial cut. D. Deployment of endoclips.
FIGURE 6-6 Endoscopic stricturotomy. A. Tight ileocolonic anastomosis stricture. B.

Stricturotomy with circumferential cut.
Endoscopic stricturotomy may have a lower risk for perforation, but a

higher risk for late-onset bleeding than EBD.
The main advantage of endoscopic stricturotomy over EBD is that
endoscopist has a full control of the depth and topographical location of
the electroincision utilized. This feature is particularly useful in the
management of strictures that are close to adjacent vital organs, such as
the anal sphincter and vagina.
In contrast to the radial force of EBD, various electroincision manners can
be performed during stricturotomy, including radial, circumferential, and
horizontal cut.
Equipment
Energy system to provide for electroincision
Needle knife or isolated-tip knife
Endoclips
Topical hemostatic agents, such as hypertonic glucose (50% glucose)
Anal intubation catheter (eg, nasogastric tube), as needed
Technique
Bowel preparation recommendations and endoscopy setting of endoscopic
stricturotomy are the same as EBD.
It is important to the keep the tip of the scope stable and to keep the
targeted stricture at front view.
The setting on the electroincision is endoscopic retrograde
cholangiopancreatography (ERCP) endocut.
Either needle knife or isolated-tip knife is used.
The manner of cutting can be radial (Fig. 6-5), horizontal, or
circumferential (Fig. 6-6), depending on the degree, depth, and location of
the stricture.
The targeted size of cutting is normally set around 15-20 mm, to keep
adequate luminal patency, while minimizing the risk of perforation.
Endoclips are routinely placed in the horizontally or radially incised
tissue, to maintain luminal patency and to prevent bleeding.
A second look is usually feasible.
PEARLS AND PITFALLS
Orientation of scope is critical, which is particularly true in treating

distal bowel or anal strictures. Recognition of the anterior wall (4-5
o’clock position on left lateral decubitus position) versus posterior wall
(10-11 o’clock position) of the rectum or anal canal is important to
avoid iatrogenic trauma to the vagina and prostate.
Endoscopic stricturotomy can result in large ulcerated area, which may
bleed 1-4 days after the procedure. Endoscopist may consider spraying
or injecting hypertonic glucose (50% glucose) to the treated area.
Following stricturotomy, especially radial or horizontal cutting, we
normally place endoclips to keep the lumen patency as well as to
prevent bleeding.
An amount of gas is introduced during the procedure. Therefore,
minimum air insufflation, use of carbon dioxide, and postprocedural
placement of nasogastric tube via anus for suction are recommended.
We recommend that the patient stays admitted to observation or the
hospital for the next 1-2 days, if there is bleeding and endoscopy
reintervention is needed.
ENDOSCOPIC FISTULOTOMY
The concept and practice of endoscopic fistulotomy derives from surgical
fistulotomy. Application of the latter is limited to perianal fistulae.
Endoscopic fistula can be performed deep in the bowel in selected patients
with IBD, especially in those with a fistula resulting from surgical leaks.
Endoscopic fistulotomy can be performed in patients with superficial (<2
cm in depth), short (<3 cm) fistulae, including ileocolonic fistula (Fig. 6-
7), pouch-to-pouch fistula, and perianal fistula (outside the external anal
sphincter). Enterocutaneous fistulas are typically not candidates for
endoscopic therapy.
FIGURE 6-7 Endoscopic fistulotomy. A. Ileocolonic fistula opening at the ileum side. B
and C. Needle knife fistulotomy. D. Placement of endoclips at the incision site.
Equipment
Soft-tip TTS wires of various sizes
Energy system to provide for electroincision
Endoclips
Technique
Endoscopic fistulotomy is normally performed in an outpatient setting,
with patients under conscious sedation, with or without fluoroscopy
guidance.
The fistula track is detected by a soft-tip guidewire via the working
channel.
The scope is pulled out while the guidewire remains.
The scope is reintroduced to the distal opening of the fistula.
The fistula track is then incised open along the guidewire, with needle
knife or isolated-tip knife in a setting of ERCP endocut.
Multiple endoclips are deployed along both edges of the incised fistula
track, to keep its patency and to prevent bleeding.
The patient is then observed in recovery unit for 30 minutes.
PEARLS AND PITFALLS
Endoscopic fistulotomy can have a high success rate, especially if

candidate patients are carefully selected.
It is important to accurately measure the depth and length of fistula.
In candidate patients, complete fistulotomy can be achieved in a
majority.
ENDOSCOPIC CLOSURE OF SURGICAL LEAK
Suture line or anastomotic leaks are relatively common after IBD surgery,
leading to abscess, sinus, or abscess. Some of them may lead to
enterocutaneous fistula (Fig. 6-8).
FIGURE 6-8 Endoscopic clipping of enterocutaneous fistula from ileocolonic
anastomosis leak. A. Skin site. B. Deployment of an over-the-scope clip.
Although endoscopic vacuum system has been used for the treatment of
acute anastomotic leak, endoscopic clips, including through-the-scope
clips (TTSCs) and over-the-scope clips (OTSCs), have also been used.
We have used the technique to treat leaks at the ileocolonic anastomosis,
the tip of the J (in patients with J pouches), and transverse staple line at
side-to-side anastomosis after ileocolonic resection (Fig. 6-9).
FIGURE 6-9 Endoscopic clips of surgical leak. A. Side-to-side anastomosis after
ileocolonic resection for Crohn disease. B. A leak at the transverse staple line. C and D.
Placement of an over-the-scope clip.
Equipment
Soft-tip TTS guidewires of various sizes
Energy system
Endoclips
Endoscopic clips, such as TTSCs and OTSCs
Betadine, methylene blue, hydrogen peroxide, or other injectates
Cytology brush
Argon plasma coagulation
Technique
Endoscopic clipping is also performed in an outpatient setting with patient
under conscious sedation.
The surgical leak can be detected with soft-tip guidewire.
Surgical leak with enterocutaneous fistula can be detected by the
observation of flow of betadine, methylene blue, or hydrogen peroxide
instilled from skin fistula.
Small leaks can be managed with TTSCs, while larger leaks can be treated
with OTSCs.
Mucosa around the orifice of the leak may be debrided with cytology
brush or argon plasma coagulation, to achieve better success rate of
endoscopic closure.
PEARLS AND PITFALLS
A high quality of abdominal imaging is needed to delineate the location,

length, and degree of the leak. Commonly used imaging modalities are
gastrografin enema, computed tomography enterography, or magnetic
resonance enterography.
CD-associated, nonanastomosis, nonsuture line fistulae have a poor
response to endoscopic clipping.
ENDOSCOPIC SINUSOTOMY
Sinus results from chronic anastomotic leaks, which commonly take place
in the presacral area in patients undergoing restorative proctocolectomy
with ileal pouch-anal anastomosis.
Presacral sinus has been treated with surgical unroofing or septectomy.
Due to the limitation of instrumentation, surgical unroofing may not be
feasible in some patients.
Endoscopic sinusotomy evolves from surgical unroofing. The principle of
endoscopic sinusotomy is the electroincision of the bowel wall between
the bowel lumen and sinus, making the sinus into an epithelialized
diverticulum (Fig. 6-10).
FIGURE 6-10 Endoscopic sinusotomy. A. A presacral sinus at the ileal pouch. B and
C. Sinusotomy with needle knife. D. Placement of endoclips at the incision area.
Various shapes of the sinus have been described.
Equipment
Soft-tip TTS guidewires of various sizes
Energy system for electroincision
Endoclips
Technique
Endoscopic sinusotomy is often performed in an outpatient setting, with
patient under conscious sedation.
The presacral sinus can be detected with a soft-tip guidewire.
Electroincision is performed with needle knife or isolated-tip knife in a
setting of ERCP endocut.
Following the electroincision, the endoscopist should place multiple
endoclips along both incised edges of sinus, to keep patency of the cavity
and to prevent bleeding.
Depending on the length, sinus can be treated with one single session or
staged sessions.
L-shaped sinus appears to have the best response to endoscopic
sinusotomy.
PEARLS AND PITFALLS
Endoscopic sinusotomy should not be performed in fresh sinus (<6

months of duration), as the sinus is not walled off. Sinusotomy may lead
to gas leak and retroperitoneal air. However, endoscopic sinusotomy
may be performed in fresh sinus in patients with diverting ileostomy.
Sinuses can recur after endoscopic therapy. The main risk factors for
recurrent sinus are weight gain and concurrent CD.
Suggested Readings
Lan N, Hull TL, Shen B. Endoscopic sinusotomy versus redo surgery for the treatment of chronic
pouch anastomotic sinus in ulcerative colitis patients. Gastrointest Endosc. 2019;89(1):144-
156.
Shen B, Kochhar G, Navaneethan U, et al. Role of interventional inflammatory bowel disease in the
era of biologic therapy: a position statement from the Global Interventional IBD Group.
Gastrointest Endosc. 2019;89(2):215-237.
Chapter 7
Office Endoscopy
JAMES CHURCH
A full armamentarium of endoscopes maximizes the effectiveness of the
office consultation, with each potentially utilized in different situations.
Before you scope: Although endoscopy should always be thorough, the
examination is directed by the provisional diagnosis reached as a result of
history and physical examination.
Patients with an obvious diagnosis on physical examination do not need
endoscopy in the office. Examples include a patient presenting with anal
pain and a lump that is an obvious thrombosed external hemorrhoid, or a
perianal abscess. Treat the thrombosis or abscess. Patients with rectal
bleeding, rectal pain, or dysfunctional defecation are good candidates for
endoscopy.
Judge the mental state of the patient sitting before you. They are usually
expecting some sort of anal examination and are often dreading it. In their
minds, it will be painful, embarrassing, and involve complete loss of their
personal dignity. This dread and anxiety demands a very relaxing and
respectful examination.
Limit the number of people in the room. This is no time to have multiple
observers and students.
Make sure the patient’s anus is covered most of the time.
Tell the patient exactly what is going to happen before it happens.
Be gentle at all times.
Use plenty of lubricant.
Use lidocaine jelly if there is anal excoriation.
Infiltrate the anus with local anesthetic if immediate anoscopy is important
and you suspect an anal ulcer or fissure.
Equipment (See Chapter 2)

Anoscopes (short and long, adult and pediatric) (Fig. 7-1)
FIGURE 7-1 A selection of closed anoscopes for office anoscopy, including adult-
sized scopes of different lengths and a pediatric-sized anoscope.
Proctoscopes (pediatric, adult standard, and adult large) (Fig. 7-2)

FIGURE 7-2 Selection of instruments for rigid anorectal endoscopy.
Flexible sigmoidoscopes (adult and narrow) (pediatric gastroscope =

“ileoscope”)
Cotton-tip applicators
Suction device
Enemas
Gloves and lubrication
Local anesthetic with corresponding betadine, 5- or 10-mm syringe, and a
27-guage needle, when required
Biopsy forceps (open and endoscopic)
Technique
Position
The easiest way to examine the anus is with the patient in knee-chest
position, on a Ritter table, tipped forward to raise the anus and lower the
head.
The examiner and an assistant on the other side of the patient spread the
buttocks.
A left lateral position can also be used and, in fact, is preferred if there is a
question of pelvic floor nonrelaxation.
Inspection
The anus is then inspected for symmetry, scars, the degree of closure, the
state of the surrounding skin of the perineum, tags, masses, or other
abnormalities.
Digital Examination
The skin beside the anus is gently touched with a Q-tip to elicit an anal
“wink,” a contraction of the corrugator cutis ani muscle that is evidence of
intact anal innervation. The “Open Sesame” technique follows.
“Open Sesame”: This technique of anal examination is based on the
tendency of many patients (especially young patients) to have a tight anal
sphincter that resists attempts at examination.
To achieve intubation, the anus has to be encouraged to relax. This
means a gentle approach with a well-lubricated finger circling the anus
and gradually inserting itself. If the anus is surprised by an attempt at
forceful insertion, there will be spasm and pain. A gradual, intermittent
insertion will avoid the spasm.
The key to comfort is asking the patient to bear down during insertion.
This relaxes the internal sphincter and allows full insertion of the
examining digit or scope.
In addition, bearing down will bring the contents of the lower rectum
down on to the finger, allowing detection of masses that might
otherwise be unreachable. This technique is useful for inserting an
anoscope or a sigmoidoscope, either rigid or flexible.1
If an initial reconnaissance reveals a very tight sphincter muscle, it is
better to examine with a fifth digit and a pediatric anoscope.
If these do not provide enough information because of the limited
vision afforded by the narrow instrument, then an examination with the
patient under a general anesthetic is warranted.
Anoscopy
No preparation is normally given, although, if a procedure (eg, elastic
band ligation of hemorrhoids) is to be done, patients are encouraged to see
if their rectum is empty.
A short beveled anoscope is good for examining the anal canal, the anal
transition zone (ATZ) and hemorrhoidal area, and the low rectum.
It is inserted with the bevel aligned along the longitudinal
(anterior/posterior) axis of the anus.
Once past the sphincters, the scope is rotated to look at the anterior
quadrant of the anus. The obturator is removed and then the scope
gradually pulled back.
With the dentate line in view, the patient is asked to bear down. Anterior
rectal mucosal prolapse and hemorrhoidal prolapse can be seen (Fig. 7-3).
FIGURE 7-3 Use of a closed anoscope to demonstrate hemorrhoidal prolapse.
Poking the mucosa with a Q-tip tests its laxity on the underlying muscle
and, therefore, the suitability for elastic banding.
Before taking the scope out completely, the obturator is replaced, the
scope reinserted into the hilt and turned through 90 degrees. This
withdrawal procedure is repeated twice so that all four quadrants of the
anal canal are inspected.
Longer beveled anoscopes allow examination of more of the lower
rectum. If these scopes are used, the knee-chest position is preferred as it
allows the rectum to balloon open and provides superior views.
Rigid Proctoscopy
Rigid proctoscopy has largely been superseded by flexible
proctosigmoidoscopy as a way of examining the entire rectum.
The view provided is inferior to that from a flexible instrument, and
therapeutic or biopsy procedures are more difficult. It is a simple way of
checking the status of the rectal mucosa, in a patient being followed for
proctitis, or checking the site of a low rectal polyp excision to exclude
recurrence.
Rigid proctoscopy has been the most accurate way of defining the location
of a cancer within the anus, by distance from the anal verge and location
within the circumference.
The technique usually involves preparation with an enema. The patient
can be in knee-chest or left lateral position, and the appropriate-sized
proctoscope is inserted through the anus using the “Open Sesame”
technique.
Once its tip is above the pelvic floor, the scope is angled forward to allow
the tip to pass posteriorly into the rectal vault.
The insufflator is then used to inflate the rectum, and advancement can
occur under direct vision.
The scope is inserted to the top of the rectum and withdrawal is
systematic, using circular movement to examine the circumference of the
rectum.
Rigid biopsy and suction are available to improve the view and to sample
abnormal mucosa.
Flexible Sigmoidoscopy
Flexible sigmoidoscopy is indicated in the investigation of complaints
such as rectal bleeding, diarrhea, and urgency. It is also useful for the
follow-up of rectosigmoid lesions that have been treated locally, proctitis,
and an ileorectal anastomosis in patients with colitis or familial
adenomatous polyposis (FAP).
The aim is to examine at least the rectum and most of the sigmoid colon,
although the 60-cm scope can at times reach the mid-transverse colon.
The intent of the examination is to accomplish this without causing pain,
in a nonsedated patient, and so the examination must be as gentle as
possible and should stop if it is uncomfortable.
Preparation is with two-fleet enemas, ideally given just before the
examination. The patient signs a consent for the examination and is placed
in left lateral position.
A “timeout” safety check is carried out, and a digital rectal examination
precedes scope insertion.
As the tip of the scope traverses the anus, insufflation of air and water
facilitates its passage and allows inspection of the anal canal. The scope is
advanced out of the rectum into the sigmoid colon.
Attempts are made to straighten the angles by judicious torqueing, pulling
back, aspirating air, and applying abdominal pressure. If the sigmoid can
be straightened, the scope can usually be advanced to the splenic flexure.
Inspection of the mucosa occurs both on insertion and withdrawal. The
examination is aborted if the patient is suffering pain that cannot be
relieved by straightening the scope.
Diverticular disease is commonly seen in patients older than 60 years and
is sometimes accompanied by spasm, rigidity, and narrowing. Such
patients will not get a complete examination.
If a more thorough examination is called for, the patient should have a full
colonoscopy. If the extent of the sigmoidoscopy is suboptimal, a full
colonoscopy is indicated.
Pouchoscopy
Patients with an ileal J- or S-pouch constructed during surgery for
ulcerative colitis, Crohn colitis or FAP needs surveillance examinations at
regular intervals (q1 year for FAP and q2-3 years for colitis), and
diagnostic examinations of their pouch when there are symptoms.
The examination begins with one or two enemas, but because pouch stool
is often liquid, it can be attempted without a prep. One of the first
differences unique to pouchoscopy is the presence of a pouch-anal
anastomosis.
A stapled anastomosis (by far the more common) is easier to examine but
even that may be stenotic. A handsewn anastomosis is frequently stenotic
and rigid, or is accompanied by a tendency for seepage of stool and some
perianal and anal canal excoriation. This causes insertion of the scope to
be very painful. Lidocaine jelly is indicated.
The anus needs to be examined on insertion so that anal polyps or ulcers
can be seen, and this is achieved by slow insertion while instilling air and
water through the scope channel. Slow insertion allows the anus to relax
and the view improves (Fig. 7-4). This is done again on withdrawal. The
technique of pouchoscopy is relatively straightforward. Advance to the
junction of afferent and efferent limbs of the “J” (Fig. 7-5). Then progress
into the afferent limb. On withdrawal, check if there is an ATZ. Answer
the following questions:
Is the pouch straight? You should be able to see the “owl’s eye” of the
afferent/efferent limb junction from the bottom of the pouch (Fig. 7-6).
If you can’t, there may be a twist or a curve. This may impair emptying
of the pouch and cause more frequent defecation.
FIGURE 7-4 View of the anal canal via pouchoscopy.

FIGURE 7-5 Junction of afferent and efferent limbs.
FIGURE 7-6 Owl’s eye.
Is the pouch normal size? A huge pouch can mean chronically

obstructed defecation and multiple stools.
Is the afferent limb kinked? If you cannot intubate, it there may be an
afferent limb syndrome.
Are there shelves in the pouch? If so, there may be a rotational twist
incorporated into the pouch, with adverse effects on pouch emptying.
Is the mucosa normal? In patients with colitis, look out for pouchitis
with ulcerations, erythema, and granularity. Longitudinal ulcers may
suggest Crohn disease. In patients with FAP, look out for adenomas.
Isolated ulcers, especially on staple lines and at the confluence of
afferent and efferent limbs, are usually normal. They do not mean
Crohn or pouchitis.
Look at the ATZ … in colitis patients, is it inflamed? In FAP patients,
are there polyps? Polyps can be quite subtle.
Can you safely and comfortably retroflex the scope to get a good look
at the low pouch and upper anus? If so, do it.
If it is an S-pouch, how long is the efferent limb? Over 2 in (5 cm) is
particularly liable to cause difficult pouch emptying.
Routine biopsies of the pouch and ATZ are reasonable, especially when
follow-up exceeds 10 years, or when the indication for the colectomy
was neoplasia.
Scoping Stomas and Diverted Bowel

Ileostomies and colostomies can be scoped in the office with either rigid
or flexible scopes.
The usual indications for an ileostomy are to check for adenomas in
patients with FAP and to check for Crohn disease in patients with that
diagnosis.
The indications for a colostomy include checking the extent of ischemia in
a newly formed stoma, checking for strictures at or just below the fascia
level, or performing surveillance colonoscopy after neoplasia surgery.
Rigid Ileoscopy
A pediatric proctoscope is ideal for this procedure.
First, insert a Q-tip into the stoma and examine it. Blood on the tip
suggests inflammation … it is not normal.
Lube the proctoscope and rest the obturator tip on the opening of the
stoma. Let the weight of the scope rest on the stoma, and the stoma will
relax to admit the scope.
Once the scope is well in to the stoma, remove the obturator and use the
air insufflator. Once through the fascia, follow the lumen. Good suction is
necessary as the small bowel constantly produces stool.
Flexible Ileoscopy
A pediatric gastroscope is a good instrument to use and can also be useful
in patients with a strictured ileal pouch-anal anastomosis or in intubating a
continent ileostomy.
The technique involves using judicious air insufflation to follow the lumen
of the bowel. The bowel can be surprisingly tortuous, so insertion,
withdrawal, tip deflection, and torque are all important. Patience is
required in allowing bowel to contract and relax.
Colonoscopy through a Colostomy

This is similar to colonoscopy through the anus. One might think it will be
easy, but sometimes, the direction of the bowel proximal to the stoma can
be surprisingly tortuous, tracking down into the pelvis, or looping across
to the right side of the abdomen.
Parastomal hernias can make colonoscopy difficult.
Scoping Diverted Bowel

Diverted bowel tends to become inflamed due to the lack of short-chain
fatty acids in its lumen, stiff, fragile, and narrow.
Sometimes, other factors such as radiation and sepsis have impacted the
situation. Use narrow scopes (pediatric colonoscopy, ileoscope), be gentle,
and stop the inspection if there is serious patient discomfort.
The bowel can be hard to biopsy due to its stiffness and the loss of
suppleness of the mucosa.
Suggested Readings
Ashburn J, Church J. Open sesame revisited. Am J Gastroenterol. 2013;108(1):143. doi:
10.1038/ajg.2012.382.
Farmer KC, Church JM. Open sesame: tips for traversing the anal canal. Dis Colon Rectum.
1992;35(11):1092-1093.
Hurlstone DP, Saunders BP, Church JM. Endoscopic surveillance of the ileoanal pouch following
restorative proctocolectomy for familial adenomatous polyposis. Endoscopy. 2008;40(5):437-
442.
PART II
Anorectal Disease
Chapter 8
Hemorrhoidectomy
MASSARAT ZUTSHI
The mere presence of hemorrhoids is not an indication for
hemorrhoidectomy. Symptoms should be directly related to the
hemorrhoids.
Many patients with “hemorrhoids” are not hemorrhoids, and a thorough
evaluation for other anorectal pathology should be performed.
Excisional hemorrhoidectomy should be reserved for those patients with
external or grade III/IV hemorrhoids that have failed conservative
management.
Patients should be appropriately counseled as to the risk of pain, bleeding,
open wounds, recurrence, and resulting skin tags prior to
hemorrhoidectomy.
Anal stenosis following hemorrhoidectomy should be a rare occurrence
and is minimized by keeping >1 cm of anoderm between resected
columns.
Similarly, new incontinence following hemorrhoidectomy should be rare,
and all efforts to identify and preserve the sphincter should be done.
For appropriate patients, or those with more concerning symptoms, ensure
the colon has been evaluated with a colonoscope to rule out more proximal
pathology.
Sterile Instruments/Equipment
Betadine solution for skin preparation
Lighted Hill-Ferguson anal retractor
Hemostats: Straight and curved
Needle driver
Assorted forceps (eg, Adson-DeBakey)
Metzenbaum scissors
Electrocautery
Lidocaine with epinephrine 0.5% and injection equipment for anal block
Surgical Approach
Preoperative preparation: two-fleet enemas
Anesthesia: general/laryngeal mask airway
Position: lithotomy or prone depending on surgeon/anesthesia preference
(Fig. 8-1)
FIGURE 8-1 Lithotomy positioning exposing the perineum.
MILLIGAN-MORGAN (OPEN)
Technique
With the patient in the lithotomy position, examine the perineum to look
for other pathology and evaluate the hemorrhoidal columns (Fig. 8-2A and
B).
FIGURE 8-2 A. Traditional three column external hemorrhoids in the right anterior,
right posterior, and left lateral positions. B. Circumferential hemorrhoidal prolapse.
Hemorrhoids are rarely the same size and anoscopy can confirm the
largest or most problematic. Begin with that one and proceed sequentially.
Sometimes one or two of the three columns can be successfully managed
by elastic ligation.
Clean the inside of the anal canal first with a gauze soaked in betadine
solution.
Clean the skin over the perineum up to the scrotum or the vagina
anteriorly and the tailbone posteriorly. On the lateral side, the preparation
should go beyond the ischial tuberosity.
Perform an anal examination by placing a finger in the anal canal, and
sweep the anal canal for any abnormalities.
Insert a Hill-Ferguson anal retractor, perform a visual examination, and
record any abnormalities and location of the hemorrhoids.
To plan the procedure accordingly, make sure that there are enough skin
bridges (>1 cm of anoderm) between the excision of the three pedicles.
Mark areas of possible excision, if needed.
Inject 0.5% Marcaine with epinephrine under the hemorrhoid pedicles
using a small-gauge needle using about 5 mm at every pedicle (Fig. 8-3).
FIGURE 8-3 Perianal block with local anesthetic.
Wait for 5 minutes to allow for the block to set in.

Evaluate all the three pedicles (Fig. 8-4).
FIGURE 8-4 Three internal hemorrhoids (asterisks) are seen prolapsing from the
anal canal. Hemostat on the skin of the left lateral pedicle.
Apply one hemostat to the skin edge and one to the mucosa (Fig. 8-5).
Gently pull on the pedicle such that the skin is minimally tented.
Alternatively, a scalpel can be used for the incision.
FIGURE 8-5 Three hemorrhoid columns (asterisks) are demonstrated by hemostat
retraction.
Using a Metzenbaum scissor with the curve facing downward, cut at the
base of the skin lifting the pedicle and pushing the muscle and connective
tissue down toward the skin. This is progressed in small increments (Fig.
8-6).
FIGURE 8-6 A hemorrhoid is elevated with clamps and excised with scissors.
Secure hemostasis using an electrocautery as needed.

Continue this dissection until the pedicle is reached. Place a curved
hemostat to include the pedicle and the mucosa.
Suture tie the pedicle using 2-0 Polysorb/Vicryl sutures, making sure that
the suture is well tied.
Additionally, a free tie may be used distal to the suture tie.
Excise the pedicle. Check for bleeding.
Move to the next pedicle and repeat this procedure, making sure that the
two areas of incision have a skin bridge between the areas excised (Fig. 8-
7).
FIGURE 8-7 Milligan-Morgan hemorrhoidectomy with three hemorrhoidectomy
incisions left open. Arrows point to initial site of excision.
Maintain hemostasis using electrocautery.

For the Milligan-Morgan procedure, this ends the procedure. A long-
acting anesthetic may be injected 20 minutes after the previous injection
of lidocaine.
Place a dressing over the wound with an antibiotic cream on it.
FERGUSON (CLOSED)
Technique
Follow the steps as in Milligan-Morgan.
Using a 2-0 Vicryl or Polysorb suture, start at the pedicle and approximate
the mucosa by burying the pedicle and then use a continuous suture and
approximate the mucosa (Fig. 8-8).
FIGURE 8-8 Ferguson closed hemorrhoidectomy.
Using an Energy Device

When using an energy device like the Harmonic Scalpel (Ethicon,
Cincinnati, OH) or the short Ligasure (Medtronic, St. Paul, MN), the steps
to be followed are the same as described earlier; however, more care is
taken as the sphincter muscle is not visible and hence the skin should not
be tented to pull the muscle up.
The energy device should not be placed too close to the area where the
muscle lies at the base of the tented area.
The excision is carried out using small bites of the skin as the skin is quite
thick and does not cauterize and seal very well if large bites are taken (Fig.
8-9).
FIGURE 8-9 Using an energy device taking small bites from the skin to the pedicle.
On reaching the pedicle, make sure the entire area is cauterized and sealed
well. Once the pedicle has been cauterized, a few sutures of 3-0 chromic
catgut may be taken as interrupted sutures to reinforce the skin (Fig. 8-10).
FIGURE 8-10 Closing of the mucosa after an energy device was used to resect the
hemorrhoidal tissue.
Inject a long-acting bupivacaine, as described earlier.
Postprocedural Management
The patient is advised the following:
Pain management using pain medications of surgeons or patient’s choice
Stool softeners such as docusate sodium 100 mg twice daily
Fiber supplementation
Mineral oil 2 tablespoons as needed
Local application of lidocaine jelly 2% before and after a bowel
movement
Local application of metronidazole 0.75% cream 1-2 times a day
Sitz bath or use of an ice pack
Follow-up visit at 4-6 weeks and/or earlier if indicated
PEARLS AND PITFALLS

For large bundles, an operating anoscope (i.e., Fansler) can be used to
see the prolapsing tissue. A Hill-Ferguson anoscope can also facilitate
pre-resection reconnaissance and to check for bleeding after excision.
Leave at least one cm between the hemorrhoidal columns that are
excised to help avoid anal stenosis.
A medium Hill-Ferguson anoscope can be placed at the completion to
help ensure anal stenosis is avoided.
Suggested Readings
Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and
Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon
Rectum. 2018;61(3):284-292.
Sohn VY, Martin MJ, Mullenix PS, Cuadrado DG, Place RJ, Steele SR. A comparison of open versus
closed techniques using the Harmonic Scalpel in outpatient hemorrhoid surgery. Mil Med.
2008;173(7):689-692.
Chapter 9
Anal Fissures: Lateral
Internal Sphincterotomy
JAMES S. WU
An anal fissure is a longitudinal tear in the anoderm of the anal canal that
exposes the internal sphincter and allows sphincter spasm when the area is
stimulated.
The majority of fissures are located in the midline (posterior > anterior) of
the anal slit (Fig. 9-1). Fissures located at lateral locations are atypical and
are associated with HIV infection, Crohn disease, syphilis, tuberculosis,
and hematologic malignancy.
FIGURE 9-1 Fissures most commonly occur at the posterior and anterior ends of the
anal slit (arrows).
Acute fissures (present for <8 weeks) appear as a longitudinal tear.

Fissures present for >8 weeks are classified as chronic; these may show a
“sentinel” skin tag at the distal end of the fissure and exposed internal anal
sphincter muscle.
First-line treatment generally is nonoperative and includes warm sitz
baths, psyllium fiber, topical anesthetics, topical nitrates, and topical
calcium channel blockers. Botulinum toxin injection and balloon dilation
are alternate therapies.
Operative treatments include lateral internal sphincterotomy, debridement,
and anoplasty.
History
A common presentation of anal fissure includes anal pain and bright red
anal bleeding associated with defecation.
Other benign causes of anal pain include abscess, external hemorrhoid
thrombosis; levator spasm; and coccygodynia.
Bleeding also can arise from internal hemorrhoids, neoplasm, and
inflammatory bowel disease.
Examination
Gentle lateral traction on the perianal skin may demonstrate a “sentinel”
pile and fissure.
If a fissure is not seen, gentle palpation of the distal anal canal with a well-
lubricated finger confirms the presence of a fissure and its location.
Because the internal anal sphincter is hypertonic and the area of the fissure
is tender, anoscopy may not be tolerated and can be omitted if the
diagnosis is established without it. Examples of fissure, shown in Figure
9-2, demonstrate a variety of appearances.
FIGURE 9-2 A. Chronic posterior anal fissure with exposed internal anal sphincter
(IAS). B. Chronic anterior anal fissure (arrows) with exposed IAS. C. Three simultaneous
posterior and posterolateral anal fissures, arrowheads depict the fissures. D. Acute anal
fissure caused by diarrhea during bowel preparation and seen during colonoscopy with
narrow-band imaging. E. Simultaneous anterior and posterior anal fissures.
LATERAL INTERNAL SPHINCTEROTOMY
Patient characteristics that might contraindicate division of the internal
sphincter are considered (Table 9-1).
TABLE 9-1 Preexisting conditions that might contraindicate division of the internal anal
sphincter
Preexisting fecal incontinence
Prior obstetric injury to the anal sphincter
Prior anal sphincterotomy
Prior anal fistulotomy
Betadine solution for skin preparation
Needle driver
Operating anoscope (lighted preferred; eg, Hill-Ferguson)
Lidocaine with epinephrine 0.5% and injection equipment for anal block
#15-blade (optional)
Electrocautery
Tonsil clamp
Forceps
3-0 Vicryl or chromic suture
Technique
The operation may be done under local or general anesthesia in the prone
jackknife or lithotomy positions using open or closed techniques.
The following examples were done under general anesthesia in the prone
jackknife position over an orthopedic frame with the buttocks separated
with 2-in adhesive tape using an open technique.
The prone position was chosen because it provides a clear view of the
operative field and allows an assistant to stand on the opposite site of the
table.
A preoperative bowel preparation was not administered. The perianal skin
and anus were prepared with topical antiseptics.
The anal orifice is enlarged with an operating anoscope. The presence of a
fissure or fissures is/are confirmed (Fig. 9-3). The internal sphincter
muscle is palpated.
FIGURE 9-3 Anoscopy with a lighted operating anal retractor identifies the fissure and
places the internal sphincter on stretch so that it can be palpated beneath the skin
(arrowheads).
Sphincterotomy in the anterior or posterior positions may result in a

“keyhole” deformity that may lead to incontinence. Therefore, the
anoscope is positioned to expose the lateral internal sphincter muscle.
Access to the internal anal sphincter is obtained through an incision in the
intersphincteric groove (Fig. 9-4).
FIGURE 9-4 A chronic posterior anal fissure with sentinel pile and exposed internal
sphincter. Hypertonicity of the internal sphincter accentuates the groove between the
internal and external sphincters.
The internal sphincter is isolated from the anoderm medially and the
intersphincteric groove laterally using a hemostat. The distal internal
sphincter is grasped with an Allis clamp, punctured with a curved tonsil
clamp, and elevated into the operative field (Fig. 9-5).
FIGURE 9-5 A. The white internal anal sphincter muscle has been grasped with an
Allis clamp. B. The distal internal sphincter muscle is punctured with a tonsil clamp and
elevated into the operative field.
The white fibers of the internal sphincter are divided under direct vision
with electrocautery (Fig. 9-6). The internal sphincter is divided for the
length of the fissure.
FIGURE 9-6 A. The internal anal sphincter (IAS) muscle is divided with electrocautery
under direct vision. B. The cut edges of the distal IAS are displayed.
Hemostasis is obtained, and the wound is left open or closed loosely. Tight
wound closure may lead to an abscess.
The surgical site is infiltrated with local anesthetic for postoperative pain
relief.
Postoperative Care
After surgery care includes:
Daily showers or baths to keep the surgical site clean
Analgesic medication
Time off from work
SUMMARY
Anal fissure is one of the most common ailments encountered by
colorectal surgeons. In 1951, Eisenhammer identified internal anal
sphincter contracture as a surgically correctable cause of chronic fissure
syndrome.
The internal anal sphincter is a continuation of the circular muscle of

the large bowel. It is therefore liable to a spastic contraction, the
greatest incidence appearing to exist in the anal canal. The structural
spastic changes have been referred to as chronic internal anal
contracture. The operation of internal anal sphincterotomy combined
with free dilatation appears to be a satisfactory method of correcting
this disability and restoring normal tone and expansibility to the anus.
This operation simplifies the surgery of the anal canal and especially
that for chronic fissure.
The percentage of sphincter necessary to be divided is not universally

agreed upon. Eisenhammer directed that “At least four-fifths of the
internal sphincter is divided.” Lesser degrees of division, “tailored
sphincterotomy,” in which the sphincterotomy is carried out only to the
apex of the fissure are used to reduce the rate of fecal incontinence.
Suggested Readings
Eisenhammer S. The surgical correction of chronic internal anal (sphincter-ic) contracture. S A Med J.
1951;25:486-489.
Nelson RL, Chattopadhyay A, Brooks W, Platt I, Paavana T, Earl S. Operative procedures for fissure
in ano (review). Cochrane Database Syst Rev. 2011;(11):CD002199.
Nelson RL, Thomas K, Morgan J, Jones A. Non-surgical therapy for anal fissure. Cochrane Database
Syst Rev. 2012;(2):CD003431.
Perry WB, Dykes SL, Buie WD, Rafferty JF. Practice parameters for the management of anal fissures
(3rd revision). Dis Colon Rectum. 2010;53:1110-1115.
Stewart DB Sr, Gaertner W, Glasgow S, Migaly J, Feingold D, Steele SRT. Clinical Practice Guideline
for the management of anal fissures. Dis Colon Rectum. 2017;60:7-14.
Chapter 10
Anoplasty for Anal Stenosis
MICHAEL A. VALENTE
Anal stenosis is most often the result of iatrogenic injury from an over
aggressive hemorrhoidectomy, in which too much anoderm is removed
(Fig. 10-1).
FIGURE 10-1 Severe anal stenosis secondary to hemorrhoidectomy.
Other causes of stenosis may include idiopathic, neoplasm, inflammatory

(Crohn), trauma, infectious, or after radiation.
Anoplasty techniques may also be utilized for cases of ectropion, anal
ulcer, fissure, fistula-in-ano, and after the excision of
premalignant/malignant anal lesions (ie, Paget disease, anal
dysplasia/carcinoma).
Other indications include when the anoderm is absent and replaced by
scar, most often following excision of anoderm during an operation.
Multiple flap configurations exist, and each type should be used based on
the etiology, size/location of the scar, anatomy, and surgeon preference
and skill.
Establish the etiology of the stenosis, as this will dictate operative
approach.
Suitability/condition of the perianal/gluteal tissues must be assessed.
The presence of Crohn disease, history of radiotherapy, prior attempts at
repair, and quality of gluteal skin must also be addressed before repair.
Delineate the location(s) and the extent of the stenosis.
The decision to create a unilateral versus bilateral flap repair is based on
the abovementioned information.
Maintain good plastic surgical principles:
Sharp dissection; little to no cautery
Broad-based flap with adequate blood supply
Mobility maximized by releasing the tethering attachments under the
donor site rather than aggressive dissection under the flap skin itself
The principle of anoplasty is to remove the scar, allow the anus to
occupy its full length, and then cover the unepithelialized anus with
epithelium, in other words, skin.
Operative Preparation
A full cathartic bowel preparation may be given on a case-by-case basis
depending on surgeon preference. We prefer a bowel preparation to clear
the colon and rectal of stool and to defer stool during early healing.
If not receiving a full bowel preparation, patients will receive two-fleet
enemas the morning of the procedure.
Venous thromboembolism prophylaxis is achieved with sequential
compression device and subcutaneous anticoagulation agents.
Intravenous antibiotic prophylaxis is given 1 hour prior to incision and
includes ceftriaxone 2 g and metronidazole 500 mg.
Foley catheter drainage is recommended for most cases.
Patient Positioning
Patients routinely undergo general endotracheal anesthesia while in the
supine position.
Once the airway is secured, the patient is flipped into the prone jackknife
position.
A large Kraske roll is utilized by being placed under the iliac crests to
properly elevate the buttock and perianal regions.
Exposure to the anus is accomplished by securing the buttocks bilaterally
to the operating room table with tape; care is taken to ensure adequate
gluteal retraction and exposure, but also that the tape allows for proper
access to the soft tissue needed for reconstruction.
The entire perineal and buttock regions are sterilely prepped and widely
draped.
Approach and Equipment

Needle-tip Bovie electrocautery pen
Indelible marking pen
3-0 absorbable suture (Vicryl or polydioxanone)
Local anesthetic (lidocaine without epinephrine)
Kraske roll
3 in adhesive tape
Lighted Hill-Ferguson anoscopes
Betadine prep for anal mucosa; alcohol-based prep for gluteal skin
Techniques for Anal Stenosis

Various types of anoplasty exist, including the house, diamond, U, or V-Y.
These are the most commonly performed anoplasty techniques for anal
stenosis. The technique of S-plasty is usually reserved for the most severe
strictures with extensive loss of anoderm.
For scarring that is >50% circumference, bilateral flaps may be needed. In
general, performing one side is acceptable initially, followed by the
contralateral side only if needed.
The goal of making a flap is to provide viable tissue to fill the defect that
is created by stricture excision and also allows for prevention of recurrent
cicatrix and contracture.
Flap Preparation and Scar Release

The flap lines are drawn with indelible marking pen (Fig. 10-2).
FIGURE 10-2 House flap.
A longitudinal incision is made proximal to the dentate line with a scalpel

to the perianal skin for the length of the stenosis. In cases where a house
flap is being utilized for a sizeable stenosis (dentate line to perianal skin),
a radial incision is also created inside the anal canal and on the anoderm
where the scar ends, in conjunction with the longitudinal incision to
completely release the large cicatrix (Fig. 10-3).
FIGURE 10-3 Indelible ink to mark out a diamond flap.
This cicatrix must be excised/removed, and the underlying anal sphincter

muscles must be preserved. The length of this initial incision will roughly
correspond to the length of the flap (Fig. 10-4).
FIGURE 10-4 Total removal of the cicatrix is imperative to the success of the flap.
The assurance that the chronic cicatrix is fully excised is of the utmost
importance for flap success.
The ability to suture the flap edges to a well-vascularized, scar-free area is
critical. There can be no inflamed or hardened tissue where the sutures
will lie inside the anal canal. This will undoubtedly lead to flap dehiscence
and failure.
A partial lateral internal sphincterotomy may also be performed at this
time. Some surgeons routinely perform sphincterotomy, and others feel it
is unnecessary; depending on the etiology and size of the stricture, internal
sphincterotomy should be performed on a case-by-case basis.
Flap Creation: Basic Steps

Regardless of the style of flap utilized, dissection begins sharply with a
#15 blade to incise the skin down to the subcutaneous tissue.
The flap is incised along the marked lines and then down into the anal
canal until normal mucosa is found.
The flap attachments are released by undermining under the edges of the
donor site. The dissection should slant obliquely outward and not inward
(Fig. 10-5).
FIGURE 10-5 The flap attachments are released by undermining under the edges of
the donor site. The dissection should slant obliquely outward and not inward.
This oblique dissection allows for a broad fat pedicle for the flap, ensuring
adequate perfusion.
The use of the cut current on the electrocautery is advised. Scalpel may
also be used.
Aggressive coagulation with the electrocautery is strongly discouraged for
flap mobilization as this leads to tissue necrosis, breakdown, and resultant
infection.
Once the apex of the flap is released laterally on the buttock, the island of
tissue should very easily “fall into” the anoderm on its own (Fig. 10-6).
FIGURE 10-6 Flap easily advancing into the anal canal with minimal to no tension.
Care is taken of the wound edges at all times during the procedure.
There should be no tension when the flap slides into the anal canal.
Securing the Flap

The advanced pedicle is sewn into place. 3-0 absorbable suture in simple
interrupted manner about 2-3 cm apart is the preferred method for the anal
canal stitches (Fig. 10-7).
FIGURE 10-7 The flap is sewn into the anal canal with simple interrupted 3-0
absorbable suture.
The suture should be placed through the skin and subcuticular layer of the
flap and the full thickness of the donor skin to maintain a good blood
supply and to not tear the flap skin.
The donor site is closed with simple interrupted or horizontal mattress
sutures. The donor site is, therefore, closed in a linear manner (Fig. 10-8).
FIGURE 10-8 The donor site is, therefore, closed in a linear manner with simple
interrupted 3-0 absorbable suture.
SPECIFIC FLAP CONFIGURATIONS
Y-V or V-Y Flap

The Y-V or V-V anoplasties have been classically used for replacement of
anoderm for a short segment stenosis at and below the dentate line with
associated mucosal ectropion. They can be performed in any quadrant and
are usually performed unilaterally, but also can be done in a bilateral
manner.
Y-V: After an anatomy is created over the stricture, the incision is then
carried into the perianal sin/buttock in a Y shape for 5-8 cm for both limbs
(Fig. 10-9). The resultant V flap is advanced into the anal canal; the tip of
the flap is sutured to the anorectal mucosa (dentate line) and internal
sphincter muscle.
FIGURE 10-9 Y-V flap.
V-Y: An alternative to Y-V, the advanced portion is wider and may have
less ischemia and necrosis (Fig. 10-10).
FIGURE 10-10 V-Y flap.
The Y-V and V-Y varieties of anoplasty flaps are not ideal for stenosis
that is proximal to dentate line, due to the limited mobility that they offer.
In order to bring the flaps more proximal to the dente line, a high degree
of tension will ensue. Additionally, the Y-V has a narrow proximal
component that is prone to ischemia.
House Flap
The house flap is utilized for moderate-to-long anal stenosis and can
accommodate proximal and distal stenosis in any all quadrants, including
circumferential involvement (Fig. 10-2).
Additionally, the house flap increases the anal canal diameter and
advances very easily into the proximal anal canal. The house flap has a
broad base, which avoids the pitfall of having a narrow apex, which may
lead to ischemia/necrosis.
The donor site is closed primarily, helping the flap to stay in the anal canal
without tension.
Diamond Flap
The diamond flap is ideally suited for moderate-to-severe stenosis, which
is mostly intra-anal and above the dentate line.
After incising the scar, a diamond defect is left behind (Fig. 10-11).
Bilateral flaps may be utilized based on the severity of the stenosis.
FIGURE 10-11 Diamond flap.
Similar to the house flap, the donor site is closed in a linear manner,
helping the flap to keep in the anal canal without undue tension.
Limited undermining of the diamond flap will preserve the vascular
integrity of the flap.
U Flap
The U flap is similar to the abovementioned flaps, but the donor site is left
open to granulate in secondarily (Fig. 10-12).
FIGURE 10-12 U flap.
This flap is especially valuable when there is a large amount of mucosal

ectropion to be excised among with the stenosis.
Rotational S Flap
The S flap is reserved for the most severe stenosis, which is usually
located high in the anorectum and circumferentially located onto the
perianal skin.
When there is a large amount of anoderm removed, as in a Whitehead
deformity after an injudicious hemorrhoidectomy, this flap is well suited.
After the scar is circumferentially excised, full-thickness S-shaped flaps
are made in the perianal skin, with the size of the base as great as its
length.
Incision starts from the dentate line to about 8-10 cm long (Fig. 10-13).
The flaps are rotated and sutured to the normal anal mucosa.
FIGURE 10-13 Rotational S-plasty. Point A should be brought to A’ and B to B’ during

closure.
This is a complex technique with associated high morbidity and longer

hospital stay.
PEARLS AND PITFALLS
Always draw the flap out larger than one may think is necessary. The
flap may look bulky at first, but they shrink in size considerably after
mobilization. It is easier to work with a flap that may be a few
centimeters too big than a few centimeters too small. If the flap is too
small, the stenosis will not be corrected and bilateral flaps will most
likely be needed.
Do not undermine the flap; always slant in an outward direction while
mobilizing.
Tension will cause the flap to become ischemic and necrotic and
potentially fail.
The scar must be excised entirely if a flap is going to be sutured in its
place.
Most often, unilateral approach is the initial step in correction of the
stenosis; bilateral flaps should be reserved for the most severe stenosis
and/or for failures.
A medium Hill-Ferguson anoscope should be easily placed into the anus
at the completion of the anosplasty; if this cannot be achieved, strong
consideration should be made for a bilateral flap (Fig. 10-14).
FIGURE 10-14 A medium Hill-Ferguson anoscope should be easily placed into the
anus at the completion of the anosplasty; if this cannot be achieved, strong
consideration should be made for a bilateral flap.
Postoperative Care
Limit the activity and direct pressure on the flap for at least 1 week after
surgery.
Many patients can have outpatient surgery, but some will need at least 1-2
days in the hospital.
Oral antibiotics should be given for up to 1 week postoperatively to
decrease the risk of infection.
Infection and separation of the flap is not uncommon; antibiotics may help
reduce this risk.
Timely examination under anesthesia may be required for debridement of
affected tissues in the early postoperative period if infection is present.
Donor site separation is common and should be allowed to granulate in
with secondary intention.
Patients should be followed in the office after the operation until full
healing is achieved.
Diabetics, smokers, and previous radiation portend the worst outcomes in
terms of wound healing and overall success.
Suggested Readings
Feingold DL, Lee-Kong SA. Anal fissure and anal stenosis. In: Beck DE, Steele SR, Wexner SD, eds.
Fundamentals of Anorectal Surgery. 3rd ed. Philadelphia, PA: Springer Publishers; 2019:241-
255.
Lagares-Garcia JA, Nogueras JJ. Anal stenosis and mucosal ectropion. Surg Clin North Am.
2002;82(6):1225-1231.
Milsom JW, MAzier WP. Classification and management of postsurgical anal stenosis. Surg Gynecol
Obstet. 1986;163(1):60-64.
Chapter 11
Anorectal Abscess
VLADIMIR BOLSHINSKY
JOSEPH TRUNZO
Principles of Dealing with Perianal Sepsis

Irrespective of the complexity of perianal sepsis and potential associated
fistula tracts, the initial step in the management of all patients is the same.
After obtaining a history and performing examination, either in the office
or emergency setting, the patient is required to undergo an examination
under anesthesia (EUA).
In the elective setting, a magnetic resonance imaging (MRI) of the
perineum is sometimes helpful to further delineate the site of pelvic sepsis
in cases with complex and multiple tracts. We prefer MRI to endoanal
ultrasound due to its quality and interpretation that are more reproducible.
In the acute setting, most anorectal sepsis can be recognized on clinical
examination, though a computed tomography (CT) can be useful to aid in
deep space abscesses preoperatively. Acute abscesses most often simply
need drainage, often done in the office under local anesthesia, with no
MRI or added imaging at all.
Multiple EUAs may be required to adequately gain source control.
Half of perianal abscesses become fistulas. Classically, in a case of a
simple cryptoglandular anorectal abscess, there is one abscess and one
tract leading to a single internal opening. Goodsall rule (Fig 11-1) can be
used to predict the internal opening and trajectory of the fistula tract based
on the location of the external opening.
FIGURE 11-1 Goodsall rule.
Understanding of the anatomy of the postanal space and appreciation of

horseshoe abscess extensions due to the communication within the
supralevator, ischioanal, and intersphincteric compartments are essential
when dealing with complex anorectal sepsis (Fig. 11-2).
FIGURE 11-2 Sites of anorectal abscesses.
Equipment used for anorectal cases includes:
Set of fiberoptic-lighted Hill-Ferguson retractors: small, medium, and
large
This is used for all perianal cases placed in lithotomy position.
Set of fiberoptic-lighted Fansler retractors: small, medium, and large
This is selectively used for perianal cases placed in prone (Kraske)
position.
Set of Lockhart-Mummery fistula probes
Set of curettes
Vessel loops (to be used as seton)
Monopolar electrocautery
We routinely use 40 cut with 60 coagulation settings
A selection of Pezzer (ie, mushroom) drains
A selection of Penrose drains
Hydrogen peroxide
Technique
Positioning
The default position to perform an examination of the perineum and
drainage of anorectal sepsis is in lithotomy with buttocks overhanging the
edge of the operating table.
Prone jackknife position may be used for selected cases, although this is
typically of most benefit for addressing anorectal fistulas with an anterior
internal opening.
Examination under Anesthesia

Following appropriate positioning, the examination is commenced by
close inspection of the perineum.
This may reveal undrained sepsis, previous scars, and external
openings.
The clinician then proceeds to a digital rectal examination and an
anoscopy. Our preferred retractor is a fiberoptic-lighted Hill-Ferguson
with lubricant applied only to its convex surface.
Some surgeons prefer to do an anoscopy prior to digital rectal
examination. A “bead of pus” from an anal crypt at the site of the dentate
line may be the only sign of an internal opening.
Sepsis in the deep postanal space may present without a visible abscess, or
an identifiable internal opening. Posterior fullness on digital rectal
examination may alert an astute examiner. A presacral tumor should be
remembered as a differential in such a scenario. Ultrasound or MRI
imaging and not aspiration is required in this setting.
PEARLS AND PITFALLS
Be mindful of Crohn disease, pilonidal cyst, and hidradenitis

suppurativa as etiologies that may be mascarading as benign external
openings of an anal fistula. Furthermore, an internal opening not located
at the dentate line should warrant suspicion for Crohn disease,
iatrogenic injury, or malignancy. Management of these conditions is
described in the appropriate chapters of this textbook.
Specific Considerations in the Management of Anorectal

Abscess
Role of Antibiotics
We do not routinely give postoperative antibiotics, but consider treatment
in patients who are immunocompromised, diabetic, or have associated
cellulitis.
Optimal drainage should typically preclude the need for antibiotics in the
absence of above.
In persistent cellulitis, consider the potential for undrained sepsis or
another process.
Identification of a Fistula at the Time of Abscess

Drainage
We do not probe the abscess cavity to identify a possible fistula in an
index anorectal abscess, as we feel that the rate of iatrogenic fistula tract
formation is underreported.
However, if, during anoscopy, there is purulent discharge into the anal
canal from a crypt, one can assume a patent fistula tract is present, and we
will then attempt to control the tract with a seton.
For recurrent abscesses, a careful probe may also aid in identification of a
fistula, though we stress outmost caution.
Perianal and Ischioanal (Also Known as Ischiorectal)

Abscess
Draining an acute abscess or cavity is essential. Principles include
minimizing the distance from incision to the anal verge (with view of
shorter fistulas being less challenging to manage).
Superficial cavities can be drained with a cruciate (with excision of
corners) or elliptical incision.
Aspiration of abscess with a medium- to large-bore needle may confirm
the presence of an abscess in a patient with erythema, but without
fluctuance.
A culture of enteric organisms from the abscess cavity, as compared to a
growth of cutaneous organisms, can aid in delineating the origin of the
pathology that precipitated the abscess.
Deep cavities are drained with the aid of a mushroom-type drain. We
rarely utilize wound packing in this treatment algorithm (Fig. 11-3).
Our preferred drain is a “Pezzer” catheter, with two extra openings
being cut prior to insertion. We find that “Malecot” catheters are more
likely to get dislodged.
FIGURE 11-3 Mushroom drain into ischioanal abscess. Seton positioned through
transsphincteric fistula tract.
Typically, drains are left for 7-10 days and removed during a
postoperative visit in the office.
PEARLS AND PITFALLS
Use of a fine needle may prove ineffective where purulent fluid is most
often quite viscous.
Submucosal Abscess
Drain into the rectum using diathermy.
Intersphincteric Abscess
These abscesses are infrequent. Patients typically report perianal pain and
may develop fevers.
This abscess is drained in combination with an internal sphincterotomy.
Supralevator Abscess
A supralevator abscess may be due to an intersphincteric abscess tracking
cranially (ie, cryptoglandular origin) or a pelvic abscess (ie, diverticulitis)
tracking caudally.
Differentiating the origin is essential, as source control dictates subsequent
management. One way to think about this from the perianal source, is
picturing the origin of a fistula via Park’s classification (Fig. 11-4).
An abscess of cryptoglandular origin may be treated with a
combination of sphincterotomy and mushroom-type drainage.
FIGURE 11-4 Park classification of anorectal fistulas. A. Intersphincteric (type I).

B. Transsphincteric (type II). C. Suprasphincteric (type III). D. Extrasphincteric (type
IV).
An abscess with a pelvic origin may require transabdominal drainage.

In severe cases, source control may only be obtained with the aid of a
temporary ostomy.
Deep Anterior or Posterior Anal Space and Horseshoe

Abscess
These are infrequent, yet very complex clinical situations.
The most common of these anal space infections is an abscess in the deep
postanal space. This is a potential space bordered by the levator ani
muscles, anococcygeal ligament, external sphincter, and sacrum, which
communicates with the ischioanal fossae (Fig. 11-5).
FIGURE 11-5 Sagittal view of posterior cavities.
CT imaging preoperatively in these cases is helpful in making the

diagnosis and establishing the extent of disease (Figs. 11-6 and 11-7).
FIGURE 11-6 Axial computed tomography imaging of horseshoe abscess. Arrows
indicate the abscess.
FIGURE 11-7 Sagittal computed tomography of horseshoe abscess demonstrating
extension into deep postanal space. Note the abscess in respect to coccyx. Arrows
indicate the abscess.
The causative anorectal pathology is typically an internal opening at the

posterior midline with an associated deep postanal abscess and
anterolateral extensions on either side of the anus.
Posterior superficial and anterior horseshoe fistulas can occur, but are very
infrequent. The principles of management of all horseshoe fistulas involve
drainage of sepsis using counterincisions (Fig. 11-8).
FIGURE 11-8 Horseshoe fistula with seton in place.
Technique
Position the patient in lithotomy, as the source of this anorectal abscess is
typically a posterior midline internal opening at the dentate line.
If external openings are seen over the anterolateral extensions, enlarge
and define the trajectory of the tracts using Lockhart-Mummery fistula
probes. Typically, these extensions will communicate posteriorly from
both sides.
Create a skin incision along the midline, just posterior to the sphincter
complex. One must traverse the anococcygeal ligament in the posterior
midline to enter and adequately drain the deep postanal space. A long
hypodermic needle on a syringe for aspiration can aid in identifying the
posterior cavity prior to making your incision.
Horseshoe fistulas have external openings. In horseshoe abscesses, no
anterolateral openings exist. Pass a Kelly clamp from your posterior
incision through the deep postanal space into the ischioanal fossa
laterally. Counterincisions over the anterolateral extension are now
made at the tip of the Kelly clamp. A silk tie is used to control the
tracts. This is performed unilaterally in a hemi-horseshoe or bilaterally
in a classic horseshoe (Figs. 11-9 and 11-10).
FIGURE 11-9 Kelly clamp inserted into deep postanal space into ischioanal fossa.
FIGURE 11-10 Bilateral extensions controlled through counterincisions.
If anterolateral external openings do exist, connect them to your

posterior incision.
After draining and irrigating the abscess cavities, curette all the fistula
tracts.
Passing an unrolled gauze square from the midline counterincision
to the anterolateral external opening via the tract is a helpful
debridement technique.
Place Penrose drains (1/4 in preferably) from the external opening to
the counterincision and secure as one would loop a seton. We find that
the Penrose drains that are secured through the counterincision aid in
decompression and reduction of the postanal space cavity (Fig. 11-11).
FIGURE 11-11 Penrose placed through bilateral counterincisions.
If the internal opening is identified, place a medium-sized vessel loop

from the internal opening to the posterior midline incision and secure as
a seton.
Postoperative Care
After resolution of the acute sepsis (usually in 2-4 weeks), we reassess the
perineum in the office. At this time, we typically remove one of the
counterincision Penrose drains. The second counterincision Penrose would
be removed ∼2 weeks following. At times, these tracts will remain open or
partially opened and would need curettage of granulation tissue at the
definitive repair of the fistula at the second stage.
Second stage closure of the fistula can be managed using anorectal
advancement flap or ligation of intersphincteric fistula tract (LIFT). A
cutting seton may also be considered when there is failure of those
techniques (Fig. 11-12). Refer to Chapter 12 for more on the LIFT
procedure.
FIGURE 11-12 Arrows mark healed counterincisions. Seton remains in posterior
midline fistula in preparation for definitive repair (prone position for planned ligation of
intersphincteric fistula tract procedure).
Alternatively, a modified Hanley procedure can be used, although this is

not typically done in our practice.
Suggested Reading
Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal
abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2016;59(12):1117-1133.
Chapter 12
Complex Anorectal Fistulas
VLADIMIR BOLSHINSKY
STEFAN HOLUBAR
Fistulas are characterized based on their relationship with the anal
sphincter: intersphincteric, transsphincteric, suprasphincteric, and
extrasphincteric (Fig. 12-1).
FIGURE 12-1 Anorectal fistula types: (A) intersphincteric (type I); (B) transsphincteric
(type II); (C) suprasphincteric (type III); and (D) extrasphincteric (type IV).
Determining the anatomy of each unique fistula is critical to maximizing
healing and minimizing problems with continence. This may involve:
Examination under anesthesia
Magnetic resonance imaging
Ultrasound
A general “rule of thumb” dictates that it is typically safe to divide <one-
third the length of the sphincter. Despite this, decreased continence may
occur even when division of the sphincter met this condition, and patients
should be counseled accordingly.
Care must be taken for those with prior anorectal surgery, Crohn disease,
baseline decreased continence, anterior fistula in women, and other
conditions where division of the sphincter may lead to further
deterioration in continence.
Patients should be aware that multiple operations may be required to
ultimately allow fistulae to heal.
Asymptomatic fistula may be surveilled without any operative
intervention.
Equipment used for anorectal cases are as follows:
Anal retractors, fiberoptic lighted: small, medium, and large
Hill-Ferguson retractors (Fig. 12-2): often used for perianal cases
placed in lithotomy position (Fig. 12-3)
FIGURE 12-2 Hill-Ferguson lighted anoscopes of various sizes.
FIGURE 12-3 Lithotomy position.
Fansler retractors (Fig. 12-4): small, used selectively for perianal cases
such as those placed in prone (ie, Kraske) position (Fig. 12-5A and B)
or those with large redundant mucosa
FIGURE 12-4 Fansler lighted anoscope.
FIGURE 12-5 A. Operating room table setup with padding for the patient in prone
(ie, Kraske) position. B. Kraske position on the operating room table.
Pratt bivalve anal retractor (Fig. 12-6)
FIGURE 12-6 Pratt bivalve anoscope.
Right-angle retractors
Set of Lockhart-Mummery fistula probes (Fig. 12-7)
FIGURE 12-7 Set of Lockhart-Mummery fistula probes.
Set of curettes (Fig. 12-8)

FIGURE 12-8 Set of curettes to debride the tract.
00-silk ties
Silicon, radio-opaque yellow (mini) vessel loop, 1.3 mm wide and 0.9 mm
thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick (Fig. 12-9)
FIGURE 12-9 Silicon vessel loop for draining seton.
We routinely use 40 cut/60 coagulation settings, pure or blend
A needle tip may be used for endorectal advancement flap (ERAF)
Pezzer (mushroom) drains, size ranging from 10 to 32Fr (Fig. 12-10)
FIGURE 12-10 Pezzer (ie, mushroom) drains, size ranging from 10 to 32Fr.
¼ and ½ in Penrose drains

Hydrogen peroxide diluted 50-50 with sterile normal saline, placed in a
10-mL syringe with a 14-gauge angiocatheter or a blunt-tip needle
Positioning
Positioning of the patient is dependent on the site of the internal opening,
with prone jackknife being optimal for anterior internal opening and
lithotomy for fistulas with a posterior internal opening.
In lithotomy (Fig. 12-2):
Emphasis on ergonomics cannot be understated. The edge of the
operating table may need to be moved in the caudal direction, to
ensure that the chair and feet of the operating surgeon are not
restricted by the base of the operating table. In addition, the patient’s
buttocks overhanging the edge of the operating table.
In prone jackknife:
We place two shoulder rolls under the chest (taking special care to
protect the breasts) and a foam pillow (Kraske roll) under the pelvis
(taking special care to protect the genitals from pressure injury) (Fig.
12-4A).
We typically secure the patient with a belt to prevent inadvertent
rolling (Fig. 12-4bB).
We use tape to laterally retract the buttocks, with or without
benzoin.
Excessive tape traction will result in iatrogenic tearing (fissuring) of the
anoderm—avoid.
Setons
Draining setons are used as a bridge to definitive repair (commonly
performed 6 weeks after insertion), or as semi-permanent drainage for
refractory fistulas or where definitive repair is contraindicated (eg, severe
perianal Crohn disease).
If the seton breaks and falls out, and the track is completely epithelialized,
it may not need to be replaced. However, the patient should be informed
of the risk of abscess and recurrent symptomatic fistula, heralded by a
change in symptoms such as pain or increased drainage, respectively.
Cutting setons may be used as a “slow fistulotomy” in selected cases. This
is rarely indicated.
Technique
Draining Seton
A standard perianal block is performed (Fig. 12-11) by identification of
the pudendal nerve as it traverses by the ischial tuberosity. Additional
perianal anesthetic may be placed around the sphincter complex itself.
FIGURE 12-11 Perianal block using local anesthesia.
Having identified the track using the Lockhart-Mummery fistula probes,

we secure a 00-silk tightly onto the probe and then sequentially exchange
this for an 00-silk tie and a yellow vessel loop (Fig. 12-12).
The yellow vessel loop is the smallest size to ensure adequate drainage
and is well tolerated by the patients.
FIGURE 12-12 Draining seton in place using a silastic vessel loop.
Place a hemostat on each end of the vessel loops for traction.

We overlap the two ends of the seton and assess tension.
The draining seton needs to be flat/tight enough to prevent difficulty
toileting and chafing, but loose enough to avoid skin erosion.
The correct amount of tension typically corresponds to a surgeon’s
fingertip inserted between the seton and the skin.
As the seton typically springs back after it is secured, the elastic
properties of the vessel loop need to be considered when securing it in
place.
We secure the seton by overlapping the two ends of the vessel loop with a
surgeon’s knot and an additional throw of a silk tie in a square formation
(Fig. 12-13). The knots are kept flat, and the ends of the suture and tubing
are cut short to reduce potential patient discomfort (Fig. 12-14).
If the knots are tied with excessive pressure, they may cut through the
vessel loop.
FIGURE 12-13 Different methods of securing the ends of the draining seton.
FIGURE 12-14 Two views of draining setons in place the ends overlapping and
tied together with low-profile knots.
Two yellow vessel loop setons, a blue vessel loop, or a ¼ in (rarely ½ in)
Penrose drain may be utilized for drainage of a wider caliber tracks.
Additional examinations under anesthesia and debridement may be
required in these cases.
A commercially available Comfort Drain (A.M.I. Inc.) is a knot-free ring
and may be utilized to form a draining seton. This device avoids the need
to overlap the tubing and silk ties and their knots. The smaller diameter of
the Comfort Drain tubing raises concerns of inadequate drainage. We do
not typically use this product.
Cutting Seton
As stated earlier, we rarely use cutting setons, and they should be used
only in very selected cases that either have failed other methods or have
unique conditions to warrant implementation.
They are associated with a higher rate of changes in continence and
should be especially avoided in patients deemed at risk.
The theory behind a cutting seton is that it gradually erodes through the
sphincter, allowing fibrosis to take place above it along the path (the
analogy of a hot knife slicing through a block of ice, with the ice re-
forming from top down as the knife advances down).
In such cases, a “draining” seton can be converted to a cutting seton in
the clinic as long as next step is performed.
Following identification of the track, the skin and subcutaneous tissue are
divided (as in left panel, Fig. 12-15) down to the level of the sphincter
muscle.
FIGURE 12-15 Division of the skin and subcutaneous tract with seton in place
through the fistula.
The superficial aspect of the wound may be saucerized to prevent the skin
healing over the top of the seton.
The seton is tied tightly around the muscle. We prefer to use a yellow
vessel loop rather than a silk tie, as the elasticity of the vessel loop enables
easier tightening. The two ends of the vessel loop are placed under tension
using a hemostat. A silk tie is applied to approximate the seton.
The vessel loop configuration is different from the draining seton (Fig.
12-13), with the two ends of the vessel loop secured to each other in a
parallel manner.
The cutting seton is adjusted weekly or every other week in the clinic.
This is performed by putting traction on the two ends of the vessel loop
and tying proximal to the previous knot. Some surgeons use a hemorrhoid
rubber band instead of a proximal silk tie.
Fistulotomy
This technique has the highest cure rate for fistula-in-ano of
cryptoglandular origin.
It is the preferred option for an intersphincteric fistula.
For a transsphincteric fistula, the role of fistulotomy is more controversial.
In a young male with a low, posterior transsphincteric fistula, a
fistulotomy will result in a high degree of success and a low risk of
incontinence.
For certain populations, this should be used with caution. For example, in
a high transsphincteric fistula or an anterior transsphincteric fistula in a
female with a compromised sphincter due to a prior vaginal delivery, a
fistulotomy may result in incontinence, potentially irreparable.
Care should be taken when performing a posterior midline fistulotomy
with a long track resulting from a fistula-in-ano as a keyhole deformity
may result.
PEARLS AND PITFALLS
The anal sphincter is of different length in both men and women, and
the muscle bulk is significantly more deficient anteriorly in women.
Previous obstetric injuries, perianal sepsis, and anorectal surgery may
have further reduced muscular reserve of the anal sphincter. Likewise,
proceed with caution in patients who have previously had a fistulotomy
or sphincterotomy; these patients may benefit from preoperative
assessment with anorectal manometry, endoanal ultrasound, and
consideration of a cutting seton, flap, or ligation of intersphincteric
fistula tract (LIFT) procedure.
Technique
Following reassessment of sphincter involvement, a Lockhart-Mummery
fistula probe is inserted into in fistula track (Fig. 12-16). This is typically
performed by exchanging the seton for the probe with the use of a silk tie.
FIGURE 12-16 Fistulotomy with passing of the probe and dividing some of the lower
sphincter muscle.
After passing the probe through the entirety of the track, bending the tip of
the probe prevents it from falling out (Fig. 12-17).
FIGURE 12-17 Deeper dissection to the level of the muscle in the fistulotomy tract.
We perform the fistulotomy with electrocautery by dissecting onto the

probe (Fig. 12-18).
FIGURE 12-18 Completed opening of the fistula tract.
The tract is then curetted and left open; we do not pack the wound
routinely.
Suspicious tissue should be biopsied and sent for histologic examination.
In the case of large defects, the wound edges may be marsupialized (Fig.
12-19).
The superficial aspect of the wound is saucerized to prevent a
recurrence of a subcutaneous fistula.
FIGURE 12-19 Marsupialization of the tract, typically with 3-0 chromic or Vicryl
sutures.
ENDORECTAL ADVANCEMENT FLAP
We offer this procedure for patients with a higher transsphincteric fistula,
suprasphincteric fistula, or extrasphincteric fistula, where fistulotomy is
not suitable.
It may also be needed to manage the internal opening of a horseshoe
fistula following appropriate control of sepsis.
Patients are scheduled for fistula repair a minimum of 6 weeks after
draining seton insertion, which we consider a mandatory precondition
for ERAF.
The day before surgery, the patients undergo a full cathartic bowel
preparation with oral antibiotics.
Prophylactic intravenous antibiotics are given.
We avoid using a narrow “U-shaped” flap as these are more likely to
become ischemic. We believe that broad-based symmetrical flaps
distribute the tension better, reduce ischemia, and are a contributor to
improved results (Fig. 12-20).
FIGURE 12-20 Endorectal advancement flap.
Note: Flaps can be mucosal, of partial thickness, or of full thickness. We

prefer to include some muscle in the flap.
Positioning
Positioning of the patient is dependent on the site of the internal opening,
with Kraske being optimal for anterior internal opening (ie, rectovaginal
fistulae) and lithotomy for fistulas with a posterior internal opening.
A fiberoptic-lighted Hill-Ferguson retractor is used to visualize the
pathology.
A Pratt bivalve retractor may also be used, as previously mentioned.
Technique
The procedure is commenced by removal of the seton and circumferential
excision of the internal opening with electrocautery (Fig. 12-21).
FIGURE 12-21 Endorectal advancement flap. Circumcise and de-epithelialize the
internal opening.
The track is de-epithelialized with use of a cervical brush or small curette,

followed by 50% dilute H2O2.
The site of excision is extended laterally 7 mm on either side of the
internal opening (Fig. 12-22).
FIGURE 12-22 Endorectal advancement flap. Create a transverse, partial-thickness
flap for approximately 5 mm.
Traditionally, two horizontal, full-thickness broad-based flaps are raised

(one proximal and one distal to the incision), approximately 1 cm deep.
An alternative is to use a broad-based semicircular proximal full-thickness
flap.
The internal opening is closed with interrupted 2-0 absorbable sutures on
an UR-6 needle (Fig. 12-23). The needle is grasped at the back near the
suture, at a 45-degree angle to provide maximal articulation and curve of
the needle for deep bites until closed (Fig. 12-24).
FIGURE 12-23 Endorectal advancement flap. Close the internal opening as it passes
through the internal sphincter with a series of interrupted sutures (eg, 2-0 Vicryl). Tip: Take
big bites.
FIGURE 12-24 Endorectal advancement flap. Muscle layer closed.

Integrity of the repair is leak tested by injecting fluid into the external
opening. We use the plastic sheath from a 14- to 16-gauge cannula
attached to a 10-mL syringe of normal saline of 50% dilute H2O2.
Alternatively saline can be used alone, although H2O2 may demonstrate
subtle openings.
The partial-thickness flaps are closed, ablating the dead space with
interrupted 2-0 absorbable sutures (Fig. 12-25A-C). We prefer to use a
UR-6 semicircular, strong needle.
FIGURE 12-25 Endorectal advancement flap. A. Mucosa being closed. B. Stitches in

place. C. Repair complete.
Depending on the length of the track, the external opening is either left
widely open (ie, enlarged) or drained with a mushroom catheter for 7-10
days.
Postoperative Care
Typically, patients are discharged the same day.
Patients are discharged with a week of oral antibiotics and are informed
that drainage from the external opening is expected for up to 6 weeks.
LIGATION OF INTERSPHINCTERIC FISTULA TRACT
This procedure was described in 2007 by Rojanasakul et al. from
Bangkok, Thailand, for similar indications as an ERAF.
The pre- and postoperative management of this may be interchangeable
with that of an ERAF, which presently is preferred at our institution,
although the use of LIFT procedure is increasing.
An indwelling draining seton for 6 weeks is typically a prerequisite.
In the case of LIFT for transsphincteric fistulae, patients are advised that
the success rate is approximately 50%, but in the event of failure, half
(50%) of the failure will recur as an intersphincteric fistula, which would
then be amenable to fistulotomy in many cases.
PEARLS AND PITFALLS
Particularly in women, performing a LIFT procedure for an anterior

fistula is extremely difficult. The external anal sphincter is deficient in
women, so the surgeon is likely to misidentify the plane and dissect
between the external sphincter and the vagina.
Positioning
Positioning of the patient is dependent on site of internal opening, with
Kraske position being optimal for anterior internal opening and lithotomy
for fistulas with a posterior internal opening.
A Lone Star Retractor System (Cooper Surgical, Trumbull, CT) may aid
in exposure of the intersphincteric grove. If unavailable, we find that 00-
silk effacement sutures are an acceptable alternative.
Technique
The procedure is commenced by exchanging the indwelling draining seton
for the probe with the help of a silk tie.
The probe is secured by bending the tip.
The track is de-epithelialized with use of a curette or cervical brush
(preferred), followed by 50% dilute H2O2.
A curvilinear incision is made at the perianal region, just outside the
intersphincteric groove (Fig. 12-26).
This incision is similar to that of an open lateral internal
sphincterotomy although larger.
FIGURE 12-26 Ligation of intersphincteric fistula tract. Entering the
intersphincteric groove and the tract is dissected free.
A 2-cm length is commonly quoted, though this is related to the

anatomy of buttocks and size/height/length of the fistula/anal verge and
depth of the anal canal.
Gentle cephalad dissection in the bloodless intersphincteric groove is
carried out with a hemostat, tonsil, or right-angle clamp.
We place more emphasis on protecting the “white” fibers of the internal
sphincter, minimizing risk of an iatrogenic injury to the anal mucosa,
than the “red” fibers of the external sphincter.
Having a fistula probe in the tract aids in its identifications, and
circumferential dissection, with an aid of a fine-tipped right-angle clamp.
Having isolated the tract, we remove the probe, suture ligate both ends of
the fistula within the intersphincteric groove with 4-0 absorbable suture
(Fig. 12-27).
FIGURE 12-27 Ligation of intersphincteric fistula tract. Suture ligation of the tract.
The tract is then divided with a #15 blade (Fig. 12-28).

We find that there is a risk of the knots being dislodged if the track is
tied, as opposed to suture ligated.
FIGURE 12-28 Ligation of intersphincteric fistula tract. Division of the tract.
Integrity of the repair is confirmed by injecting normal saline or dilute

H2O2 into the external opening.
The intersphincteric incision is approximated with 3-0 absorbable vertical
mattress sutures.
Depending on the length of the track, the external opening is either left
widely open or drained with a mushroom catheter for 7-10 days.
OTHER PROCEDURES
Note: Other procedures that supplement the techniques described in this

chapter may be found in the following chapters:
Dermal advancement flap, Chapter 10 (Anoplasty for Anal Stenosis)
Modified Hanley procedure, Chapter 11 (Incision and Drainage of
Perirectal Sepsis)
Gracilis and Martius (ie, bulbocavernosus) flaps, Chapter 14
(Rectovaginal Fistula)
Rectourethral fistula, Chapter 15 (Perineal Repair of Rectourethral
Fistula)
Crohn perianal disease, Chapter 16 (Perianal Symptoms in Patients
with Crohn Disease)
Turnbull-Cutait, Chapter 20 (Turnbull-Cutait Abdominoperineal Pull
Through with Delayed Colo-Anal Anastomosis)
Laparoscopic diverting loop ileostomy, Chapter 41 (Abdominal Crohn
Disease: Surgical Management)
The following procedures are not described as they have essentially been
abandoned due to lack of efficacy.
Fibrin glue
Fistula plug
Suggested Readings
Bolshinsky V, Church J. How to insert a draining seton correctly. Dis Colon Rectum. 2018;61(9):1121-
1123.
Causey MW, Nelson D, Johnson EK, et al. A NSQIP evaluation of practice patterns and outcomes
following surgery for anorectal abscess and fistula in patients with and without Crohn’s
disease. Gastroenterol Rep. 2013;1(1):58-63.
Vogel JD, Johnson EK, Morris AM, et al. Clinical practice guideline for the management of anorectal
abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2016;59(12):1117-1133.
Chapter 13
Hidradenitis Suppurativa
ANURADHA R. BHAMA
SCOTT R. STEELE
The prevalence of hidradenitis suppurativa (HS) is 0.1%-4% worldwide,
with the mean age of onset 20-24 years.
Multiple risk factors are known for HS.
Cigarette smoking and obesity
Dietary triggers including dairy products and highly refined simple
carbohydrates
The anal region is the second most commonly involved area after the
axilla; ∼30%-50% of patients with HS have perianal lesions as a location
of their disease (Fig. 13-1).
FIGURE 13-1 Severe hidradenitis disease in the perianal and groin.
A number of comorbid conditions can be present in patients with HS.

Acne
Inflammatory bowel disease
Spondyloarthropathy
Genetic keratin disorders
Squamous cell cancer
Local and small lesions can benefit from medical treatment, but recurrence
rates are high.
Antibiotics
Topical (eg, clindamycin)
Oral (eg, tetracycline, clindamycin, rifampin)
Monoclonal antibodies (eg, adalimumab, infliximab)
Indications for surgical treatment
Widespread disease is an indication for radical surgical excision with
possible need for reconstruction with a flap.
Acute abscess (incision and drainage [I&D])
Chronic or recurrent HS nonresponsive to medical therapy
Intolerance of medical treatment
Positioning
Positioning will depend on the location and extent of the disease.
Either prone jackknife or lithotomy positions can be utilized (Fig. 13-
2).
FIGURE 13-2 Lithotomy positioning.
Positioning may need to allow for harvesting of skin grafts or rotation of

flaps.
Changing of positioning for various segments of the operation may be
necessary.
Special Equipment
I&D/lay-open technique
Fistula probes
Electrocautery
Hydrogen peroxide
Angiocath on 10 mL syringe
Excision and grafting
Excision
#15 or #10 blade and scalpel
Electrocautery
Forceps
Grafting
Dermatome
Air-powered dermatome (Zimmer)
Electric-powered dermatome
Size of dermatome can be 1, 2, 3, or 4 in wide.
Skin mesher
Two types
With carrier—disposable carrier helps minimize risk of
damage to fragile grafts
Without carrier
Different ratios of meshing (1:1, 1:2, 1:3)
Telfa gauze soaked in epinephrine\ (1:1000 dilution)
Negative-pressure dressing (wound Vac)
Forceps
Suture or staples
Flaps
Standard soft-tissue operating set
Drain
Technique
I&D/lay-open technique
Use fistula probe to identify deeper tracts (Fig. 13-3A and B).
FIGURE 13-3 A and B. Identifying tracts using fistula probes.
If the tract is not obvious, you can use an angiocatheter to inject dilute
hydrogen peroxide into the opening and then bubbles will emerge from
any connected openings (Fig. 13-4).
FIGURE 13-4 Injection of hydrogen peroxide to identify tracts.
Excise and saucerize the tissue overlying the tract containing the fistula
probe (Fig. 13-5A and B).
FIGURE 13-5 A and B. Excision and saucerization of involved tissues.
Debride tissue with a curette (Fig. 13-6) and control hemostasis with
electrocautery.
FIGURE 13-6 Curette the tracts once they are open.
Wide excision of all apocrine-based tissue.

Excise the pathologic tissue down to the subcutaneous tissue or fat with
electrocautery (Fig. 13-7).
FIGURE 13-7 Excision of the disease.
Radical excision may result in large defects that may require flap coverage
or skin grafting (see later).
Negative-pressure dressing may assist in more rapid healing of wound
defects.
This can be used in conjunction with grafting, which can be done at a
later date after the formation of granulation tissue.
May be used for patients with mild, localized disease as this technique will
not have a long-term effect on symptoms.
If unable to graft, multiple topical dressings have been used (eg, Vaseline
gauze, xeroform).
Excision and grafting
Radical excision is the only method that may result in a cure, but
recurrence can still occur.
Negative-pressing dressing (ie, wound Vac) should be placed and kept in
place until granulation tissues have covered the entire wound.
In the perianal region, you need to avoid excising an excessive amount of
anoderm to avoid anal stenosis from excessive scarring.
Pearl: Hidradenitis is only in hair-bearing areas and should not be
adjacent to the anus.
Split-thickness skin grafts should be harvested.
Anterolateral thigh is ideal source for skin graft harvest.
Thickness of skin graft should be around 0.01 in (setting on the
dermatome).
Mark the area of harvest and lubricate the skin with mineral oil to allow
for dermatome to glide smoothly on the skin.
Apply the dermatome to the skin with even, firm, direct pressure.
Harvest the amount of skin needed to cover the granulation tissue.
Immediately after harvesting the graft, place Telfa gauze soaked in
dilute epinephrine for hemostasis.
Meshing
Meshing creates slits in the skin to allow drainage of hematoma and/or
seroma.
Also expands surface area of the graft, allowing for a larger area to be
covered.
Meshing should be done at a 1:1 or 2:1 ratio.
When placing skin through the mesher, spray with saline so skin does
not stick within the mesher.
Application of skin graft
Ensure wound bed is ready with healthy granulation tissue (Fig. 13-
8A).
FIGURE 13-8 A and B. A patient with Hurley stage III disease who underwent
radical excision and closure with split-thickness skin grafting. (Courtesy Bradley
Davis, MD.)
Align edges of skin graft within 1 mm of normal skin without

overlap (if graft overlaps normal skin, the overlapping skin will
necrose and slough)
Graft should be placed dermis side down (dermis is shiny and wet
appearing; Fig. 13-8B).
Options to secure graft
3-0 chromic suture, simple interrupted spaced about 1 cm apart
around the periphery of the graft to normal skin junction
Surgical staples
Fibrin sealant
Topical skin adhesive
Entire surface of the graft must be adherent to the wound bed.
Any portion of the graft that is not adherent to the wound bed
will become necrotic and not heal.
Ensure the entire graft is in contact with wound by securing the
graft to the wound bed where the graft may be tented.
Options for dressings
Harvest site
Wrap donor site in plastic wrap/Tegaderm/Ioban (3M)
Typically, this is most comfortable for patients.
Xeroform cut to size of donor site and slather with bacitracin,
covered with Telfa and wrapped in Kerlix gauze—remove Telfa and
Kerlix after 24 hours
AQUACEL (ConvaTec, Bridgewater, NJ)
Graft
Wound Vac is the best method to ensure that the graft will remain in
place and not dislodge.
Layer of ADAPTIC (KCI/Acelity) directly on graft
Black or silver sponge
Plastic adhesive
Set Vac to −125 mm Hg
Leave in place for 4-5 days; remove on postoperative day 5 to
assess healing
After takedown, can assess how much of the graft has taken and
then apply xeroform dressing
As the area becomes epithelialized, can transition from xeroform
to moisturizing lotion
Excision and flaps

Types of flaps: pedicled gracilis myocutaneous flaps, anterior obturator
artery perforator flaps, and superior gluteus maximus musculocutaneous
flaps
Flaps are usually performed in conjunction with plastic surgery
colleagues.
Excision should be done as described earlier—all apocrine bearing
diseased tissue should be excised down to healthy subcutaneous adipose
tissue.
Flaps rely on robust blood supply from perforators of the superior gluteal
artery, inferior gluteal artery, and deep femoral arteries.
When to divert?
Need to first assess baseline bowel function and continence
Frequency of bowel movements
Quality of stool
Sensation to defecate
Urge to defecate
Baseline continence
Assess sphincter function
Physical examination
Typically, there is no need for further diagnostic studies beyond careful
digital rectal examination, but can obtain anorectal manometry for
objective documentation of sphincter function.
Need to assess extent of dissection
Approximate the location of the excision in relation to the anal verge
and if the skin graft/flap suture lines will encroach upon the anal verge
Will the selective use of bulking and constipating agents be sufficient to
minimize dressing changes?
Can use fiber supplementation twice daily
Can add loperamide up to 16 mg per day
Postoperative Care
Patient may need to be on prolonged antibiotic therapy (ie, doxycycline),
leading to surgery and beyond.
This will help quell the active suppurative response.
Patient may need strict bed rest with bathroom privileges only to avoid
dislodgement of the graft.
Patient may need Foley catheter.
Donor site pain is usually worse than graft site.
When the Vac is deployed onto a skin graft, don’t apply suction one time
only.
To help with sealing the Vac
Stoma paste
DuoDERM (ConvaTec)
Liquid adhesive
If the Vac fails in immediate postoperative period
Remove Vac dressing and apply Xeroform gauze slathered in bacitracin
with a fluff dressing to mold the graft to the wound bed.
Fecal diversion may be required in select patients such as those with
underlying continence issues or those with wound management
problems.
Suggested Readings
Asgeirsson T, Nunoo R, Luchtefeld MA. Hidradenitis suppurativa and pruritus ani. Clin Colon Rectal
Surg. 2011;24(1):71-80. doi:10.1055/s-0031-1272826.
Church JM, Fazio VW, Lavery IC, Oakley JR, Milsom JW. The differential diagnosis and comorbidity
of hidradenitis suppurativa and perianal Crohn’s disease. Int J Colorectal Dis. 1993;8(3):117-
119.
Chapter 14
Rectovaginal Fistula
TRACY HULL
One of the most important aspects when repairing an anorectovaginal
fistula is evaluating the patient before considering the operative approach
and procedure.
The tissue must be soft, supple, and free of any sepsis.
An examination under anesthesia with seton placement (usually for a
month) and unroofing of any cavity is essential.
We completely open a fistula tract to the level of the anal muscle to allow
it to heal from the bottom up and have the shortest tract as possible. We
then wait until the area has completely healed before proceeding.
When the tissue is not soft, consideration of a stoma should be entertained.
We have found hyperbaric oxygen to be extremely helpful when tissue is
fibrotic from previous failed attempts at repair. It is also useful in
radiation-induced fistulas.
Typically, 20 treatments (one daily for 5 days per week) before and
then waiting 2-3 weeks after the last treatment before doing surgery is
our preferred choice.
Then immediately after the repair, 20 more treatments are given.
Additionally, women who are menopausal may have improved supply of
their tissue with vaginal hormone cream for a month prior.
For patients with Crohn disease, the appearance of the anal canal and
rectum is extremely important.
The internal opening of a Crohn-related fistula will typically be at the
base of an ulcer.
Placing a seton and aggressively treating with biologics many times
will then leave the woman with a dry ulcer and repair then can be
considered.
If the anal canal never becomes inflammation free, no repair will be
successful.
The status of the anal sphincter anteriorly is also an important preoperative
consideration.
Even when the perineal body is thick, the muscle may not be intact.
We have a low threshold for obtaining an anal ultrasound to look at the
muscle as it may greatly influence our choice of repair (Fig. 14-1).
FIGURE 14-1 Anal ultrasound in a woman with an intact perineal body, but
anterior defect in the IAS and EAS. EAS, external anal sphincter; IAS, internal anal
sphincter.
We cannot stress enough the importance of being patient and ensuring the
tissue is soft, supple, and sepsis free before embarking on any repair.
For all repairs, unless the patient has a stoma, a full bowel preparation is
given. A Foley catheter is inserted, and intravenous (IV) antibiotics are
given. The area is prepped with betadine (or baby shampoo if iodine
allergic). During the procedure, the perineal wound is periodically
irrigated with antibiotic irrigation (we currently use bacitracin).
Our algorithm for repair is shown in Figure 14-2.
FIGURE 14-2 Algorithm for repair. RVF, rectovaginal fistula.
Hill-Ferguson retractors: often used for perianal cases positioned in
lithotomy
Fansler retractors: small, used selectively for perianal cases such as
those positioned in prone (ie, Kraske) or those with large redundant
mucosa
Pratt bivalve anal retractor
Set of curettes
00-silk ties
thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick
We routinely use 40 cut/60 coagulation settings, pure or blend.
A needle tip may be used for endorectal advancement flap.
Pezzer (mushroom) drains, size ranging from 10 to 32Fr
Positioning
Positioning of the patient is dependent on the approach to the fistula
(vaginal or rectal).
In lithotomy
In prone jackknife:
(taking special care to protect the genitals from pressure injury).
rolling.
benzoin.
Excessive tape traction will result in iatrogenic tearing
(fissuring) of the anoderm—avoid.
Techniques of Fistula Closure
Advancement Flaps
When the anal muscle is intact and the tissue is overall healthy, an
advancement flap can be considered.
Semicircular Advancement Flap

Typically, the patient is placed in the prone jackknife position, but for a
posterior fistula, we may rarely utilize the lithotomy position if we feel
visualization for mobilization may be improved.
With the patient prone, we use #1 sutures to efface the skin in at the 2, 4,
8, and 10 o’clock positions. More sutures can be placed if needed. This
allows visualization into the anal canal (Fig. 14-3).
FIGURE 14-3 Anal everting sutures are placed at 2, 4, 8, and 10 o’clock to efface the
anal canal.
A Hill-Ferguson lighted retractor is placed in the anal canal.

The fistula is identified, and a semicircular incision is made nearly 180-
degrees, starting just distal to the internal opening.
The mucosa is initially mobilized cephalad, but with progression inward, a
portion of the internal sphincter and then the full thickness of rectum are
mobilized. It can be bloody due to vessels in the rectovaginal septum, and
Bovie electrocautery or 3-0 absorbable sutures are utilized for hemostasis.
Mobilization is carried out until the reach comes down to cover the
opening without tension (Fig. 14-4).
FIGURE 14-4 Mobilization is carried cephalad until the rectal flap comes down easily.
The fistula tract is debrided. We only try to debride at the anal sphincter
level aggressively to avoid making the internal opening excessively large.
The internal opening is then closed in layers with 2-0 or 3-0 polyglactin
sutures (Fig. 14-5). We tend to close from side to side and then front to
back in at least two layers. This takes up dead space and relieves any
tension on the neodentate line anastomosis.
FIGURE 14-5 The tract is debrided and closed.
The tip of the flap is trimmed and sutured to the neodentate line (Figs. 14-
6 to 14-10).
FIGURE 14-6 The distal end is trimmed off.
FIGURE 14-7 The flap is advanced down and sewn to the neodentate line.
FIGURE 14-8 The flap is advanced down.
FIGURE 14-9 Final sutures placed.
FIGURE 14-10 Final sutures placed.
Sleeve Advancement Flap

When there is excessive scar or stricture in the anal canal, a sleeve
advancement may be the best choice.
When consenting the patient and making your plans, it is important to
realize that if there is too much tension via the transanal mobilization, then
a transabdominal approach may be required.
Therefore, the patient and surgeon must be ready to mobilize via the
abdominal approach.
Mobilization starts at the dentate line, and a mucosectomy is done for the
proximal anal canal (Fig. 14-11).
FIGURE 14-11 A mucosectomy is done of the anal canal.
When the rectum is reached, then the dissection deepens into the same
plane used for an Altemeier procedure (Fig. 14-12).
FIGURE 14-12 Dissection circumferentially around the rectum.
The mobilization continues until there is the cuff or sleeve of rectum that
can be advanced without tension to the neodentate line. The distal end is
amputated (Fig. 14-13), and the internal opening is closed, as discussed
earlier.
FIGURE 14-13 The distal bowel is amputated.
The sleeve is then sewn to the neodentate line and resembles a coloanal
anastomosis when completed (Figs. 14-14 and 14-15).
FIGURE 14-14 After the fistula is closed, the bowel is sewn to the neodentate line
circumferentially.
FIGURE 14-15 Final sutured sleeve.
When an abdominal mobilization is required, the rectum is mobilized in

the total mesorectal excision plan transabdominally, either open or by the
minimally invasive approach. The inferior mesenteric vessels are divided,
if required, for a tension-free reach.
We almost always use a stoma when performing a sleeve advancement.
Episioproctotomy
When there is a defect in the anterior muscle, an episioproctotomy would be
our choice for repair. I prefer that the patient be in the prone position.
A probe is placed through the fistula (Fig. 14-16A) and tract unroofed
(Figs. 14-16B and 14-17). It will resemble a fourth-degree obstetric injury
after it is unroofed (Figs. 14-18 and 14-19).
FIGURE 14-16 A probe is placed through the fistula. This patient has a full perineal
body, but the anterior sphincter has a defect both in the internal and external sphincter. A.
Intra-operative photo. B. Illustration depicting anatomy.
FIGURE 14-17 The Bovie is used to unroof the fistula.
FIGURE 14-18 The result will resemble a fourth degree obstetric tear.
FIGURE 14-19
An incision is made across the rectovaginal septum (Fig. 14-20).

FIGURE 14-20 An incision is placed across the rectovaginal septum.
The sphincter muscles are identified and mobilized from the lateral edges
of the wound. We do not separate the internal from external sphincter
(Figs. 14-21 and 14-22).
FIGURE 14-21 The anal sphincter muscles are identified.
FIGURE 14-22
Once the sphincter muscles are mobilized, the rectal and anal canal
mucosa is meticulously closed with 3-0 polyglactin sutures using a
mattress suture with interspersed single interrupted to ensure the edges are
meticulously approximated (Fig. 14-23). The suture line is carried out to
the anal verge. It is important to close the rectal and anal canal lining
tissue at this stage because if it is done after the sphincter is approximated,
visualization is greatly reduced. It is important to line up the dentate line
when closing the anal canal lining tissue.
FIGURE 14-23 The anorectal mucosa is closed first.
The anal sphincter muscle is overlapped (as if doing an overlapping

sphincter repair) in a vest over pants-type manner. We prefer to use 2-0
polydioxanone (Figs. 14-24 to 14-26).
FIGURE 14-24 The anal sphincter is overlapped in a vest over pants-type manner.
FIGURE 14-25
FIGURE 14-26 First row of sutures in sphincter repair tied down.
An important step is to ensure that all dead space is taken up in the most
proximal portion of this overlap. If this is not done, a cavity can form,
which may lead to recurrence at the very proximal extent of the dissection.
The free end is tacked down in a similar manner with 2-0 polydioxanone
(Fig. 14-27).
FIGURE 14-27 Second row of sutures is placed along the overlapping muscle and
scar.
Closure of the vaginal mucosa and perianal body is done with simple or
mattress sutures of 2-0 or 3-0 polyglactin (Fig. 14-28).
FIGURE 14-28 Closure of the vaginal mucosa.
Finally, the skin over the perineal body is closed (Figs. 14-29 and 14-30).
FIGURE 14-29 Drawing of the perineal body closure.
FIGURE 14-30 Intraoperative photograph of the perineal body closure.
We sometimes do not close the skin tightly at the perineal body/vagina

junction to allow for drainage.
It is important to line up the hymnal ring when closing the vagina.
Tissue Interposition
When the sphincter is intact, particularly when there is a lot of scar in the
rectum, tissue interposition may be chosen. We use either the
bulbocavernosus (Martius) or gracilis muscle as the interposed tissue of
choice. We typically consider the bulbocavernosus first as the postoperative
problems due to mobilization of the gracilis can be significant.
For the Martius flap, we typically utilize the lithotomy position. The hair
is clipped over each labia, and the Foley is taped in the midline (Fig. 14-
31).
FIGURE 14-31 In the lithotomy position, the hair has been clipped and the Foley is
taped in the midline. This patient already has a stoma.
The entire perineal region is prepped and draped to allow access to both
areas of the labia. A probe is placed in the fistula, and a transverse incision
is made over the perineal body. The probe remains in place (Fig. 14-32).
FIGURE 14-32 The patient is prepped and draped so there is access to each labia. A
probe is placed through the tract.
A transverse incision is made over the perineal area (Fig. 14-33).

Dissection is carried in the rectovaginal plane utilizing a finger in the anus
or vagina to ensure you do not button hole during the mobilization.
FIGURE 14-33 A transverse incision is made.

The dissection continues until the probe is identified (Fig. 14-34).
FIGURE 14-34 The probe remains in place to guide the dissection into the
rectovaginal plan.
It is crucial that the mobilization continues at least 3-4 cm cephalad from

where the fistula is encountered. The probe is removed during the
mobilization when it is no longer needed to guide the operator for
identification (Fig. 14-35).
FIGURE 14-35 The mobilization continues at least 3-4 cm cephalad from where the
probe had been in the tract.
The rectal side is cored out and closed in layers with 2-0 and 3-0
polyglactin sutures. Typically, in both a side to side and forward to back
(Fig. 14-36).
FIGURE 14-36 The rectal side is cored out and closed in layers.
We leave the needle on the forward to back suture that is located at the
most medical and cephalad extent to use to anchor the flap.
We also close the internal opening from the anal side with figure-of-eight
sutures (Fig. 14-37).
FIGURE 14-37 Closure of the anal side.
The external opening at the vagina or labia is cored out (Fig. 14-38).
FIGURE 14-38 The external opening on the vaginal side is cored out.
On the transverse incision side, figure-of-eight sutures are placed to close

this aspect of the vaginal opening. We sometimes leave the needle on
these to assist in anchoring the flap. The two openings in this internal
wound (the perineal wound) should be far apart if you have done sufficient
mobilization.
We place an antibiotic-soaked gauze and turn my attention to the labia.
We choose the side to mobilize the labia based on whether the fistula
tracts veers to one side or the other. For instance, if the external opening is
at the base of the left labia, we would choose the right side.
An incision is made over the labia and deepened (Fig. 14-39).
FIGURE 14-39 Antibiotic-soaked gauze in wound. Incision made over labia.
Once fat is encountered, we mobilized the skin off the fat laterally and
medically (Figs. 14-40 and 14-41) and look for the change in character of
the fat that represents the bulbocavernosus muscle pedicle.
FIGURE 14-40 Once fat is encountered, the skin is mobilized laterally.
FIGURE 14-41
We dissect widely and under the area and place a Penrose drain (Fig. 14-
42). Care is taken to avoid trauma to the fatty flap on the side toward the
perineal body as the blood supply will come from that area. The desired
tissue has minimal attachments and can be easily mobilized with scissors
cephalad.
FIGURE 14-42 A Penrose is placed around the bulbocavernosus.
When the pubic bone is reached, the tissue is divided between ties, leaving
the tail long as a handle on the flap side (Fig. 14-43). Mobility is
ascertained, and sometimes very careful distal dissection is required being
mindful of the area of the blood supply.
FIGURE 14-43 The bulbocavernosus is detached at the pubic bone.
Next the tunnel is made to the transverse perineal wound. Using a blunt
instrument (Fig. 14-44), it is constructed. It must be enlarged to easily
accommodate two fingers (Fig. 14-45).
FIGURE 14-44 An instrument can be used to make the tunnel.
FIGURE 14-45 The tunnel must be wide enough to easily accept a finger in order to
avoid compression of the flap that could lead to necrosis.
Bleeding may be encountered, and external pressure on the skin for 5

minutes usually controls this. Orientation is meticulously observed to
avoid twisting the flap. Using the long end of the tie (Fig. 14-46), it is
brought through the tunnel into the perineal wound and oriented (Fig. 14-
47).
FIGURE 14-46 The graft is brought through the tunnel and oriented.
FIGURE 14-47
The suture in the cephalad aspect (left with the needle from the internal
opening closure) is now used to anchor the graft taking small bites. Other
sutures are placed as needed to maintain orientation and stability.
If the fistula is in the mid-rectum, we would use the gracilis as the Martius
typically does not reach easily to that level. We perform this with our
plastic surgery colleagues. They harvest the muscle and bring it through
the tunnel. We assist to ensure it is oriented and sutured securely in place.
The skin is loosely re-approximated (Fig. 14-48). If there is a lot of
drainage, a Penrose ¼ in can be placed laterally. However, the skin is
again only loosely approximated as there will be drainage as this healed.
FIGURE 14-48 Closure of skin. Top: The suction drain is seen.
A suction drain is placed in the bed of the labial wound (seen at very top
of Fig. 14-48) and the skin closed over the surface. Patients typically go
home with the suction drain as we do not remove until it is about 30 mL
per day or less.
PEARLS AND PITFALLS
The use of a stoma does not guarantee success, but we prefer to use one
if there is less than ideal conditions or if there have been multiple
previous repairs.
For patients without a stoma, we keep them in the hospital overnight
and continue IV antibiotics.
We will then typically feed them and send them out the next day if they
are doing OK.
We will give them a total of 1 week of antibiotics (IV and oral).
For patients without a stoma, we advise they avoid constipation by
taking an ounce of mineral oil orally daily. If they do not move their
bowels by 3 days after they start to eat, Milk of Magnesia, 1 oz is given
nightly until there is a stool.
We allow them to take a shower but avoid a bath as that seems to
macerate the tissue.
They are advised to sit on a pillow if needed, but not a doughnut (this
will pull apart the buttocks and may stress a repair).
We also advise them to avoid lifting anything heavier than a gallon of
milk for 6-8 weeks or doing activity that forces them to grunt or push on
their pelvis. When stress is placed on their pelvis with activity that leads
to forces pushing on the perineum, it can stress the repair.
We encourage gentle walking.
Hyperbaric oxygen is ordered when tissue seemed to be less pliable, and
we have found it extremely helpful with healing.
For patients with a stoma, and examination under anesthesia is done at
about 8 weeks to assess for healing. A gastrografin enema is then done
prior to stoma closure.
Suggested Readings
Hull TL. Expert commentary on the evaluation and management of rectovaginal fistulas. Dis Colon
Rectum. 2018;61(1):24-26.
Valente MA, Hull TL. Contemporary surgical management of rectovaginal fistula in Crohn’s disease.
World J Gastrointest Pathophysiol. 2014;5(4):487-495.
Chapter 15
Rectourethral Fistulas
NICHOLAS HAUSER
HADLEY WOOD
KENNETH ANGERMEIER
Rectourethral fistula (RUF) is a challenging problem encountered by
urologic and colorectal surgeons and may result from radiation to the
pelvis, prostate cryotherapy, prior surgery, inflammatory conditions,
trauma, or congenital defects.
Although transanal or transanosphincteric (York Mason) repair may be
considered for small fistulas following surgery alone, perineal repair with
gracilis interposition is favored for complex RUFs. This category includes
fistulas that develop in the setting of prior radiation therapy or ablative
procedures, such as cryotherapy or high-intensity focused ultrasound, and
defects that are large or have failed prior reconstruction.
Prior to repair of complex RUF, it is critical to perform fecal diversion
(loop colostomy or ileostomy) and selective urinary diversion (suprapubic
catheter) for 3-6 months to decrease inflammation in the perineum and
surrounding tissues before surgery.
Careful endoscopic evaluation (Fig. 15-1A-C) and examination under
anesthesia should be performed following a period of diversion to assess
the external urethral and anal sphincters, size and location of the fistula,
quality of the rectum and tissues surrounding the fistula, the urethra for
evidence of stricture, and the approximate capacity and quality of the
bladder. Consideration of these factors will aid in generating the ultimate
surgical plan.
FIGURE 15-1 Preoperative evaluation. A. Flexible sigmoidoscopic view of the
rectourethral fistula (RUF). B. Cystoscopic view of the RUF. C. Contrast study in a patient
with prior brachytherapy for prostate cancer, demonstrating fistula between the rectum
and the prostatic urethra.
If future urinary and bowel function are likely to be adequate based on the
above evaluation, repair the urethral defect, with selective use of a buccal
mucosa graft. Restore bowel function via primary rectal repair and then
interpose a gracilis muscle flap. In rare situations when the anal sphincter
is intact and the rectum cannot be closed primarily, proctectomy with
coloanal pull-through may be considered.
If future bowel function is not likely to be adequate or the anal sphincter is
clearly compromised, repair the urethral defect, with selective use of a
buccal mucosa graft, with transfer of a gracilis muscle flap to buttress the
repair. Continue with the current fecal diversion if a colostomy or convert
the ileostomy to a colostomy. Proctectomy or rectal closure will also be
needed depending on patient anatomy.
If future bowel function is likely to be adequate, but urinary function not
restorable due to contracted bladder, extensive radiation cystitis, or
devastated bladder outlet, perform a cystoprostatectomy with ileal conduit
urinary diversion. Bowel function can then be restored via primary rectal
repair or proctectomy with coloanal pull-through and later reversal of the
diverting colostomy or ileostomy. Omental pedicle flap to the pelvis
should be considered when feasible.
Finally, if neither bowel nor urinary function is likely to be adequate,
perform a pelvic exenteration with ileal conduit and colostomy.
Sterile Equipment
Modified Denis-Browne retractor with notched grooves or modified Scott
ring retractor with elastic stay hooks
Gelpi retractor
Handheld malleable retractors
Fiberoptic-lighted handheld retractor such as St. Mark or Deaver
Skin stapler
Doppler ultrasound probe
Patient Positioning and Draping (See Chapter 3)

High lithotomy position
The patient should be positioned on the bed such that the perineum is at
the level of the foot break.
Place legs in adjustable stirrups (such as Yellowfins); raise the stirrups
until the hips are flexed about 75-80 degrees and extend the legs until the
knees are flexed approximately 90-100 degrees (Fig. 15-2).
FIGURE 15-2 A. High lithotomy position. B. Draping. C. Close-up of surgical field and
marked incision. Note the sterile towels draped just posterior to the proposed incision.
Access to the rectum is possible through a slit between the paired towels.
If surgery is prolonged, consider dropping the stirrups for short periods of

time to allow for normal lower extremity perfusion to decrease the risk of
complications such as rhabdomyolysis or neuropraxia.
Padding of Pressure Points

Use a gel pad beneath the buttock to cushion the site bearing the majority
of the patient’s weight.
Egg crate foam may be used to pad the lateral portion of the knee within
the stirrups to prevent injury to the common peroneal nerve.
Similar foam cushion can be placed between the patient and any tubing for
sequential compression devices on the patient’s lower leg.
Prepping and Draping

In addition to shaving the perineum and external genitalia, shave the
medial and posterior thigh on the leg selected for gracilis muscle harvest.
Prep the entire thigh into the field, extending just beyond the knee.
Most patients will have a previously placed suprapubic catheter for urinary
diversion. Remove the catheter and include the lower abdomen in the
prepped surgical field.
A bulb syringe can be used to gently irrigate the rectum with povidone–
iodine solution prior to prepping the remainder of the surgical field.
When draping, isolate the selected thigh with individual stick-on drapes or
sterile towels prior to covering the leg and stirrup with the leg drape.
When access is needed, the top drape can be cut back to expose the
prepped thigh.
Take care to include access to the rectum while draping. This can be done
by placing adjacent sterile towels on either side of the rectum and stapling
them in place, leaving a midline slit through which a digital rectal
examination can be performed intraoperatively.
Technique
Perineal Approach with Gracilis Muscle Interposition
Advantages of the perineal approach include excellent exposure, access to
the urethra if concomitant repair of stricture is necessary, and ability to
harvest a gracilis muscle interposition flap without repositioning.
Replace a suprapubic catheter to drain the bladder during the initial
dissection; this will decrease urine leaking via the fistula tract and improve
visualization during repair. Urethral catheter is also placed, if possible, to
allow palpation of the urethra during the perineal dissection.
The incision is made in the shape of an inverted U, with the apex just
above the level of the anal sphincter and extending to a location just inside
the ischial tuberosities bilaterally (Fig. 15-3). A midline vertical incision
may be added for increased exposure, in the case of excess soft tissue, or
for further access to the anterior urethra in cases where posterior
urethroplasty is necessary.
FIGURE 15-3 Male perineum with inverted-U incision (dotted line) extending
between the ischial tuberosities.
Initial Dissection
After deepening the incision, enter the ischiorectal fossa bilaterally and
develop these spaces using blunt dissection.
Carefully proceed to dissect the plane between the rectum posteriorly and
the urethra, prostate, and bladder anteriorly. This is started through the
area of the central tendon between the bulbospongiosus muscle and the
anal sphincter. Once beyond the anal sphincter, the dissection is carried
onto the anterior rectal wall and the perirectal fat laterally.
Follow the anterior surface of the rectum until encountering the fistula
tract. Identification of the plane may be difficult due to prior surgical
scarring or exposure to radiation and other ablative energy sources, so
periodic rectal examinations may be required to proceed to confirm the
site of the fistula and avoid entering the rectum too soon.
A handheld retractor with fiberoptic lighting may be needed for improved
visualization. An assistant can stand at the patient’s side (behind one leg)
to hold the retractor, which will also provide anterior traction. Posterior
countertraction can be provided with a handheld malleable retractor on the
rectum.
After entering the fistula tract, circumferentially transect the fistula and
continue to dissect the plane further proximally. Once through the fistula,
the dissection is oriented a little more inferiorly to follow the natural
course of the rectum and avoid inadvertent entry into the bladder.
Perirectal and perivesical fat is usually encountered, and this is a safe
plane to dissect within as one proceeds more proximally (Fig. 15-4). The
dissection should be continued, and the rectum mobilized to allow tension-
free closure with adequate space for the gracilis flap to completely cover
the repair.
FIGURE 15-4 A. Dissection between the rectum and the urinary tract. A handheld
retractor is held anteriorly to provide both countertraction and additional light. The fistula
tract has been transected circumferentially, and perirectal fat is seen beyond the fistula
tract. Defects in the prostatic urethra and the rectum can be seen. B. An Allis clamp can
be used to provide traction for the remaining proximal rectal mobilization and dissection
and to demonstrate approximation for transverse rectal closure.
Rectal Closure
Once the space between the urinary tract and the rectum has been
developed, proceed with closure of the rectum and primary closure of the
urethral defect if possible.
Rectal closure should be performed in two layers and done in a transverse
manner if the anatomy allows. The first layer can be done with full-
thickness bites utilizing interrupted 3-0 absorbable suture such as Vicryl or
polydioxanone (PDS). A second interrupted layer with 3-0 suture should
then be performed with a braided polyester suture such as Ethibond,
imbricating tissue over the first layer of closure.
Urethral Closure
If the urethral defect can be closed primarily, do so with interrupted
absorbable suture such as 3-0 PDS.
If needed, flexible cystoscopy may be performed to confirm fistula
location and to make sure closure of the defect has not resulted in
narrowing of the urethral lumen.
If the urethral defect is too large or fixed for primary closure, a buccal
mucosa graft may be required for closure.
Once the buccal mucosa graft has been harvested, thin the graft by
carefully removing attached tissue to optimize graft take.
With the mucosal surface of the graft facing the urethral lumen, patch the
urethral defect using absorbable monofilament suture, preferably 4-0 PDS
(Fig. 15-5A).
FIGURE 15-5 Anastomotic urethroplasty for coexisting posterior urethral stricture. A.
Anastomotic sutures placed into distal prostatic urethra following excision of the fistula and
associated fibrotic stricture. B. Bulbar urethra brought to level of anastomosis without
tension. C. Completed anastomosis. The rectal closure sutures are seen posteriorly. The
space between the rectal closure and urethral anastomosis will be filled with a gracilis
muscle interposition.
If there is an associated moderate stricture of the membranous urethra,

urethrotomy incision can be made from the fistula through the strictured
segment, with a longer buccal mucosa graft then used to close the urethral
defect and augment the stricture.
To check for a water-tight closure, gently fill the urethra in retrograde
manner with normal saline. Repair any large leaks with interrupted sutures
as needed.
Once the urethral repair is completed, replace a 16Fr or 18Fr soft silicone
Foley catheter.
Posterior Urethroplasty
For cases with coexisting posterior urethral stricture or obliteration,
posterior urethroplasty with primary anastomosis can be performed in
select cases. Presence of the stricture will be known preoperatively
following imaging and examination under anesthesia, so at the time of
incision, a vertical midline incision may be added to the inverted-U
incision.
Carry the midline incision down to the bulbospongiosus muscle with
electrocautery, then divide the bulbospongiosus muscle and mobilize the
urethra circumferentially with Metzenbaum scissors.
The urethra can be mobilized distally to the level of the penile suspensory
ligament.
Using a catheter or Bougie to identify the distal extent of the stricture,
transect the urethra and make a dorsal urethrotomy extending
approximately 1 cm into healthy urethra.
Dissect the scarred membranous or prostatic urethra until encountering a
sufficient lumen for urethral anastomosis. This will require excision of a
segment of the urethra and possibly a portion of the prostate until reaching
tissue sufficiently healthy to hold a suture. In cases of complete
obliteration, use of a curved metal sound or flexible cystoscope passed
into the bladder neck and posterior urethra via the suprapubic catheter
tract provides a palpable target for this dissection.
Calibrate both the proximal urethra or bladder neck and the transected
urethra to achieve a goal lumen of 26-30Fr.
To allow for a tension-free anastomosis, adjunct maneuvers may be
required to gain urethral length. The corpora cavernosa may be separated
by sharply dissecting between the two erectile bodies, starting with a
scalpel and continuing with tenotomy scissors. Separate the corpora
cavernosa until the pubic symphysis is palpable.
If further urethral length is required for anastomosis, suture ligate the
dorsal vein and perform an inferior pubectomy.
Perform an anastomotic urethroplasty with a series of interrupted 3-0 PDS
sutures, leaving the knots outside the lumen. Between six and eight sutures
are generally sufficient (Fig. 15-5).
Gracilis Muscle Interposition

Following closure of the urethral and rectal defects, interposition of well-
vascularized tissue is the final key component of complex fistula repair.
Lower the legs into a standard lithotomy position. Cut back the drape
along the selected thigh and secure to the skin with a stapler (Fig. 15-6A).
FIGURE 15-6 Gracilis muscle interposition. A. Harvest of left gracilis muscle with
incision just below the level of the mid-thigh. After transecting the gracilis tendon, the
muscle will be passed through a subcutaneous tunnel to the perineum. B. Vascular
pedicles of the gracilis muscle. The primary pedicle is located approximately 9 cm from the
pubic tubercle; all remaining secondary pedicles should be ligated to mobilize the muscle
after ensuring a good arterial wave of the primary pedicle with Doppler ultrasound. C.
Gracilis muscle passed into the perineal wound through a large subcutaneous tunnel over
the ipsilateral ischiopubic ramus. D. Schematic illustration of gracilis muscle secured
beyond the level of both rectal and urethral closures. Note that the muscle reaches a level
posterior to the bladder and proximal to both the urethral and rectal repairs. E. Completed
rectal and urethral closures with interposed gracilis muscle. The muscle provides good
bulk to fill the space created by the dissection and separate the closures.
Make an incision over the inner thigh along the course of the gracilis
muscle. The distal tendon of the muscle can generally be palpated at the
knee as a thick cord, and the incision can end a few centimeters proximal
to the tendon.
Deepen the incision with electrocautery and identify the muscle. Dissect
the fascia off the muscle distally to identify the tendon and, therefore,
positively identify the gracilis, then continue the dissection proximally.
Preserve the vascular pedicles to the muscle during dissection (Fig. 15-
6B). The primary pedicle is located approximately 9 cm from the pubic
tubercle. Use a Doppler ultrasound probe to ensure adequate arterial flow
at the primary pedicle before ligating any secondary pedicles to complete
the muscle mobilization.
Free the fascial tissue off the muscle to the level of the primary pedicle to
maximize its ability to rotate into position. Divide the distal tendon with
electrocautery.
With a combination of blunt and sharp dissection, create a wide
subcutaneous tunnel over the ischiopubic ramus between the perineal and
thigh incisions. Rotate the gracilis on the primary pedicle and pass the
muscle into the perineum (Fig. 15-6C).
Place a series of interrupted 3-0 PDS sutures at the distal extent of the
perineal dissection, in order to anchor the muscle flap beyond the repaired
rectal and urethral defects. Pass these sutures through the appropriate side
of the muscle and tie them down to secure the muscle in place proximally
(Fig. 15-6D). The result should be bulky muscle filling the perineal
dissection (Fig. 15-6E), which can then be further secured into position
with interrupted 3-0 Vicryl sutures to the perineal musculature and fat
laterally.
Before closing the thigh wound, place a closed suction drain exiting
distally, and leave the drain in the bed of the gracilis muscle. Loosely re-
approximate muscular fascia with a series of interrupted 3-0 Vicryl
sutures.
Close the subcutaneous tissue with interrupted 3-0 Vicryl sutures with
knots buried before closing the skin with a stapler.
Wound Closure
Leave a Penrose drain in the perineal wound exiting one corner of the
inverted-U incision. Following copious irrigation of the wound, use
absorbable suture to close dead space with perineal fat. Close the
bulbospongiosus muscle with interrupted 3-0 Vicryl if it was opened to
mobilize the urethra.
Use running 3-0 Vicryl to close Colles fascia and approximate all wound
edges.
Close skin with running 4-0 Vicryl.
PEARLS AND PITFALLS
Be sure to extend the initial dissection beyond the fistula to a level

under the bladder. This allows for sufficient mobility of the rectum for
tension-free closure and provides space for anchoring the gracilis
muscle. This ensures that healthy well-vascularized tissue will
completely separate the urethral and rectal closures.
After dissecting through the fistula tract, it is critical to orient further
proximal dissection a little posteriorly, using the perirectal fat as a
guide, as further dissection straight in through the perineal tissues may
lead to injury of the posterior bladder.
Transverse closure of the rectal defect is preferred to longitudinal
closure, so as to avoid narrowing of the rectal lumen. However,
longitudinal closure may be required in some cases based on patient
anatomy.
When creating the tunnel for the gracilis muscle, aim for a width of four
fingerbreadths. This allows for postoperative swelling of the muscle
without compromising its blood supply.
Postoperative Care
Following a gracilis muscle interposition, keep the patient on
postoperative bed rest for a period of 48-72 hours. Use appropriate
pharmacologic deep vein thrombosis prophylaxis.
When ready for hospital discharge, urinary drainage can be achieved with
either a urethral catheter or suprapubic catheter with the urethral catheter
plugged.
Voiding cystourethrogram is obtained 5-6 weeks following surgery, and
urinary catheters are removed if well healed. If there is significant
extravasation of contrast, suprapubic catheter drainage is continued, and
the patient is restudied a few weeks later. Gastrografin enema is obtained
5-6 months postoperatively to document healing, followed by stoma
reversal shortly thereafter.
Suggested Readings
Lane BR, Stein DE, Remzi FH, Strong SA, Fazio VW, Angermeier KW. Management of radiotherapy
induced rectourethral fistula. J Urol. 2006;175(4):1382-1387; discussion 1387-1388.
Samplaski MK, Wood HM, Lane BR, Remzi FH, Lucas A, Angermeier KW. Functional and quality-
of-life outcomes in patients under-going transperineal repair with gracilis muscle interposition
for complex rectourethral fistula. Urology. 2011;77(3):736-741.
Chapter 16
Crohn Anorectal Disease
JAMES CHURCH
The principles of the management of perianal symptoms in patients with
Crohn disease
Define the status of the proximal bowel.
Colonoscopy
Esophagogastroduodenoscopy
Magnetic resolution enterography (MRE)/Computed tomography
enterography (CTE)
± Small bowel follow-through (MRE/CTE preferred)
Is there active Crohn disease? If there is, it needs to be managed either
medically or surgically. Medical treatment will often help perineal
Crohn disease (Crohn disease within the tissues of the perineum).
Has the patient had bowel resections?
If so, do they have diarrhea as a result and does this make them
prone to incontinence? This will exacerbate perianal symptoms.
Use of agents to slow motility, and/or bulk formers, may help.
Define the status of the anal sphincters.
What is the status of the anal sphincters? Has there been previous
surgery? Childbirth?
If anal ultrasound is available, this is worth adding to the
assessment.
A thin perineum in a woman will not support flap repair of anterior
fistulas (including rectovaginal fistulas) and is an indication for one
of the following: perineoplasty, Martius flap, and gracilis flap.
Is there sepsis? If so, control it.
This will usually need an examination under anesthesia (EUA) to fully
and completely assess the low rectum, anus, and the perineum.
During this examination, carefully check the perianal skin for
fluctuance or asymmetry.
If there is a swelling, it can be aspirated; and if pus is obtained, the
collection is incised and drained.
Openings that are already draining can be gently probed, but
remember that hidradenitis is associated with perianal Crohn disease
and an opening in the perianal skin could be from this, or a fistula
(Fig. 16-1).
FIGURE 16-1 The ravages of perianal hidradenitis suppurativa in a patient

with colonic Crohn disease.
Openings that track to the dentate line are anal fistulas. These should
be adequately drained with either a vessel loop seton or a Penrose
drain or both (Fig. 16-2).
FIGURE 16-2 Draining anterior extensions of a perianal fistula using Penrose
drains, while the primary track is drained by vessel loop setons.
Search the tracks for extensions, cavities, or sinuses, and make sure
that everything is drained or unroofed.
If the symptoms and cellulitis do not settle down during the 24 hours
after EUA, then another EUA is indicated.
If the sepsis still cannot be controlled by local means, then fecal
diversion is indicated.
Is there perineal Crohn disease?
Perineal Crohn disease is an infiltration of the perineal tissue by Crohn
disease. It is associated with a characteristic clinical appearance, and
the majority of cases have perineal granulomas reported on biopsy.
Perineal Crohn disease is a contraindication to incisional surgery, as
wounds don’t heal (Fig. 16-3A and B).
FIGURE 16-3 A. An unhealed perianal wound in a patient with perineal Crohn

disease. This wound had been present for over a year. Biopsy of the perineum
revealed typical granulomas. B. Perineal Crohn disease: Unhealed wound from
fistulotomy performed a year previously.
Perineal Crohn disease usually responds well to biologic treatment, and

this can prepare the region for successful local repair.
Equipment used for anorectal cases are as follows:
Hill-Ferguson retractors: often used for perianal cases placed in
lithotomy position
Pratt bivalve anal retractor
Set of curettes
00-silk ties
thick, or a blue (maxi) vessel loop, 2.5 mm wide, 1 mm thick
We routinely use 40 cut/60 coagulation settings, pure or blend.
A needle tip may be used for endorectal advancement flap.
Pezzer (mushroom) drains, size ranging from 10 to 32Fr
Positioning
Positioning of the patient is dependent on the site of the external and
internal opening(s), with prone jackknife being optimal for anterior
internal opening and lithotomy for fistulas with a posterior internal
opening.
In lithotomy:
In prone jackknife:
(taking special care to protect the genitals from pressure injury).
rolling.
benzoin.
Excessive tape traction will result in iatrogenic tearing
(fissuring) of the anoderm—avoid.
Technique Anal Tags (Figure 16-4)

FIGURE 16-4 Elephant ear skin tags in a patient with perianal Crohn disease.
Classic “elephant ear” tags are a sign of perineal Crohn disease and should
not be excised.
Symptomatic tags in the absence of perineal Crohn disease can be
removed, but only after bowel habits are normalized as much as possible.
Anal Stenosis (Figure 16-5)

FIGURE 16-5 Perianal Crohn disease with anal stenosis.
Anal stenosis in patients with Crohn disease can be due to chronic diarrhea
from short bowel syndrome, chronic scarring from healed anal disease, a
Crohn-related stricture, sepsis, or a cancer.
EUA with biopsy should determine the cause.
Secondary stenosis due to chronic diarrhea doesn’t need to be treated, as
long as the diarrhea is now “normal.”
Strictures due to scars can be dilated and injected with steroid. (kenalog
40mg/1cc, diluted with 4cc saline) Septic strictures are treated by drainage
of the sepsis with or without fecal diversion, and malignant strictures
treated on their merits, according to the stage of the cancer.
Anal Fissure (Figure 16-6)

FIGURE 16-6 Perianal Crohn disease with deep-wide–based anal fissure.
If patients with Crohn disease develop a typical painful anal fissure, they
are candidates for treatment with the usual ointments (diltiazem and
nifedipine), and if these are ineffective, a judicious sphincterotomy.
The pain is from internal sphincter spasm, and sphincterotomy will
resolve the fissure.
A painless fissure in a patient with Crohn disease is concerning for
perineal Crohn disease. It is more an ulcer than a fissure and needs to be
treated with biologic agents. Sphincterotomy is contraindicated.
Consideration should be given for other causes if nonhealing, even
consider culture or biopsy.
Anal Fistula
Anal fistulas present commonly in patients with Crohn disease.
Sometimes, they are related to perineal Crohn disease and are initially
drained with setons before being treated with biologics.
Once the perineal Crohn is controlled and relatively asymptomatic, the
internal opening can be repaired.
If the fistula is a “usual” cryptoglandular anal fistula that just happens to
be present in a patient with Crohn disease, biologics are not needed and
the fistula can be repaired immediately.
The technique of repair is at the discretion of the surgeon, but we favor
advancement flap. In our practice, it has a high success rate (87% healing),
no impact on continence, and if it fails, it can be repeated.
Sometimes, fistulas cannot be repaired due to ulceration or acute
inflammation in and around the anal canal. Long-term seton drainage is a
good way of controlling symptoms.
In select cases, a “watering-can” perineum is present is Crohn, and dilute
hydrogen peroxide is useful to identify all tracks (Fig. 16-7). Sepsis should
be drained and setons placed.
FIGURE 16-7 Watering-can perineum in a patient with Crohn disease. Hydrogen

peroxide is injected into one opening with multiple external connections identified.
Perianal Abscess
Needs to be drained. Look in the anus at the time of drainage to see if
there is pus coming from a crypt.
Drainage of the abscess will often lead to a fistula, which will then need to
be repaired.
Often, these patients can have a purplish hue perineum (Fig. 16-8) that
may mask the overt abscess. EUA is critical to palpate for fluctuance and
drain the sepsis.
FIGURE 16-8 Perineum of a patient with Crohn disease. Note the purple hue of and
large tags. There is evidence of fistula tracks, and palpation will demonstrate the
fluctuance of sepsis.
Hemorrhoidal Disease
Hemorrhoidal symptoms in a patient with Crohn disease may be due to
abnormal bowel habit from proximal disease, from a low residue diet, or
because the patient is prone to hemorrhoids anyway.
If there is no perineal Crohn disease, they can be treated based on the
severity of the symptoms and the degree of prolapse.
If there is perineal Crohn disease, this must be treated first by biologics.
Then if the hemorrhoids are still significantly symptomatic, very
conservative measures can be taken (try elastic band ligation first).
Suggested Readings
Church J. Missing the boat? Appreciating the importance of the pathophysiology of perianal Crohn’s
disease in guiding biological and surgical therapy. Dis Colon Rectum. 2018;61:529-531.
El-Gazzaz G, Hull T, Church JM. Biological immunomodulators improve the healing rate in surgically
treated perianal Crohn’s fistulas. Colorectal Dis. 2012;14:1217-1223.
Figg RE, Church JM. Perineal Crohn’s disease: an indicator of poor prognosis and potential
proctectomy. Dis Colon Rectum. 2009;52:646-650.
Jarrar A, Church J. Advancement flap repair: a good option for complex anorectal fistulas. Dis Colon
Rectum. 2011;54:1537-1541.
Chapter 17
Pilonidal Disease Excise versus Flap:
Technical Tips
ANURADHA R. BHAMA
SCOTT R. STEELE
Pilonidal disease is most commonly found in young adults, although it can
affect a wide range of ages, with men being more frequently affected than
women.
Obesity, sedentary lifestyle, and a deep natal cleft are risk factors for
pilonidal disease.
Pilonidal disease is felt to be an acquired disease with a resultant foreign-
body reaction to the hair follicle, though there are wide-ranging theories.
Nonoperative options for pilonidal disease have been described to include
shaving, waxing, laser, and depilatory agents.
Acute pilonidal abscess should be treated with incision and drainage
(I&D).
Excision ± marsupialization and various flaps have been described for
chronic and recalcitrant/recurrent disease.
Patient Positioning
Padded operating room (OR) table, arm boards angled toward the head of
the bed
Prone
Allows for access to natal cleft
Pad all boney prominences
Kraske roll and/or jackknife position optional (Fig. 17-1)
FIGURE 17-1 Bed setup for patient positioning. Chest roll (left), Kraske roll, foam
padding for knees, and stack of blankets for lower legs to lie upon so that feet are kept
floating.
Patient must be strapped/taped to the bed.

Take care when adjusting arms. Arms should be in goal post position
toward the head. Carefully rotate the arm into that position while avoiding
brachial nerve injury.
If I&D is being done in clinic: prone jackknife table
Patient kneels on knee rest and flexes at the hip with a pillow
supporting the chest. This allows for optimal exposure.
Basic procedure tray
#15 blade scalpel
Needle drivers and Adson pickups
Handheld electrocautery and suction
Curettes
Additional equipment
10 × 10 drapes placed over the anus to separate from operative field
Sutures
2-0 Vicryl
3-0 Nylon
Indications for Surgical Treatment

Abscesses require drainage in the clinic, but they can be done in the OR if
the patient does not tolerate the procedure without sedation.
When pilonidal disease recurs several times after conservative
management measures, surgery is indicated. While there is no “set”
number, three or more certainly warrants consideration and we discuss
after the first recurrence.
Procedures include lay-open technique, wide local excision with primary
closure, wide local excision with marsupialization of the wound and
dressing changes, wide local excision of the wound with primary closure,
and placement of negative-pressure dressing.
Types of flaps include Limberg flap, Bascom flap, and Karydakis flap.
Positioning and Preparation

Patient in prone position (Kraske or prone jackknife)
Betadine or antiseptic skin cleanser is used to prepare the operative site.
A 10 × 10 drape can be used to exclude the anus from the operative site.
Incision and Drainage

The abscess should first be examined—identify the area of maximum
fluctuance.
Anesthetize the skin overlying this area. Use 1% lidocaine or 0.25%
Marcaine with epinephrine.
Test the skin of the planned incision to ensure the patient cannot feel the
area that is about to be incised.
Make an incision overlying the area of maximum fluctuance. This should
be off of the midline.
Purulent drainage will be seen and should be irrigated from the abscess
cavity.
Saucerize the incision slightly so that the skin edges do not touch.
Pack the wound for hemostasis.
Patient should follow up for wound checks at regular intervals.
Routine antibiotics typically are not necessary.
General Technique for All Cases

Typically done in the OR with patient in prone position with the buttocks
taped apart.
Shave the hairs of the natal cleft with clippers.
The skin should be sterilely cleansed.
Identify all of the individual pits using a fistula probe (Fig. 17-2).
FIGURE 17-2 Identify pits with a fistula probe. A: Pilonidal Disease. B: Passing a
probe to identify the pits.
If there is a question about any of the possible pits, inject methylene blue
(diluted 1:1 with sterile saline) into the main pit using an angiocath. This
will highlight the location of the pits (Fig. 17-3).
FIGURE 17-3 Injection of methylene blue. A: Placement of the catheter. B. Injecting
the dye identifies the opening.
Lay-Open Technique with Marsupialized Pilonidal Pits

and Excision of Pilonidal Pits
Identify pits with fistula probe and open the pits with cautery and debride
the edges (Fig. 17-4).
FIGURE 17-4 Lay-open technique. A: Passing the fistula probe. B: After opening the
tract.
Curette the tracts and ensure the granulation tissue is debrided.

Marsupialize the edges of the tract with absorbable suture (Fig. 17-5).
FIGURE 17-5 Marsupialize edges. A: Marsupialization of the tract. B: Final wound.
Infiltrate the wound with local anesthetic.

Place a sterile dressing.
Wide Local Excision

Positioning and preparation are the same as the abovementioned steps.
Identification of pits is the same as the abovementioned steps.
An elliptical incision should be made in the skin to encompass all the pits.
Carry the incision down toward the fascia. The incision does not have to
extend to the fascia, but it needs to be deep enough to excise the base of
the pit. Be careful not to wander laterally during the dissection and stay
close to the pit—this will ensure a smaller wound.
Options are to close the wound or leave it open for twice-daily packing.
If closing the wound:
Close the wound in several layers using Vicryl suture.
Irrigate with sterile saline in between each layer.
For skin closure, use a nonabsorbable monofilament suture in a vertical
mattress manner.
There are several options for dressings:
Can use a small negative-pressure wound therapy system.
Can place a standard sterile dressing to be removed after 48 hours.
Limberg Flap (Rhomboid Flap)

Identify the extent of the resection with probing and injecting methylene
blue. The excision should be a diamond shape (Fig. 17-6).
FIGURE 17-6 Diamond-shaped excision site for Limberg flap.
Mark out the incision for the creation of the flap—the incision should
extend laterally to the right buttock for approximately the same length as
one edge of the diamond excision site (Fig. 17-7).
FIGURE 17-7 Marking of Limberg flap. A: Measuring out the lateral extension. B:
Measuring out the side to ensure it is the same.
The second incision should be parallel to the lateral aspect of the excision
site (Fig. 17-8).
FIGURE 17-8 Marking of Limberg flap.
Figure 17-9 demonstrates the planned rotation of the flap.

FIGURE 17-9 Planned rotation of flap. A: Intraoperative photograph. B: Drawing
demonstrating the proper rotation.
Start with excising the specimen in a diamond shape. Carefully dissect and
watch for methylene blue staining of the underlying subcutaneous tissues.
The excision should be lateral to the blue tissue, and the blue tissue should
be included with the specimen (Fig. 17-10).
FIGURE 17-10 Dissection to include methylene blue–stained tissues.

Incise the skin to create the flap and carry the dissection down to the fascia
of the gluteus maximus.
Using 2-0 Vicryl suture, bring the deep corners of the flap to the corners
of the excision site (Fig. 17-11).
FIGURE 17-11 Rotation of flap. A: Initial rotation. B: Flap rotated and in place.
A second layer of 2-0 Vicryl suture should be used to close the dead space
between the subcutaneous fat.
A final layer of 3-0 monofilament permanent suture is used to close the
skin in a vertical mattress manner (Fig. 17-12).
FIGURE 17-12 Final flap after skin closure.
PEARLS AND PITFALLS
Avoid placing inferior corner of flap above the anus.

Inferior portion of the incision should be off the midline.
Ensure some undermining of the subcutaneous tissues in order to make
rotating the flap easier and decrease tension.
Minimize the depth of tissue excision.
Take only the amount of tissue necessary during the excision.
Bascom Flap (Cleft Lift)

Positioning and preparation are the same as the abovementioned steps.
Mark the safe zone of the gluteal cleft by opposing the buttocks and
marking where they touch (Fig. 17-13).
FIGURE 17-13 Marking of safety zone.
Identification of pits is the same as the abovementioned steps.

A scimitar-shaped incision should be made inferiorly in the skin to
encompass all the pits. Keep the incision just off the midline (Fig. 17-14).
FIGURE 17-14 Scimitar-shaped incision.
Carry the incision down toward the fascia. The incision does not have to
extend to the fascia, but it needs to be deep enough to excise the base of
the pit. Be careful not to wander laterally during the dissection and stay
close to the pit—this will ensure a smaller wound.
Raise a short flap on the side opposite of the incision (Fig. 17-15).
FIGURE 17-15 Dissection of cleft lift flap. A: Initial wound. B: After resection. C: Flap
closed.
Close wound in layers and dressing options are the same as the
abovementioned steps.
Final skin closure should result in an incision that is just off the midline.
PEARLS AND PITFALLS
Scimitar-shaped incision should point inferiorly to aid in perianal

reconstruction.
Flap can be raised using either electrocautery or sharply with scissors or
knife.
The area of the flap toward the anus should be thicker.
Central scarring can be “diced” with electrocautery to free the
contractures.
Obliterate dead space as much as possible with Vicryl suture.
May use a closed suction drain.
Postoperative Care
I&D can be packed for 24 hours to prevent bleeding, but then be treated
with a simple dressing for drainage.
In general, antibiotics are not required in the absence of underlying
comorbidities or excessive cellulitis.
A drain may be removed in 24-72 hours depending on the amount of
drainage (typically <30 mL), though there are a large variety of surgical
practice.
Stitches for flaps are commonly left in for several weeks prior to removal.
Activity should be restricted on all flaps for several weeks (no prolonged
sitting, exercising with pressure on the flap).
Suggested Reading
Johnson EK, Vogel JD, Cowan ML, Feingold DL, Steele SR; Clinical Practice Guidelines Committee
of the American Society of Colon and Rectal Surgeons. The American Society of Colon and
Rectal Surgeons’ Clinical Practice Guidelines for the Management of Pilonidal Disease. Dis
Colon Rectum. 2019;62(2):146-157.
Chapter 18
Anal Intraepithelial Neoplasia:
Performing High-Resolution Anoscopy
MICHELLE D. INKSTER
ERIC D. WILLIS
JAMES S. WU
Anal squamous intraepithelial lesion (SIL) precedes anal squamous cell
carcinoma. The causative agent is human papillomavirus (HPV) in the
majority of cases.
Anal squamous cell cancer arises between the anal verge and the anorectal
line (Fig. 18-1).
FIGURE 18-1 A. The epithelium at risk for anal SIL extends from the anal verge to the
anorectal line. B. The anorectal line defines the junction between the ATZ and the
columnar epithelium of the rectum. The ATZ, derived from the embryonic cloaca, extends
from the anorectal line to the dentate line. Distal to the dentate skin is the pecten that has
no or few sweat glands and extends from the dentate line to the anal verge. Distal to the
anal verge is the hair-bearing perianal skin or anal margin. C. Retroflexion with the scope
delineating the anatomy. A, anterior; ATZ, anal transitional zone; PEC, pecten; R, right;
Scope, endoscope; SIL, squamous intraepithelial lesion.
Although groups at high risk include HIV-positive individuals, especially

men who have sex with men; solid-organ transplant recipients; and those
with a history of cervical, vulvar, penile, or vaginal dysplasia, anal SIL
can occur in anyone.
Anal SIL detection, necessary for diagnosis and treatment, is facilitated by
inspection of at-risk epithelium with adequate lighting, magnification, and
chemical enhancement.
Diagnostic techniques used are derived from colposcopy described by
Hinselmann et al. in 1925.
In 1989, Scholefield et al. prospectively used a microscope to examine
the anal canal to detect premalignant lesions.
In 1997, Jay et al. reported high-resolution anoscopy (HRA) using a
colposcope in conjunction with an anoscope to describe the appearance
of anal SILs and their relationship to histopathology.
In 2017, Oette and coworkers described anal chromoendoscopy (ACE)
using gastroenterological video endoscopes.
Inkster et al. described chromoendoscopy with narrow-band imaging
(NBI) and NBI with acetic acid (NBIA) using both en face and
retroflexed views to detect anal dysplasia.
Preprocedural Interview
A history is obtained and physical examination is performed. Risk factors
for anal HPV disease are identified.
Baseline anal cytology is typically obtained.
The perianal skin and anal canal are examined by inspection, palpation,
and 1× anoscopy. Perianal condyloma, as shown in Figure 18-2, is noted.
FIGURE 18-2 Perianal or anal margin condyloma acuminata (arrows) are located on
the hair-bearing skin.
Lesions of the mouth, nares, eyelids, penis, or gynecologic areas are

referred for appropriate follow-up.
Colposcope
Dilute acetic acid (3% solution)
Lugol iodine solution
Cotton-tip applicators
Forceps/needle driver/scissors
Biopsy forceps
Electrocautery
3-0 Vicryl or chromic suture
Colonoscope with NBI
Clear self-lighted plastic disposable anoscope
TECHNIQUE
Detection of Anal Dysplasia
Anal Colposcopy/High-Resolution Anoscopy

The patient undergoes a full cathartic bowel preparation with miralax prior
to the procedure.
The procedure is performed in the operating room under general
anesthesia.
The patient is placed in the lithotomy position utilizing yellow-fin stirrup.
The perianal skin and anal canal are examined through a colposcope to
identify lesions (Fig. 18-3).
FIGURE 18-3 Anal colposcopy (high-resolution anoscopy). The anoderm is inspected
through an anoscope with a colposcope.
Treatment of the anoderm with dilute acetic acid makes abnormal

epithelium appear white (“acetowhite”). This is performed using a cotton
tip applicator soaked in the acetic acid and applied to the anoderm.
Treatment with Lugol iodine solution stains the glycogen-containing
normal epithelium brown; abnormal epithelium, depleted of glycogen,
does not take up the stain. A saturated cotton tip applicator is soaked in
Lugol’s solution and it is applied directly to the area.
The appearance of anoderm stained with Lugol iodine is shown in Figure
18-4.
FIGURE 18-4 Treatment of the anoderm with Lugol iodine stains normal anoderm
brown (arrows).
Lesion detection is enhanced using a green filter.

Biopsy of abnormal-appearing epithelial lesions is done to establish their
histopathologic identity.
The appearance of anal low-and high-grade lesions, as seen through a
colposcope, is shown in Figures 18-5 and 18-6, respectively.
FIGURE 18-5 A. Diffuse low-grade anal lesion (white arrows) seen through a
colposcope. B. Histopathologic appearance of the lesion seen in A. The squamous
epithelium shows prominent koilocytes, characterized by enlarged, hyperchromatic, and
angulated nuclei (arrow) showing perinuclear halos. Binucleation is common (arrowhead).
The cells maintain an overall low nuclear-to-cytoplasmic ratio, and there is no significant
expansion of the basal layer (curved arrow). The overall findings are diagnostic of low-
grade squamous intraepithelial lesion.
FIGURE 18-6 A. Examination of the anoderm through a colposcope with a green filter
after treatment with acetic acid reveals a raised lesion (arrow). B. The squamous
epithelium of this lesion shows partial thickness atypia (arrows), characterized by
disorganized polygonal cells with eosinophilic cytoplasm, increased nuclear-to-cytoplasmic
ratio, nuclear hyperchromasia, numerous mitoses (curved arrow), and dyskeratotic
keratinocytes. The upper third of the squamous epithelium (arrowhead) shows maturation
with evenly spaced nuclei and a low nuclear-to-cytoplasmic ratio. This would previously
have been classified as AIN II; however, it is now classified as HSIL per the LAST
consensus.1 AIN, anal intraepithelial neoplasia; HSIL, high-grade squamous intraepithelial
lesion.
Anal Chromoendoscopy
Oette et al. used gastroenterological video endoscopes to perform HRA for
the diagnosis of intraepithelial dysplasia and anal carcinoma in HIV-
infected patients.
Their technique, ACE, involves anoderm examination en face after surface
staining with acetic acid and Lugol solution.
ACE is performed with a mucosectomy cap on the tip of the endoscope.
The authors conclude that ACE is a valuable method to exclude anal
dysplasia if the procedure is performed by well-trained endoscopists.
CHROMOENDOSCOPY WITH RETROFLEXION AND

INSUFFLATION
High-definition chromoendoscopic detection of anal lesions using both en

face and retroflexed views (Fig. 18-7A and B) plus NBI is documented.
FIGURE 18-7 A. A lesion in the anal transitional zone (distal rectum) is examined with
retroflexion following insufflation. B. A lesion within the anal canal is examined en face
through a beveled clear plastic anoscope.
As noted by Tanaka et al., retroflexion and insufflation distend the rectum

and facilitate visualization of the anal columns and sinuses of the anal
transitional zone (ATZ) similar to an open umbrella (Fig. 18-8).
FIGURE 18-8 A. Retroflexed view of the ATZ, bordered proximally by the anorectal
line and distally by the dentate line, seen under NBI. The pecten lies distal to the dentate
line. B. En face view of the ATZ (between the columnar epithelium and the pecten) seen
with white light through a self-lighted beveled anoscope. A, anterior; ATZ, anal transitional
zone; L, left; NBI, narrow-band imaging; R, right; Scope, endoscope.
Inkster and coworkers visualized the anoderm by chromoendoscopy with

both en face and retroflexed views aided by NBI and NBIA to detect anal
SIL.
A clear self-lighted plastic disposable anoscope is used to facilitate
identification, biopsy, and removal of lesions in the anal canal.
Approach Advantages
Retroflexion with rectal air insufflation provides a view of the effaced
ATZ.
Examination through a beveled self-lighted clear plastic anoscope
provides en face views of the ATZ and pecten. The anoscope increases the
diameter of the anal canal, facilitating magnified endoscopic visualization
of the epithelium.
Chromoendoscopy with NBI and NBIA facilitates identification of anal
SIL.
Lesions can be biopsied and ablated endoscopically using standard
endoscopic equipment.
The location and appearance of the lesion are preserved as part of the
electronic record (ProVation/Epic, Provation Medical. Minneapolis, MN).
The appearance of any area can be compared with that seen in previous
examinations.
The techniques used are part of routine gastrointestinal practice.
Normal Anal Anatomic Landmarks

Retroflexion and en face views of both the distal rectum and the anal canal
show the anorectal line, the ATZ, the dentate line, and the pecten.
These anatomic structures in normal patients are shown in Figure 18-8.
Examples of Chromoendoscopy with Retroflexion and

Insufflation
The following abbreviations were used in the images that follow: A,
anterior; ARL, anorectal line; ATZ, anal transitional zone; L, left; P,
posterior; PEC, pecten; R, right; Scope, endoscope.
Figure 18-9 shows how the rectal anatomy can be determined by
identification of prominent anatomic landmarks and by the position of
water.
FIGURE 18-9 This examination was performed with the patient lying on their left side.
Liquid lies in the dependent position. The contour of the right and left levator ani is seen.
The levator sling is open anteriorly, allowing the pecten distal to the dentate line to be
seen. A, anterior; DL, dentate line; L, left; P, posterior; R, right; Scope, endoscope.
In Figure 18-10A, multiple lesions are seen tangentially with an en face

view of the anal canal seen at routine white light screening colonoscopy.
Retroflexion brings multiple lesions into view (Fig. 18-10B).
FIGURE 18-10 A. En face view of the anal with white light showing multiple ill-defined
lesions (white arrows). B. Retroflexed view of the rectum with insufflation and white light
illumination showing multiple discrete ATZ lesions (black arrows). Biopsy showed LSIL.
ATZ, anal transitional zone; LSIL, low-grade squamous intraepithelial lesion; Scope,
endoscope.
The patient depicted in Figure 18-11 underwent screening colonoscopy.
FIGURE 18-11 A. A lesion is seen on the left anterior ATZ with retroflexion and white
light illumination. B. The same lesion as in A seen with NBI shows punctation (black
arrow) and mosaicism (white arrow). C. Follow-up examination of the same site after
lesion ablation shows a scar (black arrow) without residual tumor. Pathology showed
HSIL. A, anterior; ARL, anorectal line; ATZ, anal transitional zone; HSIL, high-grade
squamous intraepithelial lesion; L, left; NBI, narrow-band imaging; R, right; Scope,
endoscope.
A lesion was identified by chromoendoscopy with retroflexion and
insufflation under both white light and NBI illumination (Fig. 18-11A and
B).*
The lesion was ablated. Follow-up examination showed no residual lesion
(Fig. 18-11C).
Figure 18-12A and B illustrates the importance of obtaining both posterior
and anterior views of the anorectum by rotating the endoscope during
retroflexion.
FIGURE 18-12 A. No lesions are seen on posterior retroflexed view of the rectum
with NBI and acetic acid. B. Anterior retroflexed view of the rectum in the same patient
showing a large anterior lesion (arrows). C. Retroflexion view with the endoscope. Biopsy
showed LSIL. A, anterior; ARL, anorectal line; ATZ, anal transitional zone; L, left; LSIL,
low-grade squamous intraepithelial lesion; P, posterior; R, right; Scope, endoscope.
There are occasions where the lesions can be particularly difficult to find.
Chromoendoscopy was performed to detect anal SIL because of high-
grade SIL on anal cytology for the patient depicted in Figure 18-13.
FIGURE 18-13 A complex lesion seen in the anal pecten following treatment with
acetic acid and illumination with NBI through a self-lighted beveled anoscope. The
prominent surface vessels attest to the hypervascular character of the lesion. The lesions
were biopsied and ablated. Biopsy showed HSIL consistent with the anal cytology.
Asterisks indicate the areas of concern. HSIL, high-grade squamous intraepithelial lesion;
NBI, narrow-band imaging.
Three small high-grade lesions were found in between anal epithelial folds
and ablated.
*This is the same lesion as is shown by anal colposcopy in Figure 18-6A.
Postoperative Care
Resume normal diet
Resume normal activity
Follow-up on pathology
This will dictate the interval for the next procedure/surveillance.
Conclusions
Anal SILs are HPV-associated neoplasms that can progress to squamous
cell carcinoma. Lesion detection is necessary for diagnosis and
management.
Magnification, green filter/NBI, and treatment of the anoderm with acetic
acid and other chemical agents facilitate lesion identification.
Methods currently used for anal SIL detection include anal colposcopy
and ACE.
Suggested Readings
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Chou YP, Saito Y, Matsuda T, et al. Novel diagnostic methods for early-stage squamous cell
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Philadelphia, PA: Wolters Kluwer; 2012:484-538.
Darragh TM, Colgan TJ, Cox JT, Heller DS, Henry MR, Luff RD. The lower anogenital squamous
terminology standardization project for HPV-associated lesions. Arch Pathol Lab Med.
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Hinselmann H. Verbessereung der Inspektionsmöglichkeitein von Vulva, Vagina und Portio. München
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Horimatsu T, Miyamoto S, Ezoe Y, Muto M, Yoshizawa A, Sakai Y. Gastrointestinal: case of early-
stage squamous cell carcinoma of the anal canal diagnosed using narrow-band imaging system
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Inkster MD, Wu JS. Detection of anal dysplasia by chromoendoscopy with narrow band imaging and
acetic acid (NBIA) in 182 patients. Clin Surg. 2017;2:1-5.
Jay N, Berry JM, Hogeboom CJ, Holly EA, Darragh TM, Palefsky JM. Colposcopic appearance of
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Morisaki T, Isomoto H, Akazawa Y, et al. Beneficial use of magnifying endoscopy with narrow-band
imaging for diagnosing a patient with squamous cell carcinoma of the anal canal. Dig Endosc.
2012;24:42-45.
Oette M, Wieland U, Schünemann M, et al. Anal chromoendoscopy using gastroenterological video
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follicles. Anal margin. Radiopaedia. Available at: radiopaedia.org
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Rectal Surg. 2004;15:196-200.
PART III
The Abdomen
Chapter 19
Anastomotic Construction Techniques
MATTHEW F. KALADY
There are a variety of ways to construct safe and effective bowel
anastomoses.
No one particular anastomosis is considered “the best,” and the method
selected is often made based on surgeon preference, the clinical situation
at hand, and experience.
Surgeons should be aware of various anastomotic techniques, using
staplers or sutures.
It is imperative that surgeons use clinical judgment to decide which
anastomotic technique is most appropriate for each individual case based
on anatomy, quality of tissue, and patient- and disease-related factors.
The anastomotic technique may also rely on the availability of particular
instruments, instrument malfunction, and technical feasibility.
Clinical judgment, especially regarding when not to do an anastomosis, is
equally important as how do construct one.
Patients with severe malnutrition, immunosuppression, sepsis, shock, or
fecal contamination should be considered for a stoma without an
anastomosis.
General Technical Considerations

Use healthy tissues for anastomosis.
Ensure adequate blood supply to both ends of the bowel.
Mobilize both ends of the bowel to avoid tension.
Align corresponding mesentery without twisting or torsion.
TYPES OF ANASTOMOSES BASED ON ANATOMY
Enteroenteric or Ileocolonic Anastomoses
Perioperative Consideration/Approach
Enteroenteric anastomoses are commonly performed for small bowel
resection for Crohn disease (see Chapter 41), radiation enteritis, closure of
ileostomy (see Chapter 43 and 44), enterocutaneous fistulas (see Chapter
27), and resection of small bowel neoplasms.
Ileocolonic anastomoses are commonly used after ileocolic resection for
Crohn disease (see Chapter 41) or right colectomy for colon cancer (see
Chapter 22).
Equipment
Stapling devices (Fig. 19-1):
Linear cutting single-use reloadable stapler (linear cutting, 60 or 80 mm
length), 3.8-mm staple height
FIGURE 19-1 Different types of surgical staplers used in the construction of bowel
anastomoses. A. Linear cutting stapler. B. Transverse anastomosis (TA) linear
noncutting stapler. C. Laparoscopic articulating linear cutting stapler. D. PI linear
noncutting stapler. E. Circular end-to-end anastomosis (EEA) stapler.
Linear noncutting (60-mm length, 3.8- or 4.8-mm staple height)

End-to-end anastomosis (EEA) circular stapler (3.5-mm staples, 28, 31,
or 33 mm diameter)
Suture: Vicryl, polydioxanone (PDS), ethibond of various needle shape,
sizes, and thickness
Techniques
Side-to-side (functional end-to-end), stapled
Use wound protector to limit potential soilage of the wound edges.
Clear mesenteric borders and ligate mesentery.
Staple across bowel using a linear stapler at a healthy area of bowel.
Staple line should be parallel to the mesentery and go across the bowel
in the same plane from the mesenteric edge of the bowel to the
antimesenteric border.
Place the tips of the stapler on the antimesenteric side.
Angle the stapler away from the mesentery so that the antimesenteric
edge is slightly shorter than the mesenteric edge (Fig. 19-2A).
FIGURE 19-2 Stapled side-to-side anastomosis. An ileocolic anastomosis is
shown. A. Use a linear stapler to divide across the bowel. Note that the angle of the
stapler is toward the side of the bowel that will remain for the anastomosis so that
there is improved blood flow to the antimesenteric bowel wall. B. An enterotomy is
made on the antimesenteric corners of the staple line in the small bowel and a
corresponding colostomy in the colon. The openings are exposed with the use of Allis
clamps. C. The linear stapler is inserted into each limb of bowel, and the
antimesenteric bowel walls are aligned. D. Before closing and firing the stapler, the
surgeon’s hand is placed below the bowel and ensures that there is no mesentery or
other tissue included in the anastomosis and that the antimesenteric walls are
included. E. The common enterotomy is stapled across with a linear noncutting stapler.
Allis clamps are used to extend the open end of the bowel to ensure that the full
thickness of the bowel wall is incorporated in the stapler.
Open the antimesenteric corners of the staple line and anchor with Allis
clamps (Fig. 19-2B).
Place one arm of the stapler down each limb of the bowel (Fig. 19-2C).
Align the antimesenteric borders and close the stapler, place fingers
beneath the bowel and spread, pushing the mesentery laterally to ensure
that the antimesenteric borders are in the anastomosis (Fig. 19-2D), then
fire the stapler.
Close the common enterotomy (Fig. 19-2E) with a linear noncutting
stapler such as a transverse anastomosis (TA) stapler (Fig. 19-1), 3.8- or
4.8-mm staple height.
Ensure no bleeding from bowel staple lines.
Stagger the bowel staple lines when aligning to close enterotomy.
Ensure mucosa, submucosa, and serosa are all elevated and into the
stapler; check again after closing the stapler, before firing.
Resect the remaining edge distal to the staple line with a scalpel; there
will be some resistance as the scalpel cuts across the small bowel staple
lines.
Ensure hemostasis on the transverse staple line.
Imbricate the corners with 3-0 Vicryl sutures.
Reinforce the crotch of the anastomosis with 3-0 Vicryl suture.
Alternatively, oversew the full staple line with interrupted 3-0 Vicryl
sutures in Lembert manner.
Oversew the common enterotomy staple line with running 3-0 Vicryl
stitch.
Alternatively, enterotomy can be closed with suture or with another
linear cutting stapler.
The author prefers to use an omental pedicle flap (Fig. 19-3A and B)
around an ileocolic anastomosis.
FIGURE 19-3 Omental pedicle flap over the anastomosis. A. The omentum is
partially freed and mobilized from the remaining transverse colon to create a floppy
omental flap. B. The omental flap is loosely secured to the bowel or mesentery with 3-
0 Vicryl sutures.
Side-to-side (functional end-to-end), sutured

As earlier, the proximal and distal margins of the bowel are stapled
across and divided.
Alternatively, they can be sewn closed.
Antimesenteric borders are aligned and stay sutures placed to align the
two segments of the bowel (Fig. 19-4A).
FIGURE 19-4 Sutured side-to-side anastomosis. An ileocolic anastomosis is
shown. A. The antimesenteric bowel walls are aligned, and stay sutures are placed to
help with alignment and retraction. A posterior wall running suture is then placed as
the deep layer of the anastomosis. B. Longitudinal enterotomy and colostomy is made
in each limb of bowel, respectively. C. The inner layer of the posterior wall is
completed with running full-thickness sutures. D. Detailed view of the transition of the
corner stitches and Connell stitch on the anterior wall inner layer of the anastomosis.
E. Completion of the outer layer of the anterior wall with Lembert sutures.
Posterior layer of a running 3-0 PDS suture through the seromuscular

layers is placed to appose the two limbs of bowel (Fig. 19-4A).
Longitudinal enterotomies are made (Fig. 19-4B).
The posterior walls of the bowel are sutured together with a full-
thickness 3-0 PDS running stitch, focusing on incorporation of the
submucosal layer. There are two initial sutures placed in the middle of
the backwall and then run to opposite ends of the anastomosis (Fig. 19-
4C).
The suture transitions to a Connell suture at the corners and along the
anterior wall (Fig. 19-4D).
The anterior second layer of the anastomosis is completed with
interrupted 3-0 PDS Lembert, imbricating the stitches (Fig. 19-4E).
This layer can also be done as a running suture if preferred.
The author prefers PDS suture for running anastomosis for its ease of
passage through the tissue.
End-to-side anastomosis, stapled
Divide both ends of the bowel between clamps sharply.
Open bowel lumens and ensure adequate health and blood supply.
Assess for size of stapler that will be accommodated by small bowel
lumen.
Secure anvil into the open end of the small bowel using a “0” Prolene
purse-string suture (Fig. 19-5A).
FIGURE 19-5 Stapled end-to-end anastomosis. An ileocolic anastomosis is
shown. A. The anvil is secured in place with a running “0” Prolene suture. The closed
bowel wall should not have any gaps on the anvil. B. The stapler is introduced through
the open end of the colon, and the spike is brought out on the antimesenteric wall,
about 5 cm from the open edge. C. The spike is mated with the anvil and D. closed to
appose the two ends of bowel, ensuring that no other tissues are involved and that the
mesentery is appropriately aligned. E. The open end of colon is then stapled across
with a linear noncutting stapler.
Use full thickness but small bites of bowel so that the entire bowel wall
gets brought into the anvil, but there is no bunching of tissue.
Prepare the bowel so that peritoneum and fat are not in the anastomosis.
The entirety of the fat does not need to be removed, rather, just the
peritoneal or outer lining so that the fat is essentially pushed out of the
stapler when it is closed.
Avoid pulling the mesentery into the circular stapler.
Open the end of the colon and introduce the stapler with the penetrating
spike to exit through the antimesenteric area of the colon,
approximately 5 cm from the open edge or where the final resection
line will be (Fig. 19-5B).
Couple the anvil and the spike (Fig. 19-5C) and close the providing
gentle traction on the small bowel so that the stapler closes smoothly
and securely (Fig. 19-5D).
Fire and remove the stapler, check the anastomotic rings for
completeness.
Pass a Kelly clamp through the open end of the colon and ensure that
both the proximal and distal lumens are completely patent.
Staple across the open end of the colon, allowing approximately 5 cm
between the anastomosis and the linear staple line to ensure good blood
flow and no blocking in a short segment (Fig. 19-5D).
Oversew the linear staple line with 3-0 Vicryl, imbricating the ends.
Oversew the circular staple line with interrupted 3-0 Vicryl stitches.
End-to-side anastomosis, sutured
Divide small bowel between bowel clamps sharply. Divide the colon
with a linear cutting stapler.
Open small bowel lumen and ensure adequate health and blood supply.
Perform a colotomy on the antimesenteric border, approximately 5 cm
distal to the staple line for the end-to-side sutured anastomosis (Fig. 19-
6A).
FIGURE 19-6 Sutured end-to-side anastomosis. An ileocolic anastomosis is
shown. A. After the colon is closed and divided with a linear stapler and the bowel has
been sharply resected leaving an open end, a colotomy is made in the antimesenteric
colon wall to a size to match the small bowel lumen. B. Stay sutures are placed to help
with alignment and retraction. The posterior wall of the anastomosis is completed with
interrupted full-thickness sutures. C. The sides and anterior wall are completed with
full-thickness interrupted sutures.
Use full-thickness sutures through the backwall of the colotomy and

small bowel (Fig. 19-6B).
Complete the front wall of the anastomosis with full-thickness 3-0
Vicryl suture (Fig. 19-6C). An additional imbricating suture layer
anteriorly may be considered.
End-to-end, sutured
This technique is preferred for anastomosis dilated bowel, thickened
bowel wall, or if there is a size mismatch between bowel lumens.
Divide bowel at each resection point sharply between noncrushing
bowel clamps.
Place stay sutures in two areas of the bowel, 1800 apart on the
circumference, to avoid excessive handling the bowel lumen (Fig. 19-
7A).
FIGURE 19-7 Sutured end-to-end anastomosis. An ileocolic anastomosis is

shown. A. Stay sutures are placed to minimize handling of the bowel. B. The posterior
wall of the anastomosis is constructed using interrupted Turnbull sutures. C. If there is
size mismatch between the bowel lumens, a Cheatle slit may be performed on the
smaller lumen. D. The anterior wall is reinforced with imbricating sutures.
Place backwall sutures, as Turnbull sutures that incorporate full

thickness of the bowel wall and then vertical mattress back through the
mucosa, inverting the mucosa (Fig. 19-7B).
If there is a size discrepancy, dilated bowel, or thickened bowel wall, a
Cheatle slit may be employed to enlarge the lumen for anastomosis
(Fig. 19-7C).
Transition at the corners to seromuscular sutures, inverting the mucosa.
Place 3-0 ethibond imbricating sutures over the anterior layer (Fig. 19-
7D).
PEARLS AND PITFALLS
Submucosa is the strongest area of the bowel wall and is the cornerstone
of any handsewn anastomosis. Ensure that sutures incorporate this
layer.
Test for adequate blood supply by unclamping the artery before ligating
it. Also, there should be vigorous bleeding in the cut edges of the bowel.
Always ensure there is enough mobility to the ends of the bowel that are
being connected so that there is no tension or torsion on the
anastomosis.
Avoid or limit “dog ears” on the anastomosis. This can be done by
incorporating one of the dog ears into the staple line. If dog ears are
present on the corner, use suture to imbricate them.
Hematomas can cause separation of the anastomotic suture line or
compromise the arterial and/or venous blood flow. Always confirm
hemostasis of the completed anastomosis. When creating a stapled side-
to-side anastomosis, the lines should be inspected before closing the
common enterotomy.
Ensure that there is adequate distance between the stapled across end of
the colon and the end-to-side anastomosis so that there is not a short
watershed area with decreased blood flow, which can cause ischemia.
ILEORECTAL AND COLORECTAL ANASTOMOSES
Ileorectal anastomosis is commonly used after a total colectomy for Crohn
disease, familial adenomatous polyposis, constipation, or for colon cancer
in the setting of a hereditary syndrome.
Colorectal anastomosis is commonly used after a sigmoid colectomy or
left colectomy for diverticulitis or cancer.
Equipment
Stapling devices (Fig. 19-1)
Laparoscopic: Medtronic Endo GIA purple load tristaple technology,
45 or 60 mm long
Medtronic DST Series GIA single-use reloadable stapler (linear,
cutting, 60 or 80 mm length), 3.8- or 4.8-mm staple height
Medtronic DST Series TA titanium staples (linear, noncutting, 60 mm
length), 3.8- or 4.8-mm staple height
DST Series EEA circular stapler; 3.5-mm staples, 28, 31, and 33 mm
diameter
Suture: Vicryl (polyglactin), PDS, ethibond
Techniques
End-to-end, stapled
The rectum is cleared of surrounding mesorectum to the bowel wall and
then stapled across.
If done laparoscopically, an articulating linear cutting stapler is
preferred. Usually, the mesenteric fat can be cleared sufficiently so
that a single firing of the stapler can be used.
A laparoscopic view of a stapled across rectal stump is shown in
Figure 19-8A.
FIGURE 19-8 Stapled end-to-end anastomosis (EEA). A colorectal
anastomosis is shown. A. Laparoscopic view of a stapled across end of the rectum.
B. The exteriorized colon is held open with Babcock clamps, and a purse-string
suture is placed to secure the anvil of the EEA stapler. C. Laparoscopic view of
stapler spike brought out through the transverse staple line on the rectal stump. D.
Laparoscopic view of the colon and rectum joined via closure of the EEA stapler. E.
Schematic of joining the stapler. F. Endoscopic view of the completed anastomosis
demonstrating patency and hemostasis.
During a laparoscopic technique, the proximal portion of the bowel is

exteriorized after distal resection. The ileum or colon is divided sharply
between bowel clamps.
Open the proximal bowel lumen and ensure adequate health and blood
supply.
For a colorectal anastomosis, the marginal artery is cut sharply
before being completely clamped and tied to evaluate the degree of
blood flow.
Adequate mobilization is performed to avoid tension on the
anastomosis. This usually requires mobilization of the splenic flexure
with a colorectal anastomosis.
Secure an appropriately sized anvil into the open end of the
proximal bowel using a “0” Prolene suture.
When performing the purse-string suture, use full thickness but small
bites of bowel so that the entire bowel wall gets brought into the anvil.
Ensure there is no bunching of tissue.
The author’s preference is to use a 33-mm EEA stapler, but a 31 mm is
more commonly used due to the bowel lumen size. To help place the
anvil into the lumen, Babcock clamps are placed on opposite ends of
the bowel lumen to provide traction (Fig. 19-8B).
Once the anvil is in the lumen, tie the purse-string suture so that it
bowel wall pulls in snug on the anvil. Avoid pulling the mesentery into
the circular stapler.
Prepare the bowel so that peritoneum and fat are not in the anastomosis.
The entirety of the fat does not need to be removed, rather, just the
peritoneal or outer lining so that the fat is essentially pushed out of the
stapler when it is closed.
Insert the EEA stapler into the anus and advance it to the top of the
rectal stump, avoiding injury to the rectal mucosa, and also avoiding
penetration of the top of the rectal stump staple line.
Alternatively, a sigmoidoscopy in air can be used.
If these do not work, also look for a peritoneal band at the reflection
that may be preventing passage of the stapler to the apex.
Finally, ensure there is not retained sigmoid that may have to be
resected.
Once the stapler is at the top of the rectal stump, the spike is advanced
through the tissue at the transverse staple line. Efforts are made to bring
the spike out slightly asymmetrically so that one of the corners of the
transvers staple line is incorporated into the circular anastomosis.
A laparoscopic view is shown in Figure 19-8C.
This maneuver avoids have two small “dog ear” corners with short
distance to the circular staple line, which may be prone to leak.
Alternatively, a purse string can bring the corners in to be
incorporated into the stapled anastomosis.
The anvil is coupled onto the spike and the stapler is closed, ensuring
that other structures such as ovaries, ureters, and fallopian tubes are
away from the anastomosis (Fig. 19-8D). A schematic of this step is
shown in Figure 19-8E.
The appropriate orientation of the mesentery is checked again so that
there is no tension or torsion.
Only after the two safety check points above are satisfied, should the
stapler be fired and removed.
The anastomotic donuts are check for completeness.
If there is a corner “dog ear,” it is imbricated with a 3-0 Vicryl stitch.
Evaluation of the anastomosis is performed. The pelvis is filled with
saline or sterile water (for cancer cases), and the bowel proximal to the
anastomosis is gently occluded.
A flexible sigmoidoscope is inserted through the anus and advanced
to the level of the anastomosis, with insufflation of air.
From the abdominal exposure, the surgeon ensures there are no
bubbles seen from the submerged anastomosis. On the endoscopy
side, an observation can be made regarding the patency and
hemostasis of the anastomosis (Fig. 19-8F).
End-to-end, sutured
In preparation for a sutured EEA, the rectum is divided sharply after
occlusion with a bowel clamp.
The proximal bowel for the anastomosis is prepared as above.
Size discrepancy should be evaluated and lumens prepared for
reasonable size match.
A Cheatle slit may be needed to enlarge the lumen of the small bowel
for an ileorectal anastomosis.
It is the author’s preference to perform a side-to-end if there is a size
mismatch significant enough to require a Cheatle slit in the small
bowel.
A colorectal anastomosis usually presents a reasonable size match.
The anastomosis is done with interrupted 3-0 Vicryl sutures. The
backwall is completed first using interrupted Turnbull stitches that
incorporate full-thickness in-to-in and passage back through just the
submucosa and mucosa in-to-in with tying on the same side of the
lumen to evert the mucosa. After the backwall is completed, the corner
stitches transition to seromuscular only with inversion of the mucosa.
The anterior wall is completed with interrupted seromuscular stitches.
The anterior wall is reinforced with a second layer of interrupted 3-0
imbricating sutures. This technique is similar to that as illustrated in
Figure 19-7.
A leak test and anastomotic evaluation is done as described earlier.
Side-to-end, stapled
The proximal and distal bowel are stapled across with linear cutting
staplers.
An enterotomy or colotomy is made on the antimesenteric border of the
proximal bowel, approximately 5 cm proximal to where the final staple
line closure will be. This can be done via the sharp spike introducer
(Fig. 19-9A), which is then removed.
FIGURE 19-9 Stapled side-to-end anastomosis. A. The stapler is introduced
through the open end of the colon, and spike is brought out. B. The open end of the
colon is stapled across and closed, ensuring that at least 5 cm of the colon remains
between the end of the colon and the circular anastomosis to avoid potential ischemia.
C. The colon with the transverse staple line oversewn and the anvil exposed in
preparation to return to the abdominal cavity and completion of the colorectal
anastomosis. D. Drawing of the orientation of a completed side-to-end colorectal
anastomosis.
The open end of the colon or small bowel is then stapled across with a
TA60 green–loaded stapler (Fig. 19-9B).
The author prefers to oversew the transverse staple line with 3-0 Vicryl
running suture to promote hemostasis and decrease leak (Fig. 19-9C).
The EEA stapler is then inserted into the anus and advanced to the top
of the rectal stump, avoiding injury to the rectal mucosa, and also
avoiding penetration of the top of the rectal stump staple line (as shown
in Fig. 19-8C). Rounded EEA sizers may be utilized to gently dilate the
rectum along its entire length to allow accommodation for the stapler.
The anastomosis is then completed as described for the stapled EEA, as
described earlier. A leak test is performed. A drawing of the completed
side-to-end stapled anastomosis is shown in Figure 19-9D.
Side-to-end, sutured
The proximal bowel is divided with a linear cutting stapler. The distal
bowel (the rectum) is divided sharply with a bowel clamp distal.
An area is chosen in the proximal bowel approximately 5 cm proximal
to the staple line, and an enterotomy (or colotomy) is made on the
antimesenteric border (Fig. 19-10A). The length of the bowel opening
should be commensurate with the lumen of the distal bowel for the
anastomosis.
FIGURE 19-10 Sutured side-to-end anastomosis. An ileorectal anastomosis is

shown. A. The antimesenteric border of the small bowel is aligned with the open end
of the rectum, and an appropriately sized enterotomy is made to match the rectal
lumen. B. The posterior wall of the anastomosis is completed with interrupted Turnbull
sutures. C. After completion of the inner layer of the anterior wall of the anastomosis,
an outer layer is completed by placing interrupted imbricating sutures.
The anastomosis is performed with interrupted 3-0 Vicryl sutures. The
backwall is completed first using interrupted Turnbull stitches that
incorporate full thickness in-to-in and passage back through just the
submucosa and mucosa in-to-in with tying on the same side of the
lumen to evert the mucosa (Fig. 19-10B). After the backwall is
completed, the corner stitches transition to seromuscular only with
inversion of the mucosa.
The anterior wall is completed with interrupted seromuscular stitches.
The anterior wall is reinforced with a second layer of interrupted 3-0
imbricating sutures (Fig. 19-10C).
A leak test and anastomotic evaluation is done as described earlier.
TIPS
Rounded EEA sizers may be utilized to gently dilate the rectum along
its entire length to allow accommodation for the stapler.
PEARLS AND PITFALLS
For handsewn anastomoses, use a monofilament as it glides nicely

through the tissue.
Ensure there is no tension on the anastomosis.
It may be difficult to mobilize the proximal colon for a colorectal
anastomosis.
Maneuvers to release tension and provide adequate length for the
anastomosis include performing a high ligation of the inferior
mesenteric vein at the inferior border of the pancreas, mobilization of
the splenic flexure, and separation of the omentum from the colon.
For colorectal anastomoses, always assess appropriate blood supply by
unclamping the marginal artery on the colon side to check for pulsatile
bleeding. Nuisance bleeding in the submucosa is another sign of
adequate blood supply. This can be noted when dividing the bowel
sharply.
Always perform an anastomotic leak test.
If there is a small anastomotic defect noted on leak test, the defect can
be repaired with suture and rechecked.
Suggested Reading
Chapter 20
Complicated Anastomoses: Turnbull-
Cutait
SHERIEF SHAWKI
The Turnbull-Cutait technique is typically used in setting of reoperative
pelvic surgery or when dealing with large recto-urethral fistulas secondary
to radiation for prostate cancer.
Reoperative surgery is one of the most complex facets of colorectal
surgery, in which success relies mainly on planning and an optimal
decision-making process.
Preoperative Assessment and Evaluation

Review prior clinical events and any health-related medical and/or
surgical episodes.
Review of operative notes, pathology slides, and imaging are of utmost
importance. One should understand the patient’s current anatomy, prior
postoperative complications, and duration of problems—the latter can
reflect the potential hostility of the intra-abdominal and pelvic cavity.
Evaluate functional and nutritional status and candidacy for successfully
undergoing a major surgery.
Evaluate functional status of the anal sphincter mechanism.
Discussion with the Patient

Is it worth it? It is crucial to discuss with patients the risks and benefits, as
well as the potential complications prior to any reoperative pelvic surgery.
Set realistic expectations.
Discuss expected bowel function as this will be altered from the past.
Ensure the timing of the procedures allows for optimizing success.
When the indication for such procedure is leak and infection, proper
sepsis control is a key.
Do not allow for a long-standing pelvic infection to commence, if
possible, to avoid frozen pelvis and fibrosis of surrounding pelvic
tissues.
This will render the surgical procedure more difficult and may not
provide space for the new colonic conduit to fit in the pelvic cavity
nor reach through the pelvic floor.
Review all radiographic and endoscopic anatomy. Ask yourself:
How much colon is left?
Has there been a prior mobilization of splenic flexure?
Was the inferior mesenteric artery (IMA) and or left colic vessels
divided?
What is the status of the inferior mesenteric vein (IMV)—has it been
divided already?
All of these questions will give an estimation for potential problems with
achieving the length needed to perform a pull-through procedure.
Operative Planning
Prepare for a long case; these often will take several hours.
Obtain an appropriate level of assistance across the entire operating room
team.
Assure you have the capability of rapid resuscitation.
Type and cross the patient for the potential need for blood transfusion.
Positioning
Modified lithotomy Lloyd-Davis position
Bilateral ureteric stents (in case of reoperative abdominopelvic surgery)
Skin preparation for both the abdomen and the perineum to include a
vaginal preparation, as indicated.
All extremities should be properly positioned and padded.
The patient perineum should be placed on the edge of the operative table,
with a blanket roll underneath the sacrum to facilitate accessibility during
perineal phase.
Special Equipment
Standard laparotomy set
Mechanical staplers, if required
Long instruments
Deep pelvic retractors, lighted preferred
Vaseline gauze and cotton gauze to wrap the exteriorized colon and
retained full sutures to be used in future delayed anastomosis
#1 Vicryl sutures or Lone Star (Cooper Medical) device for anal eversion.
Technique
Stage I
Abdominal phase: preparing the conduit. (Note: Only the main steps are
mentioned here, as the primary chapter focuses on the perineal phase of
the Turnbull-Cutait.)
Identify anatomy and perform a proper and safe adhesiolysis.
Perform a complete splenic flexure mobilization.
If needed, to gain maximum length: ligate the IMA, left colic artery,
and IMV below the inferior border of the pancreas.
Entering the pelvis:
Identify both the ureters.
Enter the pelvis in the correct plane and avoid entering in the
presacral plane.
Be ready to deal with presacral bleeding, however, try to avoid it if
possible.
Electrocautery
Thumbtacks
Bone wax
Suture ligation
Muscle weld
Packing
Keep the great vessels away from harm.
Dissection should continue to the pelvic floor/levator muscle.
Transect the bowel—to include the prior anastomosis—as distally
as possible.
When present, a pelvic abscess must be properly drained.
Phlegmonous and devitalized tissues are debrided.
Remove any chronic inflammatory rind in the pelvis to avoid
continued sepsis.
The pelvic floor is often very fibrotic and rigid. This makes
passage of the conduit through the levator hiatus difficult.
Leave a pelvic drain.
Construct a diverting loop ileostomy if it was not created before.
Perineal phase
TIPS
Maintaining the marginal artery is crucial as this is the only supply for
the colonic conduit.
TIPS
Identifying the ureter at the pelvic brim does not guarantee any injury
distal in the pelvis. The chronic scarring draws both the ureters
toward the midline.
TIPS
Radial slits along the floor can create an accommodating space for the
colonic conduit in preparation to exteriorization.
Pre-exteriorization
Exposure to the perineum is key. The legs should be placed in a high
lithotomy position to properly access the perineum.
Place four to six perianal eversion sutures for better exposure of the distal
anal canal (Fig. 20-1A).
FIGURE 20-1 A. Eversion sutures are placed circumferentially for optimal exposure.
B. Lone Star retractor in place with good exposure of anal canal.
Alternatively, a Lone Star retractor can be used with good exposure (Fig.
20-1B).
A circumferential mucosectomy is performed starting at the dentate line to
ensure no mucosa is left behind and ensure proper adherence between the
conduit and anal canal.
Saline with epinephrine solution (1:100 000) can be used to infiltrate the
submucosal plane to facilitate with dissection (Fig. 20-2).
FIGURE 20-2 The mucosectomy after completion. Note this is at the level of the
dentate line.
Eight sutures, 2-0 polyglactin, are placed along the circumference of the
anal canal to allow for maturation of the anastomosis in the second stage.
In this step, the first bite is passed including mucosa and some fibers of
the internal anal sphincter. The sutures are then secured to the drape (Fig.
20-3A).
FIGURE 20-3 A. The sutures are in place and colonic conduit pulled through. B. The
colonic conduit is delivered to the anal canal in a properly oriented manner.
Exteriorization
The colonic conduit is now pulled through the anal canal, ensuring proper
orientation. In cases of an underlying complex rectovaginal or
rectourethral fistula, the colon may be rotated 180 degrees to lay the
mesenteric side against the vaginal or urethral fistula (Fig 20-3A and B).
The exteriorized colonic segment is wrapped with a petroleum gauze and
cotton gauze (Fig. 20-4). To avoid needle punctures, the sutures are rolled
over 4 × 4 gauze. 2-3 sutures for one rolled gauze. These are then
incorporated in the gauze wrap around the colon (Fig. 20-4B).
FIGURE 20-4 A. Inner gauze wrap around the conduit. B. Petroleum gauze and
cotton gauze wrapped around the conduit. The preplaced sutures are protected within this
wrapping.
Stage II—Delayed Anastomosis

This phase takes place after 5-10 days after stage I, and after adhesions
between the colon and anal canal had occurred; maturation of the coloanal
anastomosis can now be completed.
Anesthesia general
No need for urinary catheterization
Position
Lithotomy position
The gauze wrap is unraveled, and sutures are placed in organized manner
(Fig. 20-5).
FIGURE 20-5 The gauze is removed, and the eight previously placed sutures are
placed in an organized manner.
The exteriorized colon is now amputated at level of the anoderm. Avoid

amputating too much as this can lead to dehiscence and stricture (Fig. 20-
6).
FIGURE 20-6 The exteriorized colon is amputated at the level of anoderm.
The anastomosis is matured in a progressive manner while amputating the

colon. The second suture bite is now passed through full thickness of the
colon (Fig. 20-7A-C).
FIGURE 20-7 Amputation of the exteriorized colon continues in a consecutive manner
(A and B), while respective sutures are completed (C).
The sutures are then tied, and the delayed anastomosis is now completed
(Fig. 20-8A and B).
FIGURE 20-8 A. Completing the anastomosis. B. Anastomosis completed.
Postoperative Care
Between Stages I and II

The patient may ambulate and resume a diet.
Avoid sitting directly on the conduit.
There is no need for routine removal of the gauze unless there is a concern
for an ischemic or necrotic conduit, which should be appropriately
evaluated and managed.
There is no need for prolonged antibiotics.
Patients may shower.
Venous thromboembolism (VTE) chemoprophylaxis
Following Stage II
Patients may resume routine enhanced recovery care pathways.
Avoidance of nasogastric tube
Early urinary catheter removal
VTE chemoprophylaxis
Early ambulation
Suggested Readings
Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW. Outcomes following Turnbull-Cutait
abdominoperineal pull-through compared with coloanal anastomosis. Br J Surg.
2009;96(4):424-429.
Rosselli Londono JM, Aytac E, Gorgun E. Turnbull-Cutait abdominoperineal pull-through: a safe
approach for recurrent sacrococcygeal teratoma complicated by rectovaginal fistula. Tech
Coloproctol. 2014;18(8):761-763.
Chapter 21
Left Colectomy
MICHAEL A. VALENTE
Left Colectomy
Surgical excision of the left and/or sigmoid colon is most often performed
for malignant disease and also for benign conditions, such as diverticulitis.
Inflammatory bowel disease and ischemic colitis are other less common
indication for a left colectomy.
The location and extent of the disease dictates the amount of colon to be
removed.
Benign conditions such as diverticulitis or sigmoid colon malignancies
usually only require a sigmoid colectomy with a descending colon to
rectum anastomosis (Fig. 21-1).
FIGURE 21-1 Sigmoid colon carcinoma. High ligation of the inferior mesenteric artery.
Descending colon to rectum anastomosis may be performed for these lesions.
Malignancies of the left colon require complete mesocolic excision; thus,

the left and sigmoid colon must be removed, secondary to high ligation of
the inferior mesenteric artery (IMA) and the entire mesocolic fascia is kept
intact on the anterior and posterior surfaces (Fig. 21-2).
FIGURE 21-2 Left colon carcinoma. High ligation of the inferior mesenteric artery and
inferior mesenteric vein will mandate both the left and sigmoid colon to be removed.
Perioperative Consideration
Formal preoperative assessment, including cardiopulmonary evaluation,
basic blood work, and appropriate imaging tests, should be performed to
prepare the patient for the operating room.
For cases of carcinoma, complete staging is compulsory, including
computed tomography scans of the chest, abdomen, and pelvis, as well as
obtaining a carcinoembryonic antigen level.
Nutritional parameters are checked, including albumin and prealbumin.
All patients (unless contraindicated) should receive preoperative oral
antibiotics (eg, metronidazole and neomycin), along with a full
mechanical bowel preparation, and are provided a chlorhexidine body
wash for the night prior to surgery.
In patients who have a diagnosis of neoplasia (adenomatous lesion or
invasive cancer), accurate preoperative localization of the lesion is
imperative.
If the lesion has not been endoscopically marked (ie, tattoo), a repeat
colonoscopy by the surgeon should be performed before the patient is
taken to the operating room for accurate localization.
Patient Positioning
Patients are placed in the modified lithotomy position with Yellowfins
stirrups or alternatively placed in a split-leg table (Fig. 21-3).
Careful attention is paid to protect bony prominences so as to prevent
nerve damage, especially the peroneal and ulnar/radial nerves.
FIGURE 21-3 Modified lithotomy position. Notice both arms tucked to the patient
side for either open or laparoscopic procedures.
It is our preference to tuck both arms at the patient’s sides for all
abdominopelvic cases (open or laparoscopic) for easy access and
ergonomic comfort for the surgeons performing the operation.
In general, for laparoscopic cases, the patient is secured to the table
over the chest, either with 3-in tape or a Velcro strap.
An inflatable bean bag or foam is also an option.
Guidelines for appropriate antibiotic use are strictly followed in all
patients, including 2 g of intravenous ceftriaxone and 500 mg intravenous
metronidazole within 60 minutes of incision; penicillin allergic patients
will receive 400 mg intravenous ciprofloxacin and 500 mg metronidazole.
Bladder catheter and orogastric tube are routinely placed.
Ureteral stents are very selectively placed to aid in identification of the
ureters.
At our institution, ureteral stents are generally reserved for complex
reoperative cases with extensive fibrosis or inflammatory changes of
the pelvis.
Operative Approach
The vast majority of left colectomies are now performed laparoscopically
(Fig. 21-4).
FIGURE 21-4 Room setup for laparoscopic left colectomy.
Robotic surgery may also be utilized, although this chapter focuses on the
laparoscopic approach.
There is still a role for the open surgical approach as well, especially in
cases of previous abdominopelvic surgery or in cases where tumor-
specific indications are present, such as a large or T4 neoplasms with
invasion into adjacent structures or in some patients who are super
morbidly obese.
Equipment
Laparoscopic
30-degree, 10- and 5-mm laparoscope
10-mm camera port
Two 5-mm ports, one 12-mm port
Endo-GIA stapler
5-mm bipolar energy device
Two 5-mm atraumatic bowel graspers
Metzenbaum and/or hook cautery tip
5-mm clip applier
Open
Self-retaining retractor
Lighted St. Mark retractor
30-60 mm linear stapler
Atraumatic bowel clamps
Both Approaches
0-Prolene suture
Absorbable 0-ties
Suture of ligature 1- or 0- absorbable suture
End-to-end stapler
Wound protector
Flexible sigmoidoscopy for air leak test
Technique
Basic Operative Steps in Left Colectomy (Regardless of
Approach)
Abdominal exploration and lesion identification
High ligation of IMA and inferior mesenteric vein (IMV)
Sigmoid and left colon mobilization
Mobilization of splenic flexure
Proximal colon transection
Distal margin transection (usually at the upper rectum)
Colorectal anastomosis
Creation of diverting loop ileostomy based on multiple factors and not
routine.
Abdominal Exploration
Periumbilical access is obtained via cut-down technique and insufflation
to 12-15 mm Hg of carbon dioxide ensues.
A 12-mm port is placed in the right lower quadrant, one 5-mm port in
the right upper quadrant, and an optional 5-mm port can be placed on
the left lower/left lateral quadrant (Fig. 21-5).
FIGURE 21-5 Port placement for laparoscopic left colectomy; the left lower
quadrant 5-mm port may not always be necessary, but may be used for an extraction
site as well.
If open, the incision is made via the midline from the above the umbilicus
down to the level above the pubic symphysis.
Upon entering the abdomen, a thorough exploration is performed to
exclude metastatic disease. The peritoneum is inspected for tumor
implantation, and the liver is examined.
Adnexal structures are examined in the pelvis for any signs of metastatic
spread.
Assessment of any lateral extension of the tumor or potential invasion into
any adjacent structures is also addressed at this time.
High Ligation of the Inferior Mesenteric Artery and Vein

A medial-to-lateral approach is typically preferred and undertaken for all
cancer operations by the author (for both open and laparoscopic
approaches).
In open cases, the peritoneum on both sides of the rectum is incised at the
level of the sacrum promontory, with care to avoid the ureters and the
sympathetic nerves.
The dissection is carried underneath the superior rectal artery and is
continued medially to the origin of the IMA off of the aorta.
Branches of the hypogastric nerve plexus are identified and cautiously
swept posteriorly toward the aorta.
The left ureter should be identified at this time before any vessel is ligated.
The IMA should be isolated and skeletonized and doubly clamped (Fig.
21-6).
FIGURE 21-6 Isolation of the inferior mesenteric artery at its origin off of the aorta.
Suture ligature is applied, and the artery and vein occasionally can be
ligated in the same suture.
In laparoscopic cases, the peritoneum is incised medially beginning at the
sacral promontory and is carried to the level of the IMA as it comes off the
aorta (Fig. 21-7).
FIGURE 21-7 Isolation of the inferior mesenteric artery (IMA) at its origin off of the
aorta during laparoscopic surgery; notice the dissection window created to the right of the
IMA in which retroperitoneal structures are swept down.
At this stage, any lateral attachments/adhesions are generally not dissected

and instead kept in situ to aid in retraction of the left/sigmoid colon.
The IMA is skeletonized and is divided with an energy device;
alternatively, clips or a stapler may be applied (Fig. 21-8).
FIGURE 21-8 Laparoscopic energy device to ligate the inferior mesenteric artery.
After the IMA and IMV have been ligated at this level, dissection is
carried toward the fourth portion of the duodenum and ligament of Treitz.
The IMV can be found just lateral to the duodenum and proximal to the
inferior edge of the pancreas before it joins the splenic vein to become the
portal vein.
It is our routine practice to ligate the IMV at this level to allow
excellent reach of the colonic conduit into the pelvis for a tension-free
anastomosis (Fig. 21-9).
FIGURE 21-9 Isolation of the inferior mesenteric vein.

When the IMA is ligated at its origin and the IMV is ligated at the
pancreatic level, the proximal blood supply to the anastomosis is
supplied via the marginal artery of Drummond by way of the middle
colic vessels (Fig. 21-10).
FIGURE 21-10 High ligation of the inferior mesenteric vein at the level of the
pancreas, lateral to the ligament of Treitz.
When these high ligation maneuvers are employed, it is rare that the colon
will not adequately reach into the pelvis.
Left Colon and Splenic Flexure Mobilization
Medial-to-lateral dissection proceeds after the IMA/IMV have been
ligated.
Although the lateral-to-medial approach may pose to be less difficult in
open surgery, this author, for oncologic purposes, utilizes a medial
approach first for all cases.
The retroperitoneal structures, including the ureter, gonadal vessels, and
the psoas muscles, are swept posteriorly, and the dissection is carried
laterally to the abdominal wall, over Gerota fascia/perinephric fat, and
toward the spleen.
Next, the lateral dissection begins at the iliac fossa and continues
superiorly toward the splenic flexure.
The dissection is carried 1 mm medial to the white line of Toldt (ie, the
white line should stay with the patient) until the spleen is reached.
The splenic flexure is mobilized carefully in order not to cause splenic
capsular tear or colonic wall damage.
Gentle traction on the colon medially will allow for the splenocolic and
retroperitoneal attachments to be safely and sharply dissected free (Fig.
21-11).
FIGURE 21-11 Mobilization of the splenic flexure. Gentle medial traction is placed
on the colon and the peritoneal attachments are divided.
If this approach becomes too difficult, we often will enter the lesser sac
where the omentum attaches to transverse colon and mobilize the colon
toward the spleen to meet up with the previous dissection plane.
Routine separation in the avascular plane between the transverse
mesocolon and the greater omentum is compulsory for proper reach into
the pelvis.
TIPS
Care should be taken to ensure proper mobilization of the posterior

retroperitoneal (ie, pancreatocolic) attachments.
Preparation of the Proximal Colon and Distal Transection

In laparoscopic cases, distal transection is performed before the colon is
exteriorized.
The endoscopic linear stapler is placed through the right lower 12-mm
port.
The posterior mesorectum on the upper rectum is cleared, and ideally, a
single firing of a 60-mm linear stapler should be all that is needed to fully
transect the bowel; occasional use of another staple load is needed in a
thicker or large diameter rectum (Fig. 21-12).
Care is taken to avoid damage to the rectal wall during the fat clearing.
This is facilitated by mobilizing the fat from the posterior wall and then
dividing the mesorectum with the posterior rectal wall in direct vision.
FIGURE 21-12 Endo-GIA 60-mm stapler via the right lower 12-mm port site in
order to transect the upper rectum.
In open cases, distal transection follows proximal transection in most

instances.
Once the proper distal transection site on the rectum has been established
based on margin status, the use of a 45- or 60-mm stapling device is most
often employed when performing a double-stapled anastomosis.
The entire circumference of the transection site should be cleared of
any mesorectum, lateral attachments, and anterior structures.
If too much material is placed in the stapler at one time, it will not fire
properly.
An off-midline extraction (ie, left lower quadrant or planned ostomy site)
site is preferred by many due to a potential in decreased hernia formation
and wound infection rates, although hernia rates may be higher when
umbilical extraction sites are chosen.
Pfannenstiel or periumbilical extraction sites can also be used with good
results.
Wound protectors are used for all extractions, regardless of technique
employed.
Before making a colorectal anastomosis, the distal colonic conduit must
have adequate perfusion.
As mentioned previously, since the IMA has been divided in a high
ligation manner, the proximal blood supply is based on the marginal artery
via the middle colic artery.
It is routine to sharply transect the marginal artery near the site of the
future purse-string suture in order to check for good vascular perfusion.
Pulsatile bleeding from the marginal artery is best, but a good, steady
flow is adequate. Essentially, if one has to clamp and ligate the
marginal artery, it will provide adequate perfusion for the anastomosis.
The use of immunofluorescence is not routinely used at present in our
institution, and it may be considered as an adjunct if deemed necessary
in select cases where perfusion is in question.
After assuring a well-perfused conduit, a handsewn purse-string suture of
0-polypropylene monofilament is placed with careful attention to include
the seromuscular layer of the bowel wall.
Shallow mucosal bites are taken in order to avoid too large a “donut”
for the circular stapler.
The appropriate size anvil for the double-stapled anastomosis is then
placed in the lumen and tied snugly into place.
The largest size anvil and stapler that is able to be accommodated by
both the proximal colon and the anus is recommended.
It is routine by this author to not use anything less than a 31-mm end-
to-end stapler, if possible (Fig. 21-13).
FIGURE 21-13 Distal transection of the upper rectum with 60-mm linear stapler.
TIPS
Only one staple load should ever have to used, if proper dissection has
been performed in this critical portion of the operation.
Colorectal or Coloanal Anastomosis

Traditional end-to-end double-stapled circular anastomosis is preferred.
Regardless of stapled anastomotic technique, the fundamentals of stapler
use hold true for all reconstruction techniques.
Upon gently placing the stapler per anus, it is carefully advanced
passed the sphincter mechanism to the rectal staple line.
The spike is advanced at or just anterior/posterior to the staple line.
Individual surgeon preference exists regarding anterior at or
posterior to the staple line. In some cases, surgeons prefer to have
the spike exit outside the side.
For end-to-side anastomosis, there should be a minimum of 2 cm
between the staple lines to avoid an ischemic intervening segment.
For low anastomosis, consideration is often given for a posterior
placement of the spike to give additional distance between anterior
structures (eg, vaginal wall).
Care is maintained to ensure the colonic conduit is not twisted (Fig. 21-
14B).
FIGURE 21-14 A. Laparoscopic colorectal anastomosis. B. Laparoscopic colorectal

anastomosis. Note how the spike comes out at or above the rectal staple line.
PEARLS AND PITFALLS
Difficulties in Reach
Proper reach of the colon into the pelvis may be difficult in certain
cases, such as due to variations in anatomy, vascular supply, and
body habitus.
If, after high ligation of the vessels, complete and full mobilization
of the left colon and splenic flexure, and along with removal of the
omentum from the transverse colon, there is still reach issues; several
maneuvers may be employed in order to have a tension-free
anastomosis.
Since the IMA and IMV have been ligated at their origin, blood
supply is based on the middle colic vessels.
The first maneuver involves creating a retroileal, transmesenteric
window through an avascular plane to the right of the superior
mesenteric pedicle near the terminal ileum (Fig. 21-15).
FIGURE 21-15 Retroileal window. A window is created to the right of the

superior mesenteric artery near the terminal ileum. The colon can be delivered
to anastomosis with the rectum. Middle colic vessels may need to be ligated.
Anastomotic rings are examined for completeness, and an air leak test is
performed with flexible sigmoidoscopy.
The author prefers to use flexible endoscopy in order to clearly view
the anastomosis intraluminally, to ensure hemostasis, integrity, and
perfusion of the bowel both proximal and distal to the staple line.
Small, pinpoint leaks are generally simply oversewn and re-tested.
Large defects are either repaired primarily or the anastomosis may
be redone completely.
Consideration should be given for diversion.
Surgical drains are rarely used.
The colon can be placed through this window and into the pelvis. If
this does not work, the surgeon must make the decision to transect
the root of the entire transverse colon, with high ligation of the
middle colic vessels.
Mobilization to the hepatic flexure and removal of the entire
omentum off the colon must be performed.
If this technique does not sufficiently provide the needed length, a
complete 180-degree counterclockwise rotation of the right colon
based on the ileocolic pedicle can be performed (Deloyer
procedure).
The hepatic flexure and right colon must be completely mobilized,
and all attachments released.
The right colic vessels and mesentery of the right colon are ligated,
and the colon is rotated in order to have the anterior wall of the
cecum/right colon against the retroperitoneum and the cecum is in
the right iliac fossa with the appendix pointing toward the hepatic
flexure (it is not necessary to perform an appendectomy) (Fig. 21-
16).
FIGURE 21-16 Deloyer procedure. The right colon and hepatic are mobilized,
and all mesentery is divided except the ileocolic pedicle. The colon is rotated
counterclockwise 180 degrees, and a right colon anastomosis is performed to the
rectum/anus.
If these maneuvers are unsuccessful, a cecal–rectal anastomosis may be

performed, or alternatively, a total colectomy with ileorectal
anastomosis can be used. These latter two should be used with caution
considering the function and other pre-operative considerations.
TIPS
A positive air leak tests are controlled on a case-by-case basis.
Postoperative Care
We follow our published standardized enhanced recovery perioperative
care plan.
Orogastric tubes are removed prior to extubation, intravenous fluids are
minimized, diet is given day 0, and urinary catheters are removed day 1.
Opioids are minimized, and patient-controlled analgesia is avoided.
Nonsteroidal anti-inflammatories are permitted and combined with oral
acetaminophen.
Subcutaneous heparin and intermittent pneumatic compression are
continued following surgery for deep vein thrombosis prophylaxis.
Suggested Readings
Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis.
ASCRS Standards Committee. Dis Colon Rectum. 2014;57(3):284-294.
Ricciardi R, Roberts PL, Marcello PW, Hall JF, Read TE, Schoetz DJ. Anastomotic leak testing after
colo-rectal resection: what are the data? Arch Surg. 2009;144:407-411.
Chapter 22
Right Colectomy
PETER MARK NEARY
SHERIEF SHAWKI
CONOR PATRICK DELANEY
An oral polyethylene-based bowel preparation is given the day prior to
surgery. Patients with concern for bowel obstruction do not receive oral
bowel preparation.
Patients receive three doses of 1 g neomycin and 500 mg metronidazole
orally the day before surgery.
Tumors are generally visualized endoscopically by the operating surgeon
and tattooed (unless already visible on preoperative imaging).
Preoperative subcutaneous heparin is administered within 2 hours of
surgery, and sequential compression devices are used to help prevent deep
venous thrombosis prophylaxis.
Imaging is reviewed to look for relative anatomical landmarks and to
exclude involvement/invasion (eg, tumor, fistula) into adjacent organs (ie,
pancreas, duodenum, retroperitoneum) that may dramatically alter surgery.
Right-sided stents are infrequently, but selectively used (eg, phlegmon,
radiation, tumor involvement).
Equipment
Bean bag (if desired)
2% chlorhexidine gluconate in 70% isopropyl alcohol skin disinfectant
Carbon dioxide insufflator
Bipolar energy device
Wound protector
Laparoscopic instrument set (Fig. 22-1)
FIGURE 22-1 Laparoscopic equipment.
Suction
10-mm 0-degree laparoscope with high definition
Camera lead
Gas tubing
12-mm balloon port
20-mm syringe
5-mm blunt-tip trocar port ×3
Laparoscopic electrocautery lead
Monopolar food switch (if desired)
Open electrocautery device
Laparoscopic towers
16Fr rubber catheter
Fluid warmer
Sterile water
Scope warmer (Fig. 22-2)
FIGURE 22-2 Scope warmer with laparoscopic lens.
Blue-loaded linear gastrointestinal anastomosis (GIA) 80-mm stapler

TA 60- or 90-mm stapler with blue cartridge
60 mL 0.25% bupivacaine with epinephrine 1:100 000
Minilaparotomy set
Closing instrument tray
4/0 absorbable monofilament suture
3/0 polyglactin
1 Maxon
A 10-mm 0-degree laparoscope with high definition is preferred by the
senior author.
The authors find a 30-degree lens usually compromises the view often
provided by inexperienced camera holders and rarely improves
visualization.
A 30-degree lens is on standby if necessary for a very obese male with
a high hepatic flexure. A typical tray is shown in Figure 22-3.
FIGURE 22-3 Full equipment set.
This varies by individual surgeon preference.
Anesthesia
General anesthesia is typically utilized. Laparoscopic right hemicolectomy
via a medial-to-lateral method is the preferred approach.
Complete muscle relaxation is necessary for effective insufflation and
laparoscopic visualization.
Epidural anesthesia is unnecessary. Pain is generally well controlled using
multimodal analgesia with transversus abdominis plain block, oral and
intravenous analgesia.
Patient Positioning
The patient is placed in modified lithotomy. Legs are held in Yellowfins
stirrups (Fig. 22-4). Both arms are tucked, and the patient is secured on a
bean bag. Edges of the bean bag are flattened when being stiffened to
prevent interference with the instruments (Fig. 22-5). In patients who are
too obese to safely strap both arms, the right arm is kept out. Lithotomy
position gives the option to the surgeon to stand between the legs when
distal transverse colon mobilization is necessary.
FIGURE 22-4 Patient positioned in modified lithotomy.

FIGURE 22-5 Patient positioning.
An orogastric tube is inserted, as well as a Foley catheter that comes out

under the patient’s right leg.
The operative technician is typically positioned between the legs.
The primary working monitor is on the patient’s right side.

A medial-to-lateral laparoscopic right hemicolectomy is our preferred
approach, as we have not found single port, hand-assist, robotics or open
surgery to add value; though each may be indicated in select conditions,
patients and institution protocols.
If progress is not being made utilizing the described technique, an open
approach is considered.
Technique
Port Insertion
The procedure begins with a surgical huddle and time-out to confirm
patient identity, procedure, allergies, history, and imaging and medication
required.
The surgeon stands on the patients left, with the assistant opposite.
A vertical 10-mm incision is made immediately below the umbilicus.
A 10-mm port is inserted using Hasson technique. Two small Kocher
clamps grasp and lift the exposed fascia. The fascia and underlying
peritoneum are carefully opened.
A 2/0 polyglactin suture is placed with a U needle around the fascia.
The 10-mm port is inserted, and a Rommel tourniquet is used to facilitate
securing adequate seal, and carbon dioxide is insufflated to a pressure of
15 mm Hg.
A 5-mm port is inserted two fingerbreadths distance medial and superior
to the left anterior superior iliac spine under direct vision, taking care not
to damage the inferior epigastric arteries (Fig. 22-6).
FIGURE 22-6 Inferior epigastric vessels.
A second 5-mm port is inserted similarly a handbreadth superior to this

(Fig. 22-7).
FIGURE 22-7 Port insertion.
A third 5-mm port is similarly inserted into the right flank (Fig. 22-8).
FIGURE 22-8 Port site positioning.
Left-sided ports are placed more medially and more superiorly for taller
more obese patients to avoid difficulties with reach to the hepatic flexure
(Fig. 22-9).
FIGURE 22-9 High left lateral port placement in obese patient.
Laparoscopic Assessment of Resectability

Right hemicolectomy is mainly performed for cancer, endoscopically
unresectable polyps, or terminal ileal Crohn disease.
The abdomen is inspected for tumor spread, including the liver,
peritoneum, ovaries, uterus, adhesions, tattoo, fixity to retroperitoneum,
and/or tethering to other organs (Figs. 22-10 and 22-11).
FIGURE 22-10 Liver.
FIGURE 22-11 Tattoo on right colon.
The extent of adhesions, inflammatory phlegmon, and the tumor size and
fixation are important considerations to help decide if the operation should
be done laparoscopically.
Patients with malignancy or Crohn’s disease have the entire abdomen,
including the intestine, inspected at this stage, and any suspicious areas are
palpated after exteriorizing the specimen.
The patient is then tilted into approximately 10 degrees Trendelenburg and
maximum right side up.
The assistant moves to the patient’s left side below the surgeon to hold the
camera (Fig. 22-12).
FIGURE 22-12 Positioning of staff in relation to patient.
The surgeon positions the small intestine with two atraumatic bowel
graspers to allow the distal ileum to stay in the pelvis with the remainder
in the left flank and left upper quadrant.
The omentum is laid superior to the transverse colon (Fig. 22-13).
FIGURE 22-13 Omentum being laid superiorly to transverse colon.
Tattoo and tumor characteristics can often be examined more thoroughly

at this point.
Isolation of the Ileocolic Pedicle

The mesentery of the ileocecal valve is lifted antero-infero-laterally to
help delineate the ileocolic vessels (Fig. 22-14).
FIGURE 22-14 Tension on the ileocolic mesentery to delineate ileocolic vessels.
This is then handed off to the assistant who retracts it in a similar position
with a ratcheted bowel grasper through the right flank port.
The scissors cautery divides the peritoneum immediately posteromedially
to the ileocolic vasculature for benign disease, and close to and parallel to
the superior mesenteric artery for malignant disease (Fig. 22-15).
FIGURE 22-15 Scoring of the peritoneum posteromedial to the ileocolic vasculature.
The incision is extended toward the origin of the ileocolic artery.

The surgeon’s left hand then inserts the bowel grasper into this dissection
plane, allowing exposure to be able to dissect out the plane between the
mesocolic fascia and the retroperitoneal or Toldt fascia. This plane is often
easiest to find near the origin of vessels (Figs. 22-16 to 22-18).
FIGURE 22-16 Window behind ileocolic vessels.

FIGURE 22-17 Tenting of ileocolic vessels upward to expose duodenum.
FIGURE 22-18 Dissection of the plane between the mesocolic fascia and the
retroperitoneum.
The duodenum and pancreas head are exposed and clearly visualized. If
the plane is challenging to identify (very obese patient, for example),
going anterior to the duodenum is always a good guide (Fig. 22-19).
FIGURE 22-19 Dissection of the plane.
A window is fashioned in the peritoneum immediately superior to the

ileocolic pedicle.
A bipolar energy sealant device skeletonizes each side of the ileocolic
vasculature (Fig. 22-20).
FIGURE 22-20 Skeletonized proximal ileocolic vasculature.

The sealant then seals the vessels twice, moving 5 mm distal after the
proximal seal, and sealing and dividing at the distal site, dividing
approximately 1 cm from the superior mesenteric artery (Fig. 22-21). It is
important to do this maneuver without tension on the vessel or the seal is
shortened and bleeding more likely.
FIGURE 22-21 Sealing and division of the ileocolic artery.
The surgeon’s left hand is positioned to grab the proximal ileocolic stump
in the rare case of bleeding that may occur on release of the pedicle
following the seal.
Mobilization of the Ascending Colon and Hepatic Flexure

Frequently repositioning the assistant’s grasper more medially along the
ileocolic pedicle allows better visualization for the surgeons to lift the
mesocolon from the retroperitoneum and aid dissection.
The cecum and hepatic flexure are then mobilized from this medial
approach, extending out toward the lateral attachments and fully
mobilizing the posterior attachments of the colon.
As much mobilization as possible of the posterior attachments
significantly aids the dissection from above later. The flexure is fully
dissected off the duodenum and pancreas (Fig. 22-22), such that the liver
is often visible through a thin leaf of residual peritoneum, or the dissection
may even come through completely, exposing the liver in thinner patients.
FIGURE 22-22 Dissected mesocolon off the duodenum and pancreas.
The right branch of the middle colic artery can be easily identified as the
vessel with the maximal point of tension on the right side of the transverse
mesocolon identified typically anterosuperior to the duodenum and head
of pancreas (Fig. 22-23).
FIGURE 22-23 Right branch of the middle colic.
This right branch of the middle colic travels toward the proximal
mesocolon. If the vessel is traveling toward the mid ascending colon, it’s
most likely that a right colic is present. The right branch of the middle
colic is divided for right-sided colon cancers as well as the right colic, if
present, at this point in a similar manner as the ileocolic vessel is taken
with the bipolar energy sealant device (Fig. 22-24).
FIGURE 22-24 Division of the right branch of the middle colic.
Unless an intracorporeal anastomosis is being performed, generally

reserved for obese males with a thick abdominal wall, the marginal vessel
is left intact so that pulsatile flow can be tested when the specimen is
exteriorized.
If the cancer is more distal than the hepatic flexure and the transverse
colon is short, or is close to the middle colic vessels, an extended right
hemicolectomy is performed. The middle colic vessel is skeletonized and
taken at its origin. This is described in detail in our transverse colectomy
chapter.
The patient is moved to steep reverse Trendelenburg.
The omentum is redraped inferiorly to the transverse colon to its normal
anatomical position to allow en bloc resection with the specimen for
cancers.
The assistant grasps the omentum superiorly approximately one-third of
the way along the transverse colon with the surgeon’s left hand counter-
retracting the transverse colon inferiorly to cause tension across the
omentum covering the lesser sac.
The omentum is divided immediately superior to the transverse colon to
gain entry to the lesser sac (Fig. 22-25), except for transverse colon tumors
where the plane of dissection is along the gastroepiploic arcade.
FIGURE 22-25 Dissection into lesser sac.
The greater omentum is further mobilized en bloc and divided off stomach
(Figs. 22-26 and 22-27), until the plane along superior surface of proximal
transverse mesocolon is clearly displayed, down to base of mesentery.
FIGURE 22-26 Lesser sac entered.

FIGURE 22-27 Lesser sac exposure extended.
This allows the dissection to continue on the superior aspect of the

transverse mesocolon, and one rapidly encounters the space created by the
previous medial-to-lateral dissection anterior to the pancreas.
This dissection is continued laterally mobilizing superior aspect of the
flexure and joins the plane of medial-to-lateral dissection to expose the
duodenum (Fig. 22-28).
FIGURE 22-28 Mobilization of hepatic flexure.
The hepatic flexure and proximal transverse colon are now mobilized (Fig.
22-29).
FIGURE 22-29 Mobilized hepatic flexure.
Mobilization of the Cecum and Small Bowel Mesentery

At this point, using the energy device, the small bowel mesentery is
ligated and divided close to the most likely transection point. The
proximal part of the ligament of Treves is a good consistent point of
reference to aim for.
The patient is moved to a steep Trendelenburg position, keeping the right
side up.
The small bowel mesentery is moved entirely out of the pelvis to the
patient’s left flank and left upper quadrant, and the cecum is retracted
supero-antero-medially by the assistant.
The plane between the small bowel mesentery and retroperitoneum is
divided with scissors cautery lateral to medial (Figs. 22-30 and 22-32)
until the duodenum and head of pancreas are visualized.
FIGURE 22-30 Dissection of small bowel mesentery from retroperitoneum lateral to

medial.
FIGURE 22-31 Further dissection of small bowel mesentery from retroperitoneum
lateral to medial.
FIGURE 22-32 Dissection of small bowel mesentery from retroperitoneum to

duodenum.
The assistant then retracts the cecum anteromedially. Any remaining

attachments of right colon and right colonic mesocolon to the lateral side
wall are divided with scissors cautery (Fig. 22-33).
FIGURE 22-33 Lateral side wall peritoneal attachments to cecum.
The surgeon grasps the right colonic appendages more distally, and the
dissection continues upward as far as the hepatic flexure (Figs. 22-34 to
22-35).
FIGURE 22-34 Lateral side wall peritoneal attachments to ascending colon.
FIGURE 22-35 Lateral side wall peritoneal attachments to hepatic flexure.
The cecum and right colon are now completely mobile. The right ureter is
not routinely searched for unless concern of breached planes exists.
The right colon should be fully mobile and able to stretch easily across the
midline exposing the first and second parts of the duodenum (Fig. 22-36).
FIGURE 22-36 Fully mobilized right colon and hepatic flexure.
A ratcheted bowel grasper is secure to the base of the appendix (Fig. 22-
37).
FIGURE 22-37 Ratcheted bowel grasper secured to the appendix.
Transversus Abdominis Plain Block

At this point, a spinal needle is blunted and inserted under direct
laparoscopic vision into all four quadrants of the abdomen in line with the
anterior superior iliac spine.
The operator is feeling for two pops before they are in the correct plane.
Upon injection the local anesthetic (15 mL 0.25% bupivacaine with
epinephrine 1:100 000, 60 mL total), a smooth indentation should be seen
laparoscopically as the transversus abdominis is pushed away from the
internal oblique.
If a peritoneal bleb is visualized, the operator has pushed the needle in too
far and should bring the needle back subcutaneously before reintroducing
through the fascial layers again.
Umbilical Incision and Exteriorization of the Right Colon

The periumbilical incision is extended vertically to a size to safely extract
the specimen.
A wound protector is inserted (Fig. 22-38), with two large towels placed
underneath to protect surrounding drapes and skin from potential fecal
contamination.
FIGURE 22-38 Wound protector for extraction.
The laparoscopic bowel grasper delivers the cecum to the midline to allow
it to be pulled out using a Babcock clamp through the midline.
The surgeon is cognizant not to twist the bowel, tear specimen, or
mesentery.
If the specimen appears too big for the extraction, the incision can be
extended or the terminal ileum can be transected with the linear stapler,
grasped with a long Babcock, and pushed back in the abdomen. The
surgeon is cognizant of the orientation of the Babcock, such to not to twist
the small bowel mesentery.
Standard Extracorporeal Resection and Anastomosis

(Also See Chapter 19)
The marginal artery is ligated proximally and divided with sharp
dissection to test for pulsatile blood flow.
The transection point is moved distally if necessary.
The orientations of both the terminal ileum and the transverse colon are
carefully scrutinized before decided to proceed with the anastomosis (Fig.
22-39).
FIGURE 22-39 Colon and ileum exteriorized prior to resection and anastomosis.
A side-to-side stapled anastomosis is completed with a linear GIA stapler

(Fig. 22-40).
FIGURE 22-40 Side-to-side anastomosis using linear stapler.
Two 3/0 polyglactin reinforcing crotch sutures are placed prior to firing
the GIA, giving time for tissue of squeeze edema out.
Following GIA deployment, the internal mucosal staple line is visualized,
and any bleeding is sutured with 3/0 polyglactin.
The enterotomy is closed with a TA stapler (Fig. 22-41).
FIGURE 22-41 Closure of enterotomy with TA stapler.
Any staple line bleeds are oversewn in a figure-of-eight manner, and the
entire TA staple line is oversewn with interrupted 3/0 polyglactin (Fig. 22-
42).
FIGURE 22-42 Ileocolic anastomosis.
The mesenteric defect is not closed.

The anastomosis is reduced gently back into the abdomen.
Free omentum is placed to overlying the anastomosis.
Wound retractors, towels, and dirty instruments are removed from the
field, and gloves changed.
The midline fascia is closed with continuous 1 polydioxanone suture and
skin closed with an absorbable subcuticular suture (Fig. 22-43).
FIGURE 22-43 Closed wounds.
Postoperative Care
care plan.
acetaminophen.
Suggested Readings
Crawshaw BP, Steele SR, Lee E, et al. Failing to prepare is preparing to fail: a single-blinded
randomized controlled trial to determine the impact of a preoperative instructional video on
residents’ ability to perform laparoscopic right colectomy. Dis Colon Rectum. 2016;59(1):28-
34.
Reynolds HL, Delaney CP. Laparoscopic right hemicolectomy. In: O’Connell PR, Solomon R, eds.
Rob and Smith Colorectal Surgery. London, England: Hodder and Stoughton Ltd; 2010.
Senagore AJ, Delaney CP, Brady K, Fazio VW. A standardized approach to laparoscopic right
colectomy: outcome in 70 consecutive cases. J Am Coll Surg. 2004; 199: 675-679.
Chapter 23
Approaching the Transverse Colon
ARJUN JEGANATHAN
JEREMY M. LIPMAN
Perioperative Consideration
The transverse colon runs across the abdomen from the hepatic flexure to
the splenic flexure.
The transverse colon has a covering of visceral peritoneum and has an
associated mesentery.
The mesentery has a variable thickness and size—this is important
when identifying the vessels.
There may be significant redundancy of the transverse colon.
Be aware of the posterior gastric wall and the ligament of Treitz when
dividing the mesentery to the transverse colon to avoid iatrogenic damage.
The transverse colon can be mobilized as a part of an operation (eg, low
anterior resection) or resected (eg, total abdominal colectomy).
TIPS
It is important that you do not inadvertently divide the mesentery when

you mean to mobilize alone. Understand the anatomy!
Anesthesia and Patient Positioning

General anesthesia with orogastric tube and Foley catheter
Complete paralysis for appropriate relaxation.
Modified lithotomy with legs in stirrups (knees and hips slightly flexed) to
permit the surgeon to stand between the patient’s legs
Alternatively, split-leg position allows for easier maneuverability if
access to the anus is not anticipated.
Both arms tucked at the patient’s side to facilitate access to the abdomen
and increase surgeon comfort.
The patient must be secured to the bed with straps, pads, or tape.
The patient should not move during the extreme positioning that can be
used to facilitate exposure.
Reverse Trendelenburg with right or left lateral rotation is useful to
improve visualization of the splenic and hepatic flexures, respectively.
Instruments and Equipment

Hasson port (12-mm diameter)
10-mm 30-degree laparoscope
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device
Technique
Port Placement
A periumbilical camera port with at least two working ports is necessary
(Fig. 23-1).
FIGURE 23-1 Periumbilical 10-mm camera port with suggested 5-mm working port
positions.
The location of the ports must be such that triangulation of the camera and
working ports to the hepatic flexure, mid-transverse colon, and splenic
flexure will be optimized.
Typically, a right and left lower quadrant location for working ports
provides adequate needs, although upper abdominal port placement may
be useful for challenging exposures.
Surgical Approaches
Approaching the transverse colon is most often performed as a component
of right, left, or total colectomy (Fig. 23-2).
The indicated procedure will usually direct the approach to transverse
colon.
FIGURE 23-2 Range of approaches to transverse colon include lateral-to-medial

from right or left, as well as supramesocolic and inframesocolic approaches via the
ileocolic artery, inferior mesenteric artery, or inferior mesenteric vein.
If access to other areas of the colon is compromised, a supramesocolic

approach may be useful.
Right-Sided Medial-to-Lateral Dissection Approach

The mobilized right hemicolon is retracted inferiorly and medially.
This will expose the gastrocolic ligament (Fig. 23-3).
FIGURE 23-3 Hepatic flexure placed on tension by drawing right hemicolon inferiorly
and medially.
The ligament is then divided moving medially (Fig. 23-4).

Care must be taken to avoid damage to the gallbladder.
FIGURE 23-4 Division of gastrocolic ligament with identification of gallbladder.
As dissection proceeds medially, the duodenum (Fig. 23-5) is exposed.

FIGURE 23-5 Division of gastrocolic ligament with identification of duodenum.
If not already completed from the medial dissection, the duodenum and
pancreas are bluntly mobilized from the transverse colon mesentery by
sweeping them posteriorly (Fig. 23-6).
The pancreatic head can bleed easily. This dissection is carried out just
anterior to the duodenum without ever actually contacting it.
FIGURE 23-6 Blunt posterior mobilization of the duodenum creation separation

from the mesocolon.
This will expose the head of the pancreas (Fig. 23-7).
FIGURE 23-7 Division of gastrocolic ligament with identification of pancreatic head.
Dividing the Transverse Mesocolon from the Right

A grasper is swept posterior to the cut edge of the colonic mesentery and
lifted anteriorly (Fig. 23-8).
FIGURE 23-8 Complete mobilization of hepatic flexure with dissection to the level of
the falciform ligament.
This will reflect the transverse colon mesentery and middle colic artery
distribution anteriorly and leave the superior mesenteric artery safely
posterior (Fig. 23-9).
FIGURE 23-9 Identification of peritoneal reflection at the takeoff of the middle colic
artery from the superior mesenteric artery.
Dissection then proceeds across the transverse colon mesentery (Fig. 23-
10).
FIGURE 23-10 Division of transverse colon mesentery from right to left.
The duodenojejunal junction will come into view and must be avoided
(Fig. 23-11).
FIGURE 23-11 Division of transverse colon mesentery past the duodenojejunal

junction.
If the omentum is to be preserved, it should be separately dissected from

its attachments to the colon (Fig. 23-12).
Alternatively, it can be dissected from the stomach and excised with the
colon (Fig. 23-13).
FIGURE 23-12 Detachment of greater omentum from the transverse colon.

FIGURE 23-13 Entry into the lesser sac can be accomplished by division of the
gastrocolic ligament immediately inferior to gastroepiploic vessels or by division of the
greater omentum just superior to the transverse colon.
Left-Sided Medial-to-Lateral Dissection Approach to the

Transverse Colon
The left hemicolon is retracted medially and inferiorly, exposing the
lateral attachments at the splenic flexure (Fig. 23-14).
FIGURE 23-14 Takedown of lateral attachments at splenic flexure with medial
traction on descending colon. (Courtesy of Dr. Conor Delaney.)
These attachments are divided avoiding Gerota fascia of the left kidney
and minimizing tension on the spleen (Fig. 23-15).
FIGURE 23-15 Division of splenocolic ligament.
Then, the lesser sac is entered by dividing the greater omentum from the
transverse colon.
The omentum is retracted anteriorly and superiorly, while the
transverse colon is retracted inferiorly. This will expose a window
through which access to the lesser sac can be attained (Fig. 23-16).
FIGURE 23-16 Entry into lesser sac by division of greater omentum.
Mesenteric Approach to the Transverse Colon

The operating table is positioned to the right with reverse Trendelenburg.
The distal transverse colon mesentery is retracted anteriorly, exposing the
inferior mesenteric vein (IMV) and duodenojejunal junction (Fig. 23-17).
FIGURE 23-17 Identification of sub–inferior mesenteric vein (IMV) avascular plane

requires initiation of dissection slightly posterior to IMV at the level of the duodenojejunal
junction.
The avascular plane between the IMV and jejunum is opened.

Dissection continues laterally and superiorly, taking care to continue the
dissection anterior to the tail of the pancreas until the lesser sac is entered.
This approach will allow complete division of the mesentery of the
splenic flexure and can be followed with the previously described
division of superior and lateral attachments to the transverse and
descending colon.
Superior Approach to the Transverse Colon

Begin with entry into the lesser sac.
Elevate the omentum superiorly and anteriorly while retracting the
transverse colon inferiorly.
The omentum is then divided from the transverse colon gaining entry to
the lesser sac (Fig. 23-12).
Dissection then continues to the right or left based on the planned
operation.
PEARLS AND PITFALLS
Liberal use of operating table manipulation will aid exposure. Ensure

the patient is well secured to the operating table to optimize this tool.
Plan to move around the table as progress is made across the transverse
colon. Moving from the patients left, to between the legs, to the
patient’s right (for a right-to-left dissection) can provide improved
access, with less surgeon muscle fatigue.
Consider whether preservation of the omentum is valuable for the
clinical setting. It is often easier to leave it attached to the transverse
colon.
The gallbladder can be densely adherent to the omentum, transverse
colon or gastrocolic ligament. Take the time to identify it to avoid
injury.
There is rarely a straight line of dissection across the transverse colon
mesentery. Be cautious to avoid stomach or colon injury when nearing
the splenic flexure.
Not a lot of traction is necessary to cause a splenic capsule tear. Keep
the spleen in view during the left-sided mobilization. If it is moving,
there is too much tension.
Postoperative Care
care plan.
minimized, diet is given day 0,
and urinary catheters are removed day 1.
acetaminophen.
Suggested Readings
Rivadeneira D, Steele SR. Transverse colectomy: laparoscopic approach. In: Bardakcioglu O, ed.
Advanced Techniques in Minimally Invasive and Robotic Surgery. New York, NY: Springer;
2015:99-105.
Sonoda T. Laparoscopic sigmoidectomy/left colectomy. In: Ross HM, Lee SW, Mutch MG,
Rivadeneira DE, Steele SR, eds. Minimally Invasive Approaches to Colon and Rectal Disease
Technique and Best Practices. New York, NY: Springer; 2015:71-80.
Chapter 24
The Difficult Splenic Flexure
SHERIEF SHAWKI
To adequately mobilize the splenic flexure, the omental, splenic, lateral,
and retroperitoneal (pancreatic–colic) attachments must all be dissected
free.
The splenic flexure takedown may be the most difficult part of the
procedure.
Performing this step as the initial step of the operation minimizes incision
size if conversion were needed later.
The splenic flexure often needs to be approached from several directions
for successful, adequate mobilization.
Position changes from Trendelenburg to reverse Trendelenburg during the
dissection will assist successful completion and help move the bowel out
of the way.
Visualization is often better with minimally invasive approaches than
open.
Excess tension on the attachments to the spleen can lead to tearing of the
capsule and bleeding and needs to be avoided.
Patient Positioning
Modified lithotomy
Arms tucked
Joints in physiologic position and bony parts well padded
Body well secured to operative table to avoid slippage
Aim is to expose base of transverse colon mesentery, ligament of Treitz,
and inferior mesenteric vein (IMV). Usually, the table can be tilted to the
right (left side upward) and with mild reverse Trendelenburg (Fig. 24-1).
FIGURE 24-1 In this image, the gastrocolic ligament has been taken down, lesser sac
accessed, the transverse colon was stapled, and its mesocolon was divided. It shows the
plane to be traversed in order to enter the lesser sac and dissect the base of transverse
mesocolon of the body and tail of the pancreas.

Hasson port (12-mm diameter)
At least two 5-mm operating ports
Two 5-mm laparoscopic bowel graspers (atraumatic)
5-mm laparoscopic curved scissors with attachment for electrocautery
5-mm vessel sealing device
Technique
Port placement: consistent with left-sided operations (see Chapter 21 and 23)
Camera port at the umbilicus
Working ports: right upper and right lower quadrant ports
Assistant port: left lower quadrant
The greater omentum is placed in the upper abdomen, and the transverse
colon is exposed. The small bowel is placed in the right side of the
abdomen. The IMV is identified, the assistant retracts the small bowel
away from harm.
Elevate the IMV and incise the overlying peritoneum just medial to the
IMV at the embryologic fusion plan between midgut and hindgut. Allow
the CO2 to infiltrate and dissipate between tissue planes (Fig. 24-2A).
FIGURE 24-2 Incising the peritoneum overlying and just medial to the inferior
mesenteric vein (IMV) entering the plane between IMV and Gerota fascia. A. Incising the
peritoneum overlying and just medial to the inferior mesenteric vein (IMV) and B. entering
the plane between the IMV and Gerota’s fascia.
Enter the plane between the descending mesocolon, below the IMV, and
Gerota fascia (Fig. 24-2B).
Extend the peritoneal incision along the medial aspect of the IMV to
obtain better accessibility and visualization.
Avoid tunneling and achieve maximum medial-to-lateral dissection
(Fig. 24-3A and B).
FIGURE 24-3 A and B. Extension of peritoneal cut edge inferiorly along the
inferior mesenteric vein (IMV) (A). This can lead to the origin of the inferior mesenteric
artery (B).
Medial-to-lateral dissection is then carried out. The borders of dissection

are:
Laterally: ideally as far as the lateral abdominal wall underneath
proximal portion of descending colon (Fig. 24-4A and B).
FIGURE 24-4 A and B. Extent of lateral dissection. A. Lateral abdominal wall

below proximal portion of descending colon. B. Note that dissection can reach as far
as the spleen. IMV, inferior mesenteric vein.
Caudate: dissection is continued until the maximum extent of dissection

is achieved (Fig. 24-5).
FIGURE 24-5 Caudal extent of dissection with intact Toldt’s fascia on the
retroperitoneum.
Cephalad: the inferior border of the pancreas is identified (Fig. 24-6).

FIGURE 24-6 Superior extent of dissection showing the inferior border of the
pancreas. The inferior mesenteric vein is shown here perpendicular due to retraction.
FIGURE 24-7 Inferior mesenteric vein and descending mesocolon retracted
showing engorged left gonadal vein lying within intact Gerota fascia.
At any point when it is felt unsafe, one should use an alternative approach
to the splenic flexure, such as moving to a lateral or superior approach.
The IMV is divided high below the inferior border of the pancreas. Care
must be taken to avoid injuring the pancreas and/or the duodenum (Fig.
24-8).
FIGURE 24-8 Dividing the inferior mesenteric vein below the inferior border of the
pancreas.
At this juncture, the aim is to enter the embryologic plane between the
base of the transverse mesocolon and the anterior border of the pancreas in
order to gain access to the lesser sac.
The assistant will lift the dissected descending mesocolon and put it
under appropriate tension. Avoid overtension and tears. The surgeon
grasps the transverse mesocolon and retracts cephalad (Fig. 24-9).
FIGURE 24-9 Transected inferior mesenteric vein (IMV) depicting the correct
intended plane to be entered to the lesser sac. This will require traversing through the
both infra-transverse and supra-transverse mesocolic peritoneal layers.
With a combination of blunt and electrocautery, dissection of the

inferior peritoneal layer at the junction between base of transverse
mesocolon and peripancreatic fat is carried out (Fig. 24-10A).
FIGURE 24-10 A. Inferior mesenteric vein transected. From the previous
dissection, now the inferior body of pancreas is exposed and aim is to enter the plane
between the base of transverse mesocolon and peripancreatic fat. B. Dissection in the
peripancreatic plane leading to the supramesocolic peritoneal layer from below with
stomach shown behind this layer. The transverse colon is on the left side of the image.
C. The supramesocolic peritoneal layer is now traversed, and the lesser sac is
entered. Posterior wall of the stomach can be visualized.
This is then continued cephalad to meet the superior peritoneal layer

covering the transverse mesocolon. Penetrating this layer will gain
access to the lesser sac (Fig. 24-10B and C).
Subsequently, the base of the transverse mesocolon is dissected from the
pancreas with a combination of blunt and electrocautery dissection (Fig.
24-11A and B).
FIGURE 24-11 A. Gradual dissection of the transverse mesocolon from the body and
tail (B) of the pancreas, with continued lateral dissection towards the splenic flexure (C)
and the spleen (D).
PEARLS AND PITFALLS
Maintaining the correct plane is important to avoid injuring the pancreas

and the marginal artery, especially in the case where the mesocolon is
foreshortened. Therefore, at this juncture, we like to reassess and
inspect the mesocolon to ensure its intactness.
Further, it is easy to inadvertently miss the pancreas from the sub-IMV
approach and start to dissect under the pancreas and get into the splenic
vein especially in obese patients.
When starting under the IMV, look “up” as the inferior border of the
pancreas is brought up with the mesentery until it is disconnected.
Dissection is continued laterally until the base of transverse mesocolon
is completely separated from the underlying pancreatic body and tail
(Fig. 24-11C and D).
It is important to realize that the goal is to dissect the mesocolon off
the underlying structure and not the opposite. The latter may mislead
the surgeon to the splenic hilum inadvertently.
Subsequently, lateral attachments of the proximal descending colon are
taken down commencing at the white line of Toldt. This will connect
easily with initially dissected sub-IMV plane, as described earlier (Fig.
24-12A and B).
FIGURE 24-12 Dividing the lateral attachments (A) and meeting the previously
dissected plane (B).
At this point, the attachments between the greater omentum and the
transverse colon are taken down using an energy device, starting
proximally and heading toward the splenic flexure to completely
separate the omentum from the colon (Fig. 24-13A and B).
FIGURE 24-13 Dividing the attachments between the greater omentum and the
transverse colon medially (A) and more laterally (B).
This will leave that last and most challenging portion of the splenic
flexure, which is usually adherently attached to the splenic capsule
and/or the underlying tail of the pancreas relatively easier to navigate
(Fig. 24-14A, B).
FIGURE 24-14 Intra-operative imaging demonstrating how the flexure is initially
(A) and even after dissection (B) adhered to the spleen.
The last attachments can be disconnected in a controlled manner and

with confidence without injuring the colonic conduit, spleen, and/or
pancreas (Fig. 24-15A-D).
FIGURE 24-15 A-D. Image showing after mobilization, how the last adherent and
challenging attachment between the flexure and the spleen can be taken under vision
and with confidence, while keeping the pancreas, spleen, and colonic conduit safe.
TIPS
Care must be exercised here to:
Avoid breaching Gerota’s fascia. Occasionally, the left gonadal
vein is well developed, and its presence may cause confusion,
resulting in deviating from the correct plan (Fig. 24-7).
Avoid thermal injury while underneath the proximal descending
colon as this is the future conduit for reconstruction and restoring
gastrointestinal continuity.
Suggested Readings
Chand M, Miskovic D, Parvaiz AC. Is splenic flexure mobilization necessary in laparoscopic anterior
resection? Dis Colon Rec-tum. 2012;55(11):1195-1197.
Ludwig KA, Kosinski L. Is splenic flexure mobilization necessary in laparoscopic anterior resection?
Another view. Dis Colon Rectum. 2012;55(11):1198-1200.
Chapter 25
Cytoreductive Surgery and
Hyperthermic Intraperitoneal
Chemotherapy
ANTHONY COSTALES
ROBERT DEBERNARDO
Preoperative Considerations
The use of hyperthermic intraperitoneal chemotherapy (HIPEC) has been
evaluated in a number of malignancies, and although each of these differs
in fundamental ways, there is one overarching similarity—the benefit of
HIPEC is only realized following an optimal cytoreductive surgery (CRS),
preferably with no gross residual disease.
Low-grade appendiceal
Pseudomyxoma
Mesothelioma
Ovarian cancer
Primary, following neoadjuvant chemotherapy
Recurrent
Certain recurrent gastrointestinal cancers
Recognizing this, successful surgical cytoreduction often involves
multivisceral resection prior to instilling HIPEC (Fig. 25-1).
Pelvic exenteration
FIGURE 25-1 Multivisceral resection from peritoneal carcinomatosis.
Multiple bowel resections

Peritonectomy
Splenectomy +/− distal pancreatectomy
Partial liver resection
Diaphragm stripping or resection
Preoperative planning and assessment of the tumor distribution are
essential to determine how extensive the disease may be and what surgical
procedures would be necessary to render an R0 (complete) resection.
Calculating a peritoneal carcinomatosis/cancer index (PCI) will have a
predictive capability preoperatively to determine who is an appropriate
candidate (Fig. 25-2).
FIGURE 25-2 Peritoneal carcinomatosis/cancer index.
Careful preoperative assessment will often identify the need for a

multidisciplinary team of surgical specialists, such as surgical oncology,
gynecologic oncology, urology, plastics, hepatobiliary, or vascular
surgery.
TIPS
CRS should not be undertaken with curative intent in patients with PCI
≥20, as the results of CRS + HIPEC are no different than with
systemic therapy alone.
Intraoperative Assessment
Prior to committing to a radical surgery, determine whether the disease
can be completely resected.
Careful exploration: complete and thorough assessment of the abdomen
and pelvis (Fig. 25-3).
FIGURE 25-3 Carcinomatosis in the abdominal cavity.
Our preference is for laparotomy to ascertain the extent of disease.

Hand-assisted laparoscopy is preferred, especially if there are concerns
for unresectable carcinomatosis.
Complete lysis of adhesions and mobilization of the colon are
generally preformed.
Identification of major vessels and tagging ureters to facilitate
radical resection.
Ureteral stents are an alternative commonly used.
It is useful to have a complete understanding of the disease burden early in
the case to coordinate the efforts of your surgical team.
Using a completeness of cytoreduction score will help determine
prognosis and ability to undergo HIPEC (need to have CC 0/1; Table
25-1).
TABLE 25-1 CC score: completeness of cytoreduction score
CC No residual tumor (= R0 resection)
0 (en bloc resection)
CC <0.25 cm residual tumor tissue
1 (complete cytoreduction)
CC 0.25-2.5 cm residual tumor tissue
2 (incomplete cytoreduction with moderate residual tumor
proportion)
CC >2.5 cm residual tumor tissue
3 (incomplete cytoreduction with high residual tumor proportion)
Generally, we proceed quadrant by quadrant until the disease is
completely removed. Care is taken to evaluate the retroperitoneum and
identify urinary and vascular structures (Figs. 25-4 to 25-7).
FIGURE 25-4 View of the retroperitoneum.

FIGURE 25-5 View of the right pelvis with the iliac artery.
FIGURE 25-6 Gonadal vessels and ureter dissected free.
FIGURE 25-7 Closer view of the ureter and exposed retroperitoneum.
Once complete cytoreduction is accomplished, and prior to any bowel

anastomotic procedures, HIPEC tubing is placed, the abdomen is
closed, and the chemotherapy infusion is performed.
Program Requirements
Infusing chemotherapy in the operating room (OR), at first glance, appears
to be a simple process. What many fail to realize is that in order to
successfully infuse chemotherapy in an OR, numerous obstacles need to
be addressed well ahead of time.
Recommend identifying a team of health care professionals who are
committed to safely and efficiently administering HIPEC (Fig. 25-8).
Motivated surgeons
FIGURE 25-8 Operating team for cytoreduction and hyperthermic
intraperitoneal chemotherapy.
Dedicated anesthesiologists and nurse anesthetists

OR nurses, perfusionist (to run HIPEC pump)
Pharmacists and medical oncologist
Hospital administration
If there is little or no experience administering HIPEC, it is helpful for the
surgeon to enroll in a course or travel to a center to observe a few cases.
Developing a Successful Hyperthermic Intraperitoneal

Chemotherapy Program
Unless the surgeon has chemotherapy privileges, partnership with medical
oncology and pharmacy is necessary.
Protocols need to be written and vetted.
Mechanism to deliver and administer cytotoxic agents in the OR needs to
be established.
Hospital administration may require a written standard operating
procedure for administration of these agents to:
Ensure patient safety
Ensure safety of the OR personnel
Credentialing may be an issue that should be addressed prior to beginning
any new HIPEC program.
Commonsense Guidelines for Fewer Complications,

Frustrations, and Improving Safety
Cases should be planned in advance, and the HIPEC team be informed
with a minimum of 1-week notice.
Allow ample time to adjust nursing schedules, check equipment
availability, and prepare the chemotherapy.
Inform the pharmacist to mix the chemotherapy only after the patient has
been explored and there is reasonably certainty of an optimal CRS.
Given the complexity and length of these cases:
Schedule as a first start—or at the very least early in the day
Discourage the same surgeon from doing more than one case per day
Hyperthermic Intraperitoneal Chemotherapy Perfusion

Technique
Two techniques have been described.
Open “coliseum” technique—abdomen remains open during
chemotherapy infusion.
Surgeon’s hands used to circulate and distribute drug.
Closed technique (Note: We strongly recommend this technique.)
Tubing is placed, and the abdomen closed (Fig. 25-9).
FIGURE 25-9 Closed technique for hyperthermic intraperitoneal
chemotherapy.
Once “chemotherapy circuit” is complete:

Chemotherapy vehicle can be heated to the appropriate
temperature (typically 42°C).
Circulate vehicle to assure the circuit is functioning and leak free.
Chemo agent(s) can be added once circuit running.
Maintain constant temperature/flow/pressure by adjusting inflow
and outflow.
This approach results in minimal exposure of OR personnel to
cytotoxic chemotherapy.
Employ a perfusionist, a technician whose sole responsibility is
to monitor the pump and make adjustments to temperature, flow,
and pressure.
Highly trained individuals are well versed in troubleshooting when
problems arise.
Recommend a dedicated HIPEC pump purchased specifically to
administer heated chemotherapy rather than using existing cardiac
equipment.
Temperature must be continually monitored to avoid “hot spots.”
Pooling perfusate may lead to overheating segments of bowel or
other viscera.
May result in ischemia, bowel necrosis, and other thermal injury if
not recognized.
Surgical Considerations
It is assumed that surgeons performing HIPEC are well versed in the
techniques required to obtain an R0 resection. The focus of this next
section is to share some observations from our experience that may not be
readily apparent to those with limited experience administering HIPEC.
Careful surgical technique, minimizing blood loss, and attention to
intraoperative anesthetic concerns will help minimize morbidity.
Proper surgical technique
Monopolar cautery
Vessel sealing devices
Surgical stapling devices
Retractors to aid in visualization of the operative field
Management of Bowel Resections

Stapling devices are preferred for speed, ease of use, and leak-free–stapled
ends.
Allow surgeon to judiciously proceed with the surgical debulking.
Exposing the stapled ends of the bowel to chemotherapy.
Marginal blood supply could compromise the integrity of the
anastomosis, increasing leak rates.
Protective stoma at the discretion of the surgeon.
TIPS
Recommend delaying the bowel re-anastomosis until after the

administration of HIPEC.
Disease on the Hemidiaphragm

Ablation with argon or pure plasma energy for small volume tumor
Stripping the peritoneum off the diaphragm for larger tumor
Full-thickness defect requires diaphragm resection.
Recommend exploring the defect with the surgeon’s finger to ascertain
the extent of any residual tumor to facilitate a complete resection.
You can leave this diaphragmatic defect open to perfuse the hemithorax
during HIPEC infusion.
Communication with anesthesia is paramount in this situation as
there is risk of acute lung injury in the perfused hemithorax and
there may be need for one lung ventilation with low tidal volumes.
Postoperatively, it is recommended to leave a chest tube for
management of possible hydrothorax/pneumothorax.
Abdominal Wall and Pelvic Viscera

Repair defects in the pelvic viscera prior to HIPEC.
Closing the vaginal cuff after hysterectomy (Fig. 25-10).
Intact, leak-free circuit outweighs exposing vaginal cuff to
chemotherapy.
FIGURE 25-10 Close of the vaginal cuff after a hysterectomy.
Closing the bladder defect best done prior to HIPEC to accurately

measure urine output.
It is important to recognize, however, that all suture material should be
re-inspected after the HIPEC infusion is complete. We have noted that
some absorbable suture material degrades when exposed to HIPEC
infusion, losing much of its integrity.
This is why serosal injuries to the bowel are routinely tagged prior to
and then repaired after HIPEC infusion.
Abdominal wall defects, such as hernias or stomas, are closed/created at
the completion of the perfusion to allow HIPEC to circulate into these
areas without leaking.
Temporarily close the skin.
Repair/reconstruct after HIPEC complete.
Placement of Hyperthermic Intraperitoneal

Chemotherapy Tubing (Closed Technique)
Proper placement of tubing and adherence to several guidelines will
minimize frustrations and leaking.
Use of a pump specifically designed to administer HIPEC (Fig. 25-11):
Use only tubing designed for use with the pump.
FIGURE 25-11 Perfusion pump used for hyperthermic intraperitoneal
chemotherapy.
Use a lasso-type tube with multiple perforations for outflow channel.

Either resect or dissect the falciform ligament off the anterior
abdominal wall to place tubing (Fig. 25-12A).
FIGURE 25-12 A. Exposure of the falciform ligament. B. Formation of a
loop for the tube.
Place on liver surface with perforations facing the ceiling (Fig.

25-12B).
Outflow tract should exit the inferior portion of the incision.
Inflow tubing placed as deep as possible in the pelvis joined by a Y
coupler (Fig. 25-13).
Secured at the apex of the incision.
FIGURE 25-13 Y coupler for the tubing.
Closing the abdomen to minimize leaks.

Do not close the fascia, instead reapproximate the skin and the soft
tissue (Fig. 25-14).
FIGURE 25-14 Temporary closure of the abdominal wall.
Use adhesive antimicrobial drape (eg, 3M Ioban) or similar product

on skin and place over closure to prevent chemotherapy skin toxicity
in case of small leakages.
Two running, either looped or nonlooped, nonabsorbable
polypropylene sutures that meet in the midline
Tie the suture behind the tubing, run past the tubing and then tie
the two ends together.
Allow tubing to pass through the abdominal wall on an angle,
creating a better seal.
Once this is secure, we run the suture to the midline and tie the
two sutures together.
Once closed, a second layer of adhesive antimicrobial drape is
placed over the incision (Fig. 25-15A-D).
FIGURE 25-15 A-D. Using adhesive dressing to close the abdomen and
minimize leaks.
Remaining suture is retained in case of leak.
If leak identified, a figure-of-eight suture is typically adequate.
Connect inflow and outflow temperature probes (Fig. 25-16A and B).
Once the perfusion is complete, the circuit is emptied.
Normal saline is used to perfuse the circuit to dilute any residual
chemotherapy.
FIGURE 25-16 A and B. Connection of the temperature probe.
Tubing is removed and properly discarded in chemotherapy waste

disposals.
Careful inspection is necessary to check for perfusion injury, bowel
ischemia, and any residual tumor.
Bowel re-anastomosis and a diverting stoma are performed at the
discretion of the surgeon.
Intraoperative and Anesthesia Concerns

Intraoperative management of patients receiving HIPEC is not
substantially different than those undergoing similar radical surgery.
Careful attention to fluid balance, blood pressure, and temperature are
paramount to assure good outcomes. It should go without saying that prior
to beginning HIPEC perfusion, the patient should be adequately
resuscitated and hemodynamically stable.
During Hyperthermic Intraperitoneal Chemotherapy

Administration
Close monitoring of the patient’s temperature
A cooling blanket to keep the patient normothermic
Temperatures above 38.5°C with a cooling blanket on
Adjust inflow temperature of HIPEC
Add ice packs to the axilla
Stop infusion if temperature is above 39.5°C
Anesthesia responsibilities
Recommend arterial line
Monitor blood pressure, glucose, and pH
Management of acidosis
Etiology unclear, may be a response to hyperthermia or drugs
themselves
Insulin drip for hyperglycemia
Aberrations recover shortly after HIPEC completion
Administration of premedications for chemotherapy
At the end of this chapter, I have included links to HIPEC protocols used at
our institution. Unlike others, we recommend the routine use of
premedications prior to administering chemotherapy despite the fact that the
role of premedications has not been evaluated specifically in HIPEC. Our
protocols include antiemetics, steroids, intravenous fluids, and diuretics.
These medications are known to decrease chemotherapy-induced nausea.
Mannitol, in particular, is especially important when giving cisplatin, given
its renal toxicity. This may explain why we rarely see renal toxicity in our
patients receiving HIPEC, whereas other centers report a rate as high as 5%.
SUMMARY
In summary, with careful attention to patient selection, preoperative
planning, and intraoperative management, HIPEC can be administered in a
safe and effective manner. Newer data, especially in the treatment of
gynecologic cancers, suggest that more HIPEC programs will be coming
online. Until these programs mature, experience will be limited and the
learning curve steep. It is our hope that sharing some of the lessons we
have learned preforming HIPEC over the years will lessen this learning
cure.
Postoperative Management
HIPEC patients can be managed similarly to those who have undergone
radical surgery without chemotherapy. These patients do not typically
become neutropenic or thrombocytopenic from HIPEC; however, they may
have a delay in their return of bowel function.
Surgical intensive care unit observation dictated by typical postoperative
parameters
Uncorrected acidosis or hyperglycemia requiring insulin drip
Hemodynamic instability
Prolonged need for intubation
Post-op lab monitoring per routine practice
Recommend avoiding JP drains unless necessary
Minimize potential exposure to nursing personnel
Enhanced recovery after surgery pathways recommended in HIPEC
patients unless clinical judgment dictates otherwise.
Suggested Readings
Kuncewitch M, Levine EA, Shen P, Votanopoulos KI. The role of cytoreductive surgery and
hyperthermic intraperitoneal chemotherapy for appendiceal tumors and colorectal
adenocarcinomas. Clin Colon Rectal Surg. 2018;31(5):288-294.
Solomon D, DeNicola NL, Feferman Y, et al. More synchronous peritoneal disease but longer survival
in younger patients with carcinomatosis from colorectal cancer undergoing cytoreductive
surgery and hyperthermic intraperitoneal chemotherapy. Ann Surg Oncol. 2019;26(3):845-851.
Sugarbaker PH. Peritoneal metastases, a frontier for progress. Surg Oncol Clin N Am. 2018;27(3):413-
424.
Chapter 26
Desmoids
JAMES CHURCH
Genetics
Desmoid disease is the result of an abnormal proliferation of fibroblasts
that happens when the Wnt/wingless signal transduction pathway is
abnormally activated.
Patients with familial adenomatous polyposis (FAP) are prone to desmoid
disease because APC is an integral part of the Wnt/wingless pathway,
controlling the entry of beta-catenin into the nucleus.
Loss of one APC allele potentiates the loss of APC protein, which is
realized by the “second hit.”
In FAP patients, it appears that the second hit, which results in the loss of
APC protein, is usually surgical trauma.
Definitions
Desmoid disease in FAP includes desmoid tumors, mass lesions that
appear homogeneous on computed tomography (CT) scan, and desmoid
reaction.
Desmoid reaction is a flat, white, plaque-like lesion that develops on the
small bowel mesentery and in the retroperitoneum (Fig. 26-1).
FIGURE 26-1 Retroperitoneal desmoid reaction: a flat, sheet-like lesion with
adhesions to the mesentery of multiple loops of small bowel.
It distorts and puckers surrounding tissue and can cause small bowel and
ureteric obstruction, even without there being an obvious mass lesion.
Desmoid tissue can also infiltrate the entire small bowel mesentery,
compressing and weakening vessels and eroding small bowel.
Incidence and Risk with Regard to Surgical Planning

The overall incidence of desmoid tumors is 15%, while an unappreciated
desmoid reaction can be found in an extra 15%, for a total incidence of
30%.
The risk of developing desmoid disease varies among patients with FAP,
and assessing this risk is an important part of developing a surgical
strategy.
Patients with a high risk of desmoid disease need to avoid abdominal
surgery as long as possible, and when surgery is no longer avoidable, they
need to have the least desmoidogenic operation.
This would be a minimally invasive colectomy with ileorectal anastomosis
(see Chapter 21-24).
There is a risk factor score that is accurate in predicting development of
desmoid disease (Table 26-1).
TABLE 26-1 Risk factor score for the development of desmoid disease in patients
with FAP
Factor 1 point 2 points 3 points
Gender Male Female
Family history of desmoid disease No 1 relative ≥2 relatives
Extracolonic manifestations of 0 1 ≥2
Gardner syndrome
APC mutation 5′ of codon Codons 701- 3′ of codon
700 1399 1399
FAP, familial adenomatous polyposis.
Patients with 10-12 points were at very high risk (>80%) of developing
desmoid disease, while the risk for 6-9 points was 35% and that for <6
points was 5%.
Family history is the strongest of all risk factors and the site of the APC
mutation the weakest, reflecting the severity of the desmoid disease more
than its incidence.
Clinical Presentation
Desmoid tumors may occur within the abdomen, in the abdominal wall, or
at extra-abdominal locations (Fig. 26-2).
FIGURE 26-2 Extra-abdominal desmoid located to the left of the thoracic spine.
Most patients have multiple tumors, or a combination of tumor and

reaction. Symptoms and signs appear from 2 to 5 years after prophylactic
colectomy.
Desmoid reaction and some desmoid tumors may be asymptomatic. They
are diagnosed on CT scan or laparotomy performed for other reasons.
Desmoid tumors cause discomfort by their mass effect.
Desmoid tumors and reaction can cause a variety of complications,
including bowel obstruction, ureteric obstruction, mesenteric ischemia,
bowel perforation, tumor necrosis, and enterocutaneous fistula, or may just
grow rapidly to overwhelm the patient. Clinical consequences include
superior mesenteric artery aneurysms, bowel perforation with abscess and
fistula, and bowel ischemia with stricture.
A study reported from our institution described incidences of bowel
obstruction of 50% (70/154), ureteric obstruction of 30% (45/154), and
enterocutaneous fistula of 14 % (21/154).
The important aspects of the desmoid disease as it relates to treatment are
encapsulated in a staging system as follows (Table 26-2).
TABLE 26-2 Staging system for abdominal desmoid disease

Stage I: asymptomatic, stable growth, <10 cm
Stage II: mildly symptomatic, stable growth, <10 cm
Stage III: moderately symptomatic (bowel/ureteric obstruction); slow
growth (<50% diameter in 3 months); 10-20 cm
Stage IV: severely symptomatic (abscess, fistula, perforation); rapid
growth (>50% in 3 months); >20 cm
Treatment
Stage I: intra-abdominal tumors may need no treatment at all, or sulindac
150-200 mg by mouth (PO) twice daily, with food. CT scan for follow-up
in 6 months.
Stage II: add raloxifene in dose from 120 to 240 mg/day. Repeat CT in 3
months.
Stage III: need chemotherapy with a choice of methotrexate/vinorelbine,
imatinib, sorafenib, and doxil.
Stage IV: need chemotherapy with doxil or intravenous
doxorubicin/dacarbazine.
Patient Positioning
Patients are placed in Lloyd-Davies position with stirrups (Yellowfins or
similar); alternatively, a split-leg table may be utilized.
Access to the perineum should be readily accessible in cases where a
colorectal anastomosis may be constructed or if colonoscopy is
indicated.
The patient’s arms should be tucked at their sides bilaterally and padded
appropriately to avoid nerve injury.
This allows for optimal exposure to all quadrants of the abdomen and
may enhance the surgeon’s ergonomics in these sometimes-lengthy
operations.

These operations are generally not suited for minimally invasive
techniques, and as such, an open approach is warranted.
Ureteral catheters may be utilized, when appropriate. In cases of prior
pelvic dissection and/or radiation therapy, catheters should be strongly
considered.
Packed red blood cells should be readily available, as these procedures are
generally lengthy and difficult with a potential steady blood loss
throughout its duration.
Standardized laparotomy set with deep instruments available
Wound protector
Abdominal wall retractor
Appropriate lighting
Technique
Resecting abdominal wall tumors:
If they are small, stable, and asymptomatic, they may be observed. If
they are symptomatic or appear to be growing, they need to be resected.
Technique of Resection
Abdominal wall desmoids usually arise from the rectus abdominis muscle
or rectus sheath.
Sometimes, a loop of bowel is attached to their underside.
Make an incision along the long axis of the tumor and deepen it to the
tumor itself.
Retract the skin and dissect to the fascia all around the margins of the
tumor. Incise the rectus sheath and, on one corner of the tumor, dissect
down to get into a plane below the tumor.
Follow this plane under the tumor, lifting the tumor up. Remove the
tumor.
Margins of excision on the fascia can be 1 cm, but unsuspected extension
of the tumor can mean closer margins.
The same principles can be followed for tumors on the ribcage, but a plane
under the tumor is harder to gain. The gap in the abdominal wall is closed
with mesh.
Resecting intra-abdominal tumors:
Intra-abdominal desmoid disease often involves the retroperitoneum, or
the mesentery of the small bowel, and is, therefore, unresectable
without enterectomy.
However, some symptomatic desmoids may be distal in the mesentery
and able to be resected, with minimal loss of small bowel (Fig. 26-3).
FIGURE 26-3 Resected intra-abdominal desmoid showing attachment to the

mesentery of one loop of small intestine. No recurrence after 15 years follow-up.
These can be selected based on physical examination, where they are

relatively mobile and ballotable, and CT scan.
Once entering the abdomen, explore the entire abdomen looking for
extent of disease.
Identify the extent of the lesion, especially as it pertains to major
vascular structures or the retroperitoneum.
Should it be distal, determine whether or not bowel must be resected as
well, based on vascular or direct involvement.
Control the mesentery using a series of clamps and ties or an energy
device.
If a bowel resection is needed, determine proximal and distal extent and
divide with a Kocher clamp on the specimen side and atraumatic bowel
clamp on the side remaining.
Resect en bloc.
Re-anastomosis of the bowel may be performed by a stapled or
handsewn method.
Debulking intra-abdominal desmoid tumors surgically is a last resort,
but can be effectively done.
Hemorrhage is the main risk.
In our unpublished series of 24 patients undergoing resection of intra-
abdominal desmoid tumors, the recurrence rate was 54%, not
necessarily of the resected lesion but including a progression of the
desmoid disease as a whole.
Surgery for small bowel obstruction:
Multiple options exist for relieving a desmoid-related small bowel
obstruction, including lysis of adhesions, bypass of obstructing
adhesions, resection of the obstructing desmoid, resection of the
obstructed bowel loop, and diverting stoma.
Choice of the best option is dictated by the findings at surgery, and
sometimes, multiple options are used.
In our report on bowel obstruction related to FAP desmoid disease, we
operated on 68% of our patients, performing lysis of adhesions in 30%,
bypass in 20%, resection of the obstructing desmoid in 5%, resection of
the obstructed bowel loop in 28%, and diverting stoma in 5%.
TIPS
In our unpublished series of 40 patients, the recurrence rate was 35%.

This was not influenced by the status of margins, R0 or R1.
TIPS
Trying to remove large, partially fixed desmoid tumors can lead to

major intraoperative and postoperative morbidity, including
hemorrhage, bowel perforation, and ischemia. This is often not
recommended.
TIPS
The art of removing intra-abdominal desmoid tumors is in their
selection. If the tumor involves multiple loops of small bowel, the
procedure will need to be aborted unless the patient has consented to a
small bowel transplant (Fig. 26-4).
FIGURE 26-4 Desmoid tumor extensively involving multiple small bowel loops and their
mesentery: this was unresectable.
TIPS
We have made extensive use of antiadhesive barriers after lysis of

adhesions, but anecdotally, it doesn’t seem to have a particularly
beneficial effect.
PEARLS AND PITFALLS: LYSING ADHESIONS IN

PATIENTS WITH DESMOID DISEASE
Desmoid adhesions are particularly dense, with the white plaques
tightly gripping the small bowel mesentery and dragging the bowel edge
down toward the retroperitoneum (Fig. 26-1).
Separating bowel from desmoid means cutting through the white
plaque, risking a bleed from an underlying mesenteric or desmoid-
related vessel.
If the bowel itself in gripped by the desmoid, separating it risks making
a hole in the bowel.
Either situation is unpleasant, as suturing bowel requires the bowel to be
further mobilized for effective closure of the hole, and this may not be
possible.
Bleeding needs suture ligation of the mesenteric vessel, and this may
cause mesenteric ischemia that itself needs resection.
Operating for obstruction requires a careful look at the most recent CT
to make sure that there are no other obstructing points downstream that
might predispose to anastomotic leak, and to see if there is unobstructed
distal bowel that could be the recipient of a bypass.
These cautions apply to any intra-abdominal operation on a FAP patient
with desmoid disease.
Surgery for desmoid-related enterocutaneous fistulas:
Enterocutaneous fistulas often develop spontaneously in patients
with desmoid disease, presumably from erosion of the small bowel
by the tumor itself, or erosion by an abscess that follows tumor
necrosis.
Operative repair of the fistula is always difficult because of the
inflammation, the adhesions, and the desmoid.
Preoperative imaging should show the site of the fistula and the
anatomy of the gastrointestinal tract proximal and distal to it.
The surgical approach is to lyse all the adhesions proximal and distal
to the fistula before approaching the fistula itself.
Then a decision can be made about whether to try to resect the
fistula, perform a Thiery-Vela bypass, a standard bypass, or to divert
proximally.
The Thiery-Vela bypass involves stapling off each end of a loop of
bowel going into the desmoid and performing an end-to-end
anastomosis from the proximal and distal segments of bowel, leaving
the fistulized/adherent loop of bowel on the desmoid.
In our report on surgical repair of enterocutaneous fistulas, we
describe performing surgery on 16 patients, 8 of whom had a
successful outcome.
Postoperative Care
care plan.
Orogastric tubes are removed prior to extubation, though in select
instances with proximal fistula and extensive dissection and dilated bowel,
a nasogastric tube may be kept in.
While the patients are resuscitated, intravenous fluids are minimized.
In general, diet is advanced more slowly with prolonged operations and
hostile abdomens. Occasionally with very proximal anastomosis, patients
may be kept NPO and on total parenteral nutrition.
In general, urinary catheters are removed day 1.
acetaminophen.
Suggested Readings
Church J, Lynch C, Neary P, LaGuardia L, Elayi E. A desmoid tumor-staging system separates
patients with intra-abdominal, familial adenomatous polyposis-associated desmoid disease by
behavior and prognosis. Dis Colon Rectum. 2008;51:897-901.
Elayi E, Manilich E, Church J. Polishing the crystal ball: knowing genotype improves ability to predict
desmoid disease in patients with familial adenomatous polyposis. Dis Colon Rectum.
2009;52:1623-1629.
Hartley JE, Church JM, Gupta S, McGannon E, Fazio VW. Significance of incidental desmoids
identified during surgery for familial adenomatous polyposis. Dis Colon Rectum. 2004;47:334-
338.
Quintini C, Ward G, Shatnawei A, et al. Mortality of intra-abdominal desmoid tumors in patients with
familial adenomatous polyposis: a single center review of 154 patients. Ann Surg.
2012;255:511-516.
Xhaja X, Church J. Enterocutaneous fistulae in familial adenomatous polyposis patients with
abdominal desmoid disease. Colorectal Dis. 2013;15:1238-1242.
Xhaja X, Church J. Small bowel obstruction in patients with familial adenomatous polyposis related
desmoid disease. Colorectal Dis. 2013;15:1489-1492.
Chapter 27
Enterocutaneous Fistula
MICHAEL A. VALENTE
Basic principles of enterocutaneous fistula (ECF) (Fig. 27-1) management
should be multidisciplinary in nature and include:
Controlling fistula output with nutritional and metabolic support
FIGURE 27-1 Multiple enterocutaneous fistulas (midline and lateral) in a morbidly

obese patient with Crohn’s disease and previous placement of permanent mesh.
Wound care
Proper timing of definitive repair (delay for minimum of 6 months)
Achieving fistula closure
Restoring/maintaining intestinal continuity
Operative Preparation
Imaging such as water-soluble enema, fistulogram, small bowel series,
computed tomography scans, or stoma injection should be obtained prior
to any operative intervention to fully delineate the anatomy of the
gastrointestinal tract and to plan the appropriate operation.
Patient Positioning
Patients are placed in Lloyd-Davies position with stirrups (Yellowfins or
similar); alternatively, a split-leg table may be utilized.
Access to the perineum should be readily accessible in cases where a
colorectal anastomosis may be constructed or if colonoscopy is
indicated.
The patient’s arms should be tucked at their sides bilaterally and padded
appropriately to avoid nerve injury.
This allows for optimal exposure to all quadrants of the abdomen and
may enhance the surgeon’s ergonomics in these sometimes-lengthy
operations.

Ureteral catheters may be utilized, when appropriate. In cases of prior
pelvic dissection and/or radiation therapy, catheters should be strongly
considered.
Packed red blood cells should be readily available, as these procedures are
generally lengthy and difficult with a potential steady blood loss
throughout its duration.
Standardized laparotomy set with deep instruments available
Wound protector
Abdominal wall retractor
Technique
Opening of the abdomen in the midline is performed above (occasionally
below) any prior incision. These incisions are usually quite large and may
require a xiphoid process to pubic symphysis approach.
The use of aggressive electrocautery is generally discouraged in these
reoperative cases, and rather, sharp dissection with the scalpel is the
preferred method of entry into the potentially hostile abdominal cavity.
Once the abdomen is entered, a general survey of the upper abdomen
should be undertaken, and the amount of adhesions are to be assessed.
A decision at this time is to be made if further opening of the abdomen
is warranted versus aborting the operation and backing out due to
severe adhesions/frozen abdomen.
If deemed appropriate, the incision is continued in the midline to then
include the fistula tract(s) (Fig. 27-2).
Some fistulae are located off the midline; these tracts will need to be
separately removed by coring out the tract down to the affected bowel
segment(s).
FIGURE 27-2 Large midline incision that skirts around the fistulae. The incision
begins either high above or below the area of concern.
Once the abdomen is fully opened, it is imperative that the entirety of the
small bowel from the ligament or Treitz to the ileocecal valve is evaluated
and freed of adhesions.
Full adhesiolysis of the small bowel will ensure that the full anatomy is
ascertained and as well as to exclude any distal obstruction or other
fistulae.
Small bowel adhesions that are severely matted together should be
released en masse, especially if adhered down in the pelvis.
Dissection of adhesions from the least difficult to the most difficult is
the generally accepted method in these difficult cases. Dissection is
carried out in known anatomic planes if possible.
The bowel that is involved with the fistula should be dissected last, as this
is generally the most difficult and potentially dangerous portion to free up
(Fig. 27-3).
FIGURE 27-3 Dissection of the bowel in which the enterocutaneous fistula is

dissected last.
The method of adhesiolysis should be performed with sharp dissection
with scissors (Harrington- or Metzenbaum-type scissors).
The utilization of a #15-blade scalpel may also be necessary in dense
adhesions, and often, an extrafascial dissection is necessary in which an
extra-anatomical plane is created to release the bowel from the
fascia/abdominal wall/peritoneum.
In this scenario, it is advantageous to leave behind a piece of
peritoneum/fascia/muscle on the bowel wall, rather than trying to clean
the bowel off and causing further damage.
Hydrodissection can also be used in the most difficult cases of chronic
adhesions.
Sterile normal saline is injected between adhered bowel loops to allow
a safe dissection.
The saline separates the adhered bowel away from other bowel loops
and/or surrounding structures, such as the abdominal wall/fascia, giving
a slightly wider space or plane to dissection (Fig. 27-4A and B).
FIGURE 27-4 A and B. The hydrodissection is a valuable adjunct tool used in the
most severe cases of adhesions. The saline provides a safe cushion between adhesed
segments of bowel.
Serosal tears and defects as well as enterotomies should be addressed and

repaired immediately. 3-0 Vicryl or 3-0 polydioxanone (PDS) is the
preferred suture.
Often, the bowel is friable, and care should be taken to not place the
suture needle through the deserosalized segment, but rather through the
seromuscular layers of healthy tissue.
Once the fistula(s) have been fully isolated, they are generally resected
with the skin/subcutaneous tissues en bloc. Any other adjacent diseased
bowel segment may need to be excised as well (Fig. 27-5).
FIGURE 27-5 En bloc resection of abdominal wall, small bowel, colon, and mesh.
Anastomoses can be either in a handsewn (preferably) or stapled manner.

Handsewn end-to-end small bowel anastomosis is performed in a one- or
two-layer technique.
Variations in suture type exist, with absorbable material such as 3-0
Vicryl or 3-0 PDS utilized. This author performs a single-layer
anastomosis with interrupted 3-0 PDS suture in the majority of cases.
If an abscess cavity or heavy granulation tissue is present, the anastomosis
must be quarantined away from the inflammation. Presence of
inflammatory tissue surrounding a fresh anastomosis may lead to leak/new
fistula formation due to the breakdown of suture lines.
The abscess cavity/granulation should be debrided and undergo curettage.
Standard or uterine curettes can be used.
If available, omentum should be placed between the abscess
cavity/granulation tissue and the anastomosis. If no omentum exists or if
unable to be mobilized, large Penrose drains may be placed into the cavity
and brought out through the incision. These can be gradually pulled back
until their removal several weeks postoperatively.
In these instances, a wedge resection or oversewing of the ECF is
undertaken (Fig. 27-6).
FIGURE 27-6 Oversewing of enterocutaneous fistulas in a patient with short

bowel syndrome.
It is preferable to then proximally divert the oversewn ECF with an

ileostomy/jejunostomy.
It should be noted that ECF recurrence rates are higher in oversewn
patients than if resection and anastomosis is performed.
In cases with multiple ECF takedowns, multiple anastomoses, an
unusually long and difficult case, proximal fecal diversion should be
strongly considered.
High ileostomy or jejunostomy may be required in these instances.
Temporary total parental nutrition (TPN)/intravenous fluids in addition
to enteral nutrition may be required in these patients after ECF surgery.
The addition of a gastrostomy tube should be considered in patients in
which prolonged ileus is expected.
Before closing the abdomen, the small bowel must be evaluated carefully
for any missed serosal tears or enterotomies; the use of a bulb syringe is a
valuable tool to fill the intestines with air to check for tears/leaks should
be strongly considered in these difficult cases (Fig. 27-7).
FIGURE 27-7 The use of a bulb syringe to insufflate the bowels to check for serosal
tears or leaks/enterotomies is a valuable tool to consider after a long and difficult
adhesiolysis.
TIPS
Occasionally, the ECF cannot be resected due to the inability of

proper mobilization/adhesiolysis or if resection would result an
inadequate bowel length, contributing to short bowel syndrome.
Abdominal Closure
In most cases, primary abdominal closure can be achieved using standard
techniques. A lateral release or component separation may help obtain
primary closure, often buttressed with an absorbable polyglycolic acid
mesh to provide a barrier in case of fascial breakdown.
In situations where bowel edema and distention preclude a safe abdominal
closure, using an absorbable mesh to bridge the fascia is advisable (Fig.
27-8). The use of permanent mesh is generally discouraged in these types
of complex cases with potential contamination.
FIGURE 27-8 The use of an absorbable mesh may be required in situations where
there are large amounts of edema/distention of the bowels or where a massive loss of
abdominal domain exists.
Alternatively, skin and subcutaneous tissue can be mobilized to close over

the intestinal contents. This will undoubtedly lead to a planned large
ventral hernia. Patients should be consulted on this possibility prior to any
operation.
Utilizing the plastic surgery and hernia surgery teams early is appropriate
in the most complex ECF patients.
PEARLS AND PITFALLS
Early surgery should be avoided in the vast majority of cases unless the
patient is unstable with intra-abdominal sepsis. Reoperation during the
first 10-14 weeks after the initial operation carries a high morbidity and
mortality rate, with potential resulting new fistula formation.
If forced to reoperate in the early postoperative period for missed
enterotomies or anastomotic leak, the anastomosis/enterotomy should
be exteriorized or proximal fecal diversion should be performed with an
ileostomy or jejunostomy. TPN may be necessary in these situations
(Fig. 27-9).
FIGURE 27-9 The use of a diverting loop or end ileostomy/jejunostomy may be

required in the early postoperative period if one is forced to reoperate due to
uncontrolled sepsis.
In patients with uncontrolled sepsis, multiple fistulae, and an open

abdomen, a left upper quadrant incision can be made and a loop or end
jejunostomy can be created. This is reserved for the most severe
situations where one is forced to enter an extremely hostile abdomen
(Fig. 27-10).
FIGURE 27-10 A loop jejunostomy may be necessary via a left upper quadrant
subcostal incision in the most hostile of abdomens or in those with an open abdomen.
This is often a double-barrel ostomy since proper orientation is often impossible to
ascertain.
Generally speaking, the majority of ECF cases should not be attempted

before 6 months from the inciting operation. Some scenarios may
require up to 1 year before embarking upon definitive surgery. Clear
expectations must be discussed with the patient to understand the
critical importance of this crucial timing.
Before any operation of this magnitude is undertaken, a clear
understanding with the patient and family must include the possibility
of an inoperable situation due to severe adhesions.
A clear and defined “backout plan(s)” must be made by the surgeon in
order to not cause any further harm in the most extreme cases.
Postoperative Care
care plan.
instances with proximal fistula and extensive dissection and dilated bowel,
a nasogastric tube may be kept in.
In general, diet is advanced more slowly with prolonged operations and
hostile abdomens. Occasionally with very proximal anastomosis, patients
may be kept NPO and on TPN.
acetaminophen.
Suggested Readings
Davis KG, Johnson EK. Controversies in the care of the enterocutaneous fistula. Surg Clin North Am.
2013;93(1):231-250.
Petro CC, Como JJ, Yee S, Prabhu AS, Novitsky YW, Rosen MJ. Posterior component separation and
transversus abdominis muscle release for complex incisional hernia repair in patients with a
history of an open abdomen. J Trauma Acute Care Surg. 2015;78(2):422-429.
Vertrees A, Greer L, Pickett C, et al. Modern management of complex open abdominal wounds of war:
a 5-year experience. J Am Coll Surg. 2008;207(6):801-809.
PART IV
The Pelvis
Chapter 28
Intraoperative Radiation Therapy for
Colorectal Cancer
SUDHA R. AMARNATH
Indications
Intraoperative radiation therapy (IORT) can be used for patients being
treated surgically in the definitive or recurrent setting who are at risk of
close or positive margins at the time of resection (R0/R1 resection).
IORT is not appropriate for patients with gross residual tumor at the
time of resection (R2 resection).
Typical areas at risk include tumors that are very close to the
circumferential resection margin, pelvic sidewall (vessels, ureter),
sacrum (presacral vessels/nerves and bone), and other organs (prostate,
vagina, bladder without invasion) where further surgical resection for
negative margins would lead to significant morbidity.
Patients who have received prior external beam radiation therapy to the
pelvis may receive IORT, but dosing should be chosen cautiously to
minimize long-term toxicities.
Patient positioning
IORT is delivered after the resection of the primary tumor, and
therefore, patient positioning (supine vs prone) is determined by the
colorectal surgeon based on the surgical technique being used.
The surgical technique to be used as well as the area(s) deemed most
likely to be at high risk for close or positive margins at the time of
surgery should be discussed with the radiation oncologist in advance to
ensure that IORT can be delivered at the time of resection and planned
accordingly.
Some IORT devices require specialized operating rooms (ORs) (ie,
Intraop Mobetron)—cases requiring IORT should be scheduled
accordingly.
Approach and equipment
At CCF, a Zeiss Intrabeam 50-kV unit is used for IORT applications.1
Power source
Lead aprons and thyroid shields for personnel remaining in OR during
IORT delivery
Mobile lead shields for essential personnel to sit/stand behind during
IORT delivery
Radiation safety signs to place on the doors to the OR
Geiger counter
Sterile draping for the Intrabeam device arm
Flexible lead sheets with sterile bags to help shield internal organs as
needed
Applicators (Fig. 28-1)
Spherical (1.5-5 cm in diameter): intracavitary tumor bed
applications such as circumferential resection margin (post-total
mesorectal excision), presacral hollow
FIGURE 28-1 Zeiss applicators that can be used for intraoperative radiation
therapy. Clockwise from top left: flat applicator, needle applicator (not commonly
used for colorectal applications), surface applicator, and spherical applicator.
Flat/surface (1-6 cm in diameter): surgically exposed surface

applications such as the pelvic sidewall
Recommend having a wide range of applicators available at the time
of IORT so that the most appropriate size and shape applicator can
be selected for the tumor bed/surface to be treated.
1This chapter focuses primarily on the use of the Zeiss Intrabeam device, but many of the
techniques contained herein can be extrapolated to other IORT devices.
Technique
All patients who are deemed to be possible candidates for IORT should
undergo consultation with a radiation oncologist for a full discussion of
the risks and benefits of treatment and to sign informed consent prior to
surgery. This also facilitates treatment planning and appropriate
scheduling of resources.
On the day of the planned IORT, the radiation physics team should
calibrate the IORT device early in the day so that it is ready for use when
needed (Fig. 28-2).
FIGURE 28-2 The Intrabeam device should be calibrated prior to intraoperative

radiation therapy treatment and should be handled with care to avoid the need for re-
calibration in the operating room.
After resection of the tumor, the surgeon using clinical judgment and/or
results of frozen section assessment from pathology determines whether
margins are close or positive and if there is a need for IORT. If IORT is
deemed necessary, the radiation team is called to the OR for setup and
treatment delivery (Fig. 28-3).
FIGURE 28-3 Patient with recurrent colorectal cancer after resection of tumor through
abdominal incision with retractors in place prior to intraoperative radiation therapy setup.
The surgeon and radiation oncologist both should evaluate the area(s) at
risk to determine the optimal applicator size and shape, as well as the best
approach for placement of the applicator.
Approaches may include the applicator being placed through an
abdominal incision, perineal incision, or posterior incision.
The chosen applicator should be attached to the IORT device under sterile
conditions with sterile draping of the IORT machine and applicator arm
that will come in contact with the patient (Figs. 28-4 and 28-5).
FIGURE 28-4 Setup of Intrabeam intraoperative radiation therapy system.

FIGURE 28-5 Sterile draping complete with surface applicator attached.
The IORT applicator should be placed by the surgeon involved in the

resection of the tumor to ensure that the area at highest risk of
close/positive margins is appropriately identified and covered by the
applicator. The final position should be verified by the radiation
oncologist to ensure that the surface of the applicator is directly in contact
with the surface(s) at risk (Figs. 28-6 and 28-7).
FIGURE 28-6 Surgeon placing the applicator against the area at risk.
FIGURE 28-7 Applicator in position.
After applicator placement, there should be a thorough assessment of any

tissues nearby that may benefit from retraction or internal lead shielding
for protection from radiation damage (ie, ureter, small bowel) (Fig. 28-8).
FIGURE 28-8 Retractors are used to pull small bowel and other structures at risk
away from the applicator to avoid radiation damage.
Internal lead shielding comes in flexible sheets that can be cut to different
sizes. After determining the correct size needed, place the sheet(s) in
sterile bag(s) and then place between the applicator surface and the tissue
at risk, making sure that the applicator still stays in direct contact with the
surface at risk.
Final timeout of patient name, medical record number, date of birth,
procedure being performed, site, and dose being delivered (Fig. 28-9)
FIGURE 28-9 Final checks should be made with both the radiation oncologist and
physicist performing a timeout to ensure correct patient, treatment site, and dose to be
delivered.
Ensure that radiation safety signs are posted on all doors that lead in/out of
the OR to prevent accidental exposure to personnel (Fig. 28-10).
FIGURE 28-10 Radiation safety sign on outer door of operating room (OR) to ensure
that nonessential personnel do not enter the OR during treatment.
Perform all final checks of the IORT machine to ensure treatment can be
delivered and then clear the room of all nonessential personnel.
Essential personnel who should remain in the OR during treatment
delivery are the radiation oncologist, physicist, and anesthesiologist.
They should wear lead aprons and thyroid shields and stand/sit behind
lead shields, if available (Fig. 28-11).
FIGURE 28-11 Lead shields are placed between the patient/intraoperative
radiation therapy device and the essential personnel who stay in the room during
treatment.
A member of the surgical team should remain just outside the OR in the
event of an emergency during IORT delivery.
They physicist should perform a radiation survey with the Geiger counter
before, during, and after completion of the IORT treatment (Fig. 28-12).
FIGURE 28-12 Physicist using Geiger meter to survey the room prior to radiation
delivery.
After completion of treatment, the surgeon should return to the OR and

remove the applicator and any internal lead shielding from the patient.
IORT is completed at this time, and the surgical team can resume the case.
Radiation oncologist and physicist must document the site and dose
delivered in the patient’s medical record upon completion of treatment.
PEARLS AND PITFALLS
If a patient has had prior radiation therapy to the pelvis or area at risk to
be treated, records detailing the dose delivered, areas treated, and
radiation treatment plan should be obtained prior to IORT for safe and
appropriate treatment planning.
If a patient has received prior external beam radiotherapy to the pelvis
(typically, 45-54 Gy in 25-30 fractions), IORT doses should be kept to
10-20 Gy or less (prescribed to the surface) to minimize the risk of
peripheral nerve damage, ureteral stricture, and other late toxicities to
normal tissues, as applicable. The risk of neuropathy toxicity is
decreased when doses are 15 Gy or below.
Magnetic resonance imaging of the pelvis gives the best soft-tissue
contrast delineation of tumor and surrounding tissues at risk and should
be ordered and reviewed prior to IORT to assist with planning.
Review the anatomy with the surgical team to ensure all organs at risk
are protected. Be especially mindful of structures such as the ureter and
the anastomosis to ensure that no radiation is directed at those areas if
not at risk.
The machine arm typically has multiple degrees of freedom to allow the
applicators in direct contact with the patient at various angles. However,
certain angles (including the anterior spaces) may not be possible to
reach with particular machines.
Good communication between the surgical team and the radiation
oncology team is imperative for IORT to be successful. When well
planned, IORT can be delivered more efficiently and efficaciously (with
less time for the patient under anesthesia) and lead to better patient care.
Suggested Readings
Brady JT, Crawshaw BP, Murrell B, et al. Influence of intraoperative radiation therapy on locally
advanced and recurrent colorectal tumors: a 16-year experience. Am J Surg. 2017;213(3):586-
589.
Guo S, Reddy CA, Kolar M, et al. Intraoperative radiation therapy with the photon radiosurgery system
in locally advanced and recurrent rectal cancer: retrospective review of the Cleveland clinic
experience. Radiat Oncol. 2012;7:110.
Karagkounis G, Stocchi L, Lavery IC, et al. Multidisciplinary conference and clinical management of
rectal cancer. J Am Coll Surg. 2018;226(5):874-880.
Chapter 29
Local Excision of Rectal Neoplasia
ANURADHA R. BHAMA
DAVID MARON
SCOTT R. STEELE
Indications for Surgical Treatment

Goal of treatment is to completely remove the pathology en bloc with
negative margins.
Curative for benign lesions
Can be diagnostic for what may be more advanced lesions without clear
preoperative staging, with the understanding that formal proctectomy
may still be necessary
Appropriate staging of the lesion
Prior to the operation, a full colonoscopy should be performed to
rule out synchronous lesions
document the location and extent of lesion in question
biopsy the lesion of question to confirm pathology
Obtain further staging workup as indicated (magnetic resonance
imaging for local staging and computed tomography of the
chest/abdomen/pelvis for distant staging, if indicated).
Traditional guidelines for standard transanal excision
<8 cm from anal verge (at or below the first rectal valve)
Note that higher lesions are still possible but need to have adequate
exposure.
Need to intussuscept the rectum down toward the verge.
Be prepared for full-thickness entry into the peritoneum that may
require a laparoscopy/laparotomy to repair.
≤3 cm in size
≤40% of circumference of the lumen of the rectum
All of these are guidelines, and more extensive lesions are still able to
be removed via the transanal approach.
Transanal minimally invasive surgery (TAMIS)
Proximal extent higher up in the rectum is more easily attained up to
the second or third rectal valve.
Need to consider the bulk of the mass to allow for appropriate
visualization of the proximal margin.
Larger lesions can be removed if the mucosal defect can be closed
without creating an iatrogenic stenosis.
With higher lesions, peritoneal entry remains a possibility.
Benign versus malignant pathology
Benign lesions are candidates for transanal excision if size permits.
T1 lesions can be resected locally if:
Favorable histology with low risk of metastasis (low grade, no
neurovascular invasion, no lymphovascular invasion), or
Patient cannot tolerate radical excision.
T2 or T3 lesions in patients who are unable to tolerate radical excision,
with the understanding that this is not curative in nature.
Higher local recurrence exists with >T1 lesions.
The addition of radiation or chemotherapy will not “bail out” positive
margins.
All patients with proven adenocarcinoma should be counseled of the
risk of preexisting lymph node metastases and the potential for false-
negative lymph node involvement on local staging studies.
These patients should be counseled that they may still require a
formal radical proctectomy and understand that transanal excision in
these circumstances is not curative in nature.
Limitations
Standard transanal excision
Cannot typically reach lesions higher than 8 cm from the anal verge
May have limited exposure and visibility due to body habitus and
extent of anal retractors (eg, large buttocks with a long anal canal)
TAMIS
Requires advanced laparoscopic skills
Potential to enter peritoneal cavity for higher lesions or vagina for
anterior lesions in women
Preoperative Preparation
Standard transanal excision
Rectum should be cleared with either enemas morning of the operation
or a full bowel preparation the day prior.
Preoperative antibiotics should be administered as with traditional
colon surgery.
Venous thromboembolism prophylaxis should be administered.
TAMIS
Full mechanical bowel preparation should be given.
Preoperative antibiotics should be administered as with traditional
colon surgery.
Venous thromboembolism prophylaxis should be administered.
Foley catheter should be placed in the bladder.
Patient Positioning
The location of the lesion should be identified and documented during the
full colonoscopy or during a flexible sigmoidoscopy done during clinic as
this will determine the ideal positioning of the patient.
When possible, the patient should be positioned such that the lesion is
located in the inferior quadrant.
For all of these positions, it is imperative to ensure that all pressure
points are padded appropriately and there is no pressure or strain on the
joints.
Lesions in the posterior rectum can be performed in modified lithotomy
position.
Lesions in the anterior rectum can be performed in prone for standard
transanal excision (prone jackknife or Kraske positioning) or in prone
split leg for TAMIS.
For TAMIS, lesions located laterally can be approached with the
patient in a right or left lateral decubitus position with the lesion
downward and the legs bent at the hip and knee.
Ensure that padding is placed between the legs and also under the
inferior axilla. Ensure that all bony prominences are padded
appropriately.
The buttocks should be taped apart to aid in visualization.
STANDARD TRANSANAL EXCISION
Technique
A Lone Star retractor (Cooper-Surgical) can be utilized to evert the anus.
Alternatively, anal eversion sutures (#0 Vicryl) can be used.
Various retractors can be used to expose the rectum: Hill-Ferguson, Pratt
bivalve, Fansler, and so on.
Deavers or Wiley retractors may be helpful to expose more proximal
lesions.
The use of a headlight or lighted retractors (or both) will aid in
visualization of the lesion.
Start by marking the incision line with electrocautery. A 1-cm margin
should be marked circumferentially around the lesion (Fig. 29-1).
FIGURE 29-1 Marking the lesion with 1-cm margins.
Stay sutures can be placed proximal and lateral to the lesion to help pull
the tumor down toward the anal canal.
Local anesthetic with epinephrine (or dilute epinephrine alone) can be
infiltrated to assist in hemostasis.
Using the marked intended incision, a full-thickness excision should be
performed, starting proximally and working distally toward the anal canal,
although a submucosal excision can be performed for benign lesions,
similar to an endoscopic removal (Fig. 29-2).
For malignant lesions, the deep margin should extend into the
mesorectum (Fig. 29-3). Ensure that the dissection is perpendicular as
to not compromise the oncologic margins.
FIGURE 29-2 Full-thickness excision of the lesion.

FIGURE 29-3 Defect created after removal. Note the fat.
The specimen should be pinned down onto Styrofoam and oriented for
pathologic evaluation (Fig. 29-4).
FIGURE 29-4 The lesion is pinned out to mark the boundaries and orientation.
Irrigate the wound and close the mucosal defect with absorbable suture
using full-thickness bites (Fig. 29-5).
FIGURE 29-5 Final closure of the mucosa in layers.
Ensure the lumen is open—either with direct visualization for distal

lesions or flexible/rigid proctoscopy for more proximal lesions.
For larger lesions that are benign, a submucosal dissection leaving the
muscle layer intact can be utilized to resect the lesion (Fig. 29-6).
Mobilization of the mucosa along with interrupted sutures (3-0 Vicryl)
can be used to close the defect.
FIGURE 29-6 Larger benign lesion encompassing greater circumference of the
rectal lumen.
Plication sutures are useful to bring together the resulting defect (Fig.
29-7).
FIGURE 29-7 After removal, placement of plication sutures to aid in closure.
After final closure, proctoscopy/sigmoidoscopy should be performed to

confirm patency of the lumen (Fig. 29-8).
FIGURE 29-8 Final closure of defect.
Final pathology may dictate a need for an oncologic resection.
TRANSANAL MINIMALLY INVASIVE SURGERY
Technique
TAMIS platform and laparoscopic equipment
Several TAMIS platforms are available from various device companies
(Figs. 29-9 and 29-10): stable (eg, transanal endoscopic microsurgery
[Richard Wolf, USA]) and flexible (eg, TAMIS, Gelpoint [Applied
Medical], and SILS [Medtronic]) (Figs 29-9 and 29-10). We will focus
on the flexible platform.
FIGURE 29-9 Transanal endoscopic microsurgery platform (Richard Wolf Medical
Instruments).
FIGURE 29-10 Transanal minimally invasive surgery platform (Applied Medical).
Most of these have an access channel, a removable cap, and disposable

ports.
There are several sizes that can be used based on patient body habitus.
Laparoscope: 5- or 10-mm; 30- or 45-degree angled laparoscope
Light cord adaptor: right-angled light cord adaptor
Specialized transanal instruments
Bowel graspers
Needle drivers
Electrocautery
Scissors
Suction device
Suture
Ethicon 3-0 Vicryl or 3-0 polydioxanone
Covidien 2-0 V-lock
Suturing devices
Laparoscopic needle holders
EndoStitch device (Medtronic)
LAPRA-TY suture applier (Ethicon)
Laparoscopic knot pusher for extracorporeal knot tying
AirSeal device (CONMED)
Preparation
General anesthesia
Sterile perineal preparation and draping
Preoperative antibiotics and venous thromboembolism prophylaxis
Procedure (TAMIS)
Setup of the platform
No anal eversion is required.
Ensure the anal canal is well lubricated.
Dilate the anal canal using digital examination and then the
introducer provided in the platform kit.
Compress the access channel and introduce into the anus, then allow
the access channel to unfold in the anal canal.
Suture the access channel into place with #0 Vicryl or silk suture to
secure channel in place.
Place the three disposable ports in a triangle shape through the gel
portion of the removable cap. If using the AirSeal device, use the
provided port for insufflation. Otherwise, insufflation will be
connected to the attachments on the removable cap. These ports can
also be used for smoke evacuation.
Set the insufflation pressure to 12-15 mm Hg and flow to 40 L/min.
Excision
Once insufflation is obtained, insert the camera and reevaluate the
lesion.
Mark out the 1 cm circumferential for excision with cautery (Fig.
29-11).
FIGURE 29-11 Transanal minimally invasive surgery. Marking out the lesion.
Start the excision distally with a full-thickness incision through the

rectal wall (Fig. 29-12).
FIGURE 29-12 Transanal minimally invasive surgery. Initial full-thickness
dissection.
The insufflation may create a pneumodissection, assisting in

creating the plane.
Excise the lesion from the rectal wall along the marked incision
traveling proximally.
Take care not to aggressively manipulate the tumor.
Typically, the entire excision can be done with electrocautery,
though an energy device may be utilized as needed (Fig. 29-13).
FIGURE 29-13 Transanal minimally invasive surgery. Full-thickness resection.
Note the mesorectal fat.
Remove the specimen immediately and orient on a Styrofoam for

permanent pathology.
Closure of defect
Ensure that the resection bed is hemostatic.
The defect should be closed using full-thickness bites and
absorbable suture (Fig. 29-14).
FIGURE 29-14 Transanal minimally invasive surgery. Closing the defect.
Ensure that the lumen is not narrowed (Fig. 29-15).

FIGURE 29-15 Transanal minimally invasive surgery. Final closure.
PEARLS AND PITFALLS
Perform a flexible sigmoidoscopy prior to the operation to adequately

visualize the lesion, confirm that it is amenable to TAMIS, and confirm
proper positioning.
Although some advocate performing all procedures in modified
lithotomy, prone split-leg positioning is a safe and effective position for
anterior lesions easing the dissection.
Using an angled light cord adaptor will help minimize external
collisions causing disruption of the camera view. A laparoscope with a
built-in light cord may also be used (Olympus).
Using a bariatric length camera will also help to minimize external
instrument collisions.
Billowing of the rectum may make dissection difficult. First, ensure that
the patient is adequately sedated. Confirm there is no air leaking from
the various connections. Next, attempt to increase the pressure 1-2 mm
Hg. Use suction sparingly to avoid deflating the pneumorectum.
If bleeding is encountered, manual compression with a laparoscopic
grasper may help stop the bleeding temporarily. In addition, a small
gauze pad can be introduced into the rectum to assist in hemostasis. Try
to use cautery or an energy device to definitively stop the bleeding.
Using an injection of local anesthetic with epinephrine prior to
beginning the dissection may also help minimize bleeding.
A barbed absorbable suture can be used to aid in suturing.
Using an absorbable clip can replace manual laparoscopic knot tying.
Lower insufflation pressure slightly to assist in tissue approximation for
closure.
If the peritoneal cavity is entered anteriorly, ensure that the peritoneal
cavity and the rectal wall are closed.
Take care to avoid injuring the vagina anteriorly in female patients.
If there is a large rectal wound—it can be closed as two separate
wounds.
It is imperative to demonstrate that the lumen of the rectum has not
been sewed closed or narrowed too much at the end of the procedure.
Similar to the transanal standard, a TAMIS platform can be used for a
submucosal dissection of a large benign polyp, leaving the muscular
layer intact (Figs. 29-16 to 29-18).
Final pathology may determine the need for more extensive
resection.
FIGURE 29-16 Transanal minimally invasive surgery. Sleeve resection.

FIGURE 29-17 Transanal minimally invasive surgery resultant defect. Notice
the muscular layer is intact.
FIGURE 29-18 Transanal minimally invasive surgery final mobilization for
closure.
With large lesions, these can be left open without reapproximating

the mucosa, though these may have stenosis with scarring.
Always need to have follow-up for surveillance and evaluate for
recurrence.
Postoperative Care
care plan.
acetaminophen.
There is no need for long-term antibiotics.
Diet is progressively advanced as tolerated.
Suggested Readings
Steele SR. Transanal resection for rectal lesions. In: O’Connell PR, Madoff RD, Solomon M, eds.
Operative Surgery of the Colon, Rectum and Anus. 6th ed. London, England: CRC Press Taylor
& Francis Group; 2015:615-624.
Steele SR, Mellgren AF. Outcomes after local excision for rectal cancer. Semin Colon Rectal Surg.
2008;19(1):20-25.
You YN, Baxter NN, Stewart A, Nelson H. Is the increasing rate of local excision for stage I rectal
cancer in the United States justified? A nationwide cohort study from the National Cancer
Database. Ann Surg. 2007;245:726-733.
Chapter 30
Approaching Presacral Tumors
CHRISTY CAULEY
MICHAEL A. VALENTE
Preoperative Evaluation
History and examination
Tumor location—“retrorectal space” (Fig. 30-1)
Anterior: rectum
FIGURE 30-1 The presacral space. The third sacral vertebral body is the
landmark to separate high versus low tumors of the presacral space.
Cranial: peritoneal reflection

Lateral: iliac vessels and ureters
Posterior: sacrum
Inferior: levator ani and coccygeal muscles
S3 (third sacral vertebral body) is the unofficial landmark for
distinguishing “high” versus “low” presacral tumors.
Assess potential nerve involvement: sensory, motor, sexual function,
and continence
Bilateral S3 involvement results in fecal incontinence.
Unilateral involvement usually does not result in functional
decline.
Digital rectal examination: determine the extent of the tumor and assess
invasion into the rectum (if the surgeon can palpate the uppermost
extent of the tumor, this is most likely amendable for posterior
approach in many cases)
Diagnostic studies
Magnetic resonance imaging best defines the relationship and potential
invasion of the tumor into adjacent structures (urogenital, rectum, bone,
vasculature, and nerves) (Fig. 30-2A-C).
FIGURE 30-2 A. Axial magnetic resonance imaging (MRI) representing large

presacral mass compressing the rectum anteriorly toward the prostate. (Image
courtesy of Emre. Gorgun, MD.) B. Sagittal MRI imaging of presacral mass
demonstrating that the mass extends up to the level of S2. (Image courtesy of Emre
Gorgun, MD.) C. MRI revealing large cystic presacral mass entirely below S3 without
invasion of adjacent structure in a patient who is pregnant. (Image courtesy of Sherief
Shawki, MD.)
Computed tomography scan is commonly performed initially; may rule

out metastatic disease (Fig. 30-3).
FIGURE 30-3 Computed tomography scan revealing multilobulated presacral,

cystic mass with lateral displacement of the rectum. (Image courtesy of Pedro Aguilar,
MD.)
Endoscopic examination evaluates for any other lesions/invasion into

colorectum.
Typical finding of extrinsic compression of the rectum without
mucosal changes from the space occupying mass in the retrorectal
space (Fig. 30-4).
FIGURE 30-4 Colonoscopic evaluation of the mass. On retroflexion, there is
evidence of external compression of the rectum. (Image courtesy of Emre Gorgun,
MD.)
When is biopsy indicated?

This is controversial and not always needed.
Biopsy is needed prior to neoadjuvant or definitive chemoradiotherapy
in cases of potential sarcoma or lymphoma or inoperable malignancies.
If biopsy is performed, it should never be transvaginal or transrectal in
nature due to possible tumor seeding and need for organ resection.
Biopsy site needs to be excised at time of surgery.
Tumors of the spinal cord/thecal sac should not be biopsied for risk of
meningitis.
Pathologic Considerations
All operations should be performed with the tumor capsule intact to avoid
tumor spillage, recurrence, and infection.
Malignant tumors should be removed with a clear circumferential
margin of tissue to ensure complete resection and avoid recurrence.
Adjacent structures (rectum, sacrum, ureters, blood vessels, and
nerves) require en bloc resection if involved.
Benign tumors should also be excised completely with the capsule
intact if feasible to avoid recurrence; however, adjacent structures
should be preserved, if possible, to preserve quality of life.
Natural planes might not be preserved in malignancy or
inflammatory/infectious processes.
Multidisciplinary Team Approach

Preoperative coordination is compulsory in cases where a complex
resection of adjacent structures is undertaken.
Team members may include:
Colorectal surgery (ostomy marking should be performed
preoperatively)
Orthopedic/neurosurgery
Vascular surgery
Urology
Plastic surgery
Operative Considerations
Patient positioning
Tumors located above S3 or large, bulky tumors: abdominal approach
or combined abdominal and posterior approach
Begin with the abdominal approach in a lithotomy position.
Ensure the legs are positioned neutrally to avoid nerve
impingement.
The arms should be tucked at the patient’s sides if possible.
Once the abdominal portion is complete, the patient should be
flipped into the prone position for completion of the en bloc
resection. (Occasionally, the posterior approach can be performed in
the high lithotomy position, but this may pose to be difficult
secondary to poor exposure.)
S3 and below: posterior approach
Prone jackknife position
Urinary stents
If tumor is large and bulky or if the patient has had prior radiation or
pelvic dissection, cystoscopy with ureteral stent placement should be
considered.
Full mechanical bowel preparation is performed in all cases.
Antibiotic coverage, including third-generation cephalosporin and
metronidazole, is used.
Venous thromboembolism prophylaxis with subcutaneous anticoagulation
is administered in all cases.
Urinary catheter is placed in all cases.
Equipment
Posterior approach
Osteotome
Rongeur
Headlight
Lighted right-angle retractors
Self-retaining retractor (Weitlaner-Beckman)
Bipolar forceps
Abdominal approach
Bipolar forceps for dissection around nerves
Vessel loops
Self-retaining abdominal retractor
Deep pelvic lighted retractor
Nerve stimulator to confirm nerve location and activity (optional)
Technique
The location, physical characteristics, and possible involvement of other
pelvic structures dictate the operative approach.
In general, a well-circumscribed presacral lesion whose uppermost
extent can be palpated on digital rectal examination can usually be
approached via a posterior approach.
In lesions above the S3 level, a purely abdominal approach can be
considered.
Lesions below S3 can be approached posteriorly.
Lesions spanning both above and below S3 are best approached via an
abdominal and posterior approach.
Posterior Approach
Several different incisions can be used based on the tumor size and
location and surgeon preference/experience.
The following are the general steps that can be modified based on these
factors and adjacent organ involvement.
All patients are placed in the prone jackknife position, and buttocks are
taped and affixed to the operating room table; the rectum is irrigated with
betadine and saline solution.
Incision Types
Transverse/horizontal incision (Fig. 30-5A and B)
FIGURE 30-5 A. Transverse (horizontal) incision for posterior approach. (Image courtesy
of Sherief Shawki, MD.) B. Transverse incision located laterally revealing a large presacral
cyst. (Image courtesy of Sherief Shawki, MD.)
Horizontal incision made overlying the coccyx
Can extend to one side more depending on tumor location
Vertical incision (Fig. 30-6)
FIGURE 30-6 Midline incision from lower sacrum to anus. Care must be taken to not
damage the external sphincter muscle. (Image courtesy of Pedro Aguilar, MD.)
From lower portion of sacrum and coccyx down to anus

Parasacrococcygeal incision
A wide curvilinear incision should be made in the plane between the
coccyx and anal canal outside the anal sphincter muscles.
For small tumors, it is unnecessary to divide the anal sphincter or levator
ani muscles.
Intersphincteric incision (lithotomy position)
The lowest tumors may be resected in this manner.
A curvilinear incision is made posterior to the anus.
The intersphincteric plane is opened and dissected. The anal canal and
internal sphincters are separated from the external sphincter to the level of
the puborectalis sling.
This is carried cranially toward the retrorectal space.
Technique
Posterior Technique of Dissection into the Retrorectal

Space
Skin incision is carried down to outer aspect of external anal sphincter.
Division of the lumbosacral fascia
The coccyx can be disarticulated from the S5 vertebra with
scissors/scalpel, rongeur, or electrocautery and resected to increase
exposure and ease of dissection (Fig. 30-7).
Many congenital cystic lesions will be intimately attached to the
coccyx, which will mandate resection (en bloc if able).
A bone file is used on the resected bone to smooth out any sharp or
rough surfaces that may be left behind.
FIGURE 30-7 The coccyx can be removed, and the anococcygeal ligament is
divided to gain exposure.
The anococcygeal ligament is then divided and/or resected.

If the lower segments of the sacrum require resection, an osteotome can
be used for removal.
The levator ani muscle is sometimes displaced by the tumor; and it usually
needs to be separated and potentially partially divided depending on the
size of the tumor.
For larger tumors, the gluteus maximus muscle can be detached.
The dissection should be carried cranially to the proximal extent of the
tumor, keeping a clear, consistent margin around the mass.
With smaller lesions, the surgeon’s left index finger may be introduced
into the rectum to push the mass outward away from the often-times
deep wound (Fig. 30-8).
FIGURE 30-8 The presacral mass is dissected from the rectal wall; the surgeon’s
index finger can be utilized to push the tumor out of the wound.
The mass is then carefully dissected off of the rectal wall.

Meticulous dissection is mandatory to avoid delayed rectoperineal
fistula.
Air leak test is performed after lesion is removed to check for rectal
wall violation.
There is often a feeding vessel that is encountered on the proximal aspect
of many of these lesions that needs to be controlled.
A bipolar energy source or commercially available vessel sealer may be
used to safely accomplish this.
Complete excision of the cyst wall or the capsule of solid tumors must be
accomplished to reduce the risk of recurrence and/or subsequent infection
(Fig. 30-9).
FIGURE 30-9 Intact capsule of a large presacral mass. (Image courtesy of Emre
Gorgun, MD.)
Closure of the operative space is accomplished in layers of absorbable

suture.
A small closed suction drain is placed and brought out laterally from the
incision.
Abdominal Approach
Enter the abdomen through a lower midline laparotomy incision
(laparoscopic or robotic approaches may be used for select tumors, based
on the size, location, invasion of adjacent structures, and surgeon
expertise).
Mobilize lateral attachments of sigmoid colon at white line of Toldt.
Enter the presacral space just below the sacral promontory (same as total
mesorectal excision plane).
Dissect the posterior rectum from the upper sacrum and carry this down
until the upper edge of the tumor is encountered.
Identify and protect the hypogastric nerves and ureters/iliac vessels.
Reflect the peritoneal covering over the presacral mass.
Dissect the rectum and mesorectum free from the tumor and retract away
from the tumor (Fig. 30-10).
In large tumors where space is limited, the lateral stalks can be divided,
and dissection of the rectum down to the pelvic floor can be
undertaken.
FIGURE 30-10 Robotic dissection in the presacral space demonstrating the large
presacral mass. (Image courtesy of Emre Gorgun, MD.)
Ligation of the superior rectal artery can also be performed to release

tension off the mesentery.
In situations where tumor is densely adherent or invading to the
posterior rectum, a proctectomy should be performed for en bloc
removal with the tumor.
Often, a stapled low anastomosis can be accomplished.
Permanent end colostomy may be mandated in the largest and most
aggressive of tumors.
There is often a large feeding vessel to the tumor in the midline, which
must be ligated.
Ligation of the middle sacral vessels can often help stem potential
blood loss.
Occasionally, branches of or the interior iliac vessels must be ligated.
The tumor is then dissected anteriorly off of the rectum and posteriorly off
of the sacrum and laterally off of the sidewalls.
If using a nerve stimulator, test the stimulator at the relevant nerve roots.
A closed suction drain is left in the pelvis.
Combined Abdominal/Posterior Approach

The combined approach begins with the abdominal phase and then the
patient is flipped into the prone jackknife position.
The posterior approaches previously discussed can be utilized once the
abdominal portion is complete.
Many of the large or invasive tumors will require spine surgery to
disarticulate various sacral levels and potentially sacrifice nerve roots
in the most aggressive of malignant tumors.
In cases where there is an extremely large tissue defect after resection,
plastic surgical myocutaneous flaps are beneficial and should be planned
out before the operation.
PEARLS AND PITFALLS
The majority of presacral tumors should be resected if feasible due to

risk of infection, increasing symptoms, and malignant transformation.
Cystic walls and tumor capsules should be completely removed as
recurrence rates are high if any part of the lesion is left behind.
Invasive tumors mandate en bloc multivisceral resection.
Structures surrounding the tumor, including the vessels, nerves, and
ureters, should be dissected free from the tumor circumferentially,
ensuring en bloc resection of the tumor for malignancy with an intact
capsule of tissue.
Identification of adjacent structures is paramount to ensure the best
tumor resection, while understanding the implications for the patient’s
postoperative quality of life.
Preserving neurologic function
Care must be taken to identify nerve roots and lumbosacral plexus
nerves.
Parasympathetic and sympathetic sacral nerves should be preserved
if possible. It is important to take note of the functionality of these
nerves preoperatively.
Permanent colostomy
Preoperative obstruction or fecal incontinence should be assessed.
Preoperative marking should be performed in any patient who might
need an ostomy.
Urinary diversion
Consultation with a urologist is imperative if hydronephrosis is seen
on preoperative imaging.
Ureteral stents can help with difficult dissection and identification of
an injury.
Surgery for recurrence
Recurrences may occur, and repeat surgery can be performed with
good results.
Proctectomy and/or sacrectomy may be necessary in select cases
(Fig. 30-11).
FIGURE 30-11 Resection for recurrent presacral masses is feasible;
proctectomy and sacrectomy are common in this scenario.
Postoperative Care
care plan.
acetaminophen.
Suggested Readings
Böhm B, Milsom JW, Fazio VW, Lavery IC, Church JM, Oakley JR. Our approach to the management
of congenital presacral tumors in adults. Int J Colorectal Dis. 1993;8(3):134-138.
Carchman E, Gorgun E. Robotic-assisted resection of presacral sclerosing epithelioid fibrosarcoma.
Tech Coloproctol. 2015;19(3):177-180.
Messick CA, Londono JM, Hull T. Presacral tumors: how do they compare in pediatric and adult
patients? Pol Przegl Chir. 2013;85(5):253-256.
Reynolds HL Jr. Expert commentary on presacral tumors. Dis Colon Rectum. 2018;61(2):154-155.
Chapter 31
Proctectomy from Above
JAMES P. TIERNAN
CONOR P. DELANEY
LAPAROSCOPIC LOW ANTERIOR RESECTION
An oral polyethylene-based bowel preparation is given the day prior to
surgery along with received three doses of 1-g neomycin and 500-mg
metronidazole orally the day before surgery.
Tumors are generally visualized endoscopically by the operating surgeon
and tattooed.
Magnetic resonance imaging should be reviewed prior to the operation to
have a road map regarding tumor, threatened margins, and pelvic
anatomy.
Pelvic ureteral stents are selectively used (eg, perforation, reoperative,
radiation, tumor involvement).
Sterile Instruments and Equipment

10-mm balloon port
2 mm × 5 mm port, 1 mm × 12 mm port
Red rubber catheter cut into 5 cm pieces
10-mm 0-degree camera
5-mm laparoscopic blunt-tip bipolar energy device
3 mm × 5 mm laparoscopic atraumatic bowel graspers with locking
ratchets
5-mm laparoscopic scissors with bipolar cautery attachment
Extra-long (bariatric) laparoscopic atraumatic bowel graspers and scissors
available for morbidly obese cases
5-mm laparoscopic Maryland grasper or laparoscopic Allis clamp
End-to-end circular stapler 28-31 mm
Bean bag
Patient Positioning
Begin supine with the patient positioned on the bean bag (Fig. 31-1).
FIGURE 31-1 The patient is positioned with their buttocks at the lower edge of the
operating table.
After induction of anesthesia, adopt the Lloyd-Davies position: ensure

perineum just overhangs operating table edge, with legs in Yellowfins
stirrups (Fig. 31-2).
FIGURE 31-2 Padded stirrups are used to position the legs to enable access to the
perineum without compromising laparoscopic ergonomics, and the left arm can be left out
for larger patients.
Arms should be tucked next to torso, with foam padding used to prevent
any pressure injuries at the hands and pressure points. In obese patients,
the left arm may be left on an arm board (Figs. 31-1 and 31-2).
Knees should be flexed to ∼30-40 degrees.
Lower the Yellowfins so that the thighs are almost neutral to the torso to
ensure adequate space for laparoscopic instruments to reach the splenic
flexure.
Instrument and Personnel Positioning

Primary monitor on patient’s left, secondary monitor on patient’s right.
Scrub technician stands between the legs with instrument table.
Primary surgeon begins on patient’s right; assistant begins on patient’s left
and then repositions to patient’s right, standing cephalad to surgeon.
Port Insertion
Subumbilical 10-mm vertical incision (see Fig. 31-3)
FIGURE 31-3 Port positioning.
Deepen incision to the linea alba, and grasp linea alba on each side with
Kocher clamps, elevate and incise vertically with cautery. Bluntly insert a
Kelly forceps through the peritoneum to enter the abdominal cavity.
Insert a purse-string suture into the fascial defect using 2-0 Vicryl and
apply a Rommel tourniquet, fashioned from a 5-cm piece of rubber
catheter and a hemostat (see Fig. 31-4).
FIGURE 31-4 Ports inserted with Rommel tourniquet applied.
Insert the Hassan balloon port, inflate the balloon, tighten the Rommel
tourniquet, and attach the gas and establish peritoneum to a pressure of 12-
14 mm Hg.
Perform a full laparoscopic evaluation of the abdomen.
Insert a 12-mm port at the ileostomy site. It is important that this site is
medial enough to allow access of the right lower quadrant (RLQ)
instrument to the right pelvic sidewall. In obese patients who have been
marked for a right upper quadrant (RUQ) ileostomy, a RLQ site is chosen
in line with this, and low enough to reach the anorectal junction with a
stapler. Take care not to injure the inferior epigastric vessels at insertion.
Insert an RUQ and left lower quadrant (LLQ) abdominal 5-mm ports. An
additional 5-mm port can be inserted later in the procedure if required—
most commonly in the left upper quadrant (LUQ) for a high splenic
flexure in the obese.
Technique
Left Colon Mobilization

Position the patient in steep Trendelenburg and right side down.
Assistant moves to patient’s right, caudad to the operating surgeon and
holds the camera, and holds the camera in their right hand, and will later
hold the LLQ instrument in their right hand.
Using two atraumatic bowel graspers inserted through the right-sided
ports, reflect the greater omentum over the transverse colon. A nasogastric
tube may be inserted to deflate the stomach to aid this maneuver.
To expose the inferior mesenteric vessels and sacral promontory, gently
sweep the small bowel and its mesentery to the patient’s right, exposing
the right colonic mesentery, ligament of Treitz, and sacral promontory.
The surgeon chooses the optimal part of the distal sigmoid to place the
mesentery under traction to view the groove between the mesentery and
the sacral promontory, and hands this to the assistant who is using the
LLQ port and tents the sigmoid mesentery anteriorly and cephalad (Fig.
31-5A). The sigmoid is grasped at the right mesenteric margin, or lower
on the mesentery, even halfway between the bowel and the sacral
promontory to gently stretch it upward toward the LLQ port.
FIGURE 31-5 Incision of the medial sigmoid mesentery peritoneum and medial-to-
lateral dissection. A. The mesentery is on tension to identify the groove for incision.
B. Following the peritoneal opening the carbon dioxide from the pneumoperitoneum aids
in the separation of tissue planes. C. Continued medial-to-lateral dissection between the
retroperitoneum and the mesentery of the colon.
Make an incision in the peritoneum using cautery, beginning just above

the sacral promontory in the sulcus between the mesentery and the
retroperitoneum (see Figs. 31-5B and 31-5C). This point can be difficult to
define, especially in obese males, and so immediately assess where the
CO2 is going, and if this helps define a better plane. If unsure, reassess and
start distal to the sacral promontory to get into the presacral space, and
work back proximally.
Open the peritoneum cephalad toward the origin of the tented inferior
mesenteric artery (IMA) and extend it caudally past the sacral promontory.
Using a combination of sharp and blunt dissection, lift the sigmoid
mesentery and vessels away from the retroperitoneum, ensuring the
dissection is superficial to the ureter, gonadal vessels, and autonomic
nerves, usually seeing a smooth “capsule” over the IMA, the congenital
visceral fascia of the mesentery, working laterally in a medial-to-lateral
fashion (Fig. 31-6).
FIGURE 31-6 Mesocolon dissected away from retroperitoneum (Toldt fascia) using a
medial-to-lateral approach.
We identify the ureter lateral to the IMA before ligation of the artery. If it
cannot be found, begin a lateral-to-medial dissection (discussed later),
which routinely allows ureteric identification. In the very rare event that
the ureter remains elusive, the options include insertion of ureteric stents
or conversion to laparotomy. In fact, the ureter is usually seen during the
dissection, and a specific search is rarely required.
Dissect out the origin of the IMA at its origin. Any fat and lymph nodes
should be dissected free anteriorly, and a right-angled laparoscopic grasper
or Maryland can be used to dissect the artery free posteriorly, staying very
close to the artery to ensure the retroperitoneal structures are completely
separate. The IMA can be divided using an energy device in the majority
of cases, using overlapping seals prior to cutting. In rare cases with
extensive adenopathy where a division is performed flush with the aorta, a
vascular stapler is used. If the vessel is calcified and there is ooze or
concern about the seal line, 5-mm clips are applied. Ensure the ureter is
visible and safe prior to division.
The left colic artery is now divided from the IMA with the energy device,
to facilitate easy reach of the descending colon to form a neorectum.
Continue the medial-to-lateral dissection cephalad over the perinephric fat
toward the pancreas. Dissect out and divide the IMV close to the pancreas
using an energy device. Continue the dissection over the pancreas and
laterally toward the colon and abdominal wall.
The assistant should now retract the sigmoid medially, and attention
should be focused on the lateral attachments. Divide these via sharp
dissection (Fig. 31-8), ensuring the dissection does not veer off plane into
the lateral abdominal wall, or go behind Gerota’s fascia.
FIGURE 31-7 Retro-IMV dissection. IMV, inferior mesenteric vein.

FIGURE 31-8 Division of the lateral sigmoid attachments from the pelvis toward the
spleen.
The prior medial-to-lateral dissection plane is usually easy to identify and

break into during this lateral dissection, but care should always be taken to
avoid the ureter and gonadal vessels. The dissection should then continue
cephalad, dividing the lateral descending colon attachments and following
the “white line of Toldt” toward the splenic flexure (Fig. 31-9).
FIGURE 31-9 Approaching the splenic flexure laterally.
The splenic flexure can be visualized and mobilized at this point. It is

important to carefully follow the anatomical plane between the surface of
the mesocolon, the retroperitoneum, and the omentum. The patient should
be positioned in some reverse Trendelenburg position for this step, using
more reverse Trendelenburg for more obese patients. The splenic flexure
should be mobilized in a lateral-to-medial manner as far as the view
allows. It should then be approached from the transverse colon: lift the
greater omentum anteriorly toward the abdominal wall, with the assistant
providing countertraction by gently retracting the transverse colon
caudally, standing on the patient’s right. Make an incision close to the
colon to enter the lesser sac and extend this toward the spleen, releasing
the transverse colon in the process, to meet the prior lateral dissection. The
transverse colon can be mobilized entirely to the midline.
Complete the splenic flexure mobilization by dissecting the mesocolon off
the anterior border of the pancreas. Retract the colon caudally and
medially and use bipolar diathermy or energy device to divide the areolar
attachments between the pancreas and the mesocolon to meet the earlier
medial-to-lateral dissection.
TIPS
Using a closed bowel grasper, sweep the small bowel close to the base
of its mesentery so that the loops of bowel “flop” over to the patient’s
right side. Think as if one is trying to put one-third of the small bowel
in the LUQ, one-third in the RUQ, and one-third in the RLQ.
Sometimes, it is helpful to free congenital adhesions around the cecum
and small bowel mesentery. If loops of bowel still obstruct the desired
view despite operating table positioning, a 5-mm liver retractor can be
placed through and LUQ port; however, this is rarely necessary.
TIPS
Gently move the sigmoid mesentery up and down (ie, away from the
retroperitoneum): this often displays the sigmoid mesentery “sliding”
under the peritoneum, separate from the retroperitoneum. This is
where the correct plane lies and where the incision should begin.
TIPS
If the correct plane cannot be found at this point, there are three
alternative locations to try to find it: (i) extend the peritoneal excision
caudally to the rectum and try to display the embryologic plane
between the presacral fascia and the posterior rectal mesentery. This
can then be followed cephalad toward the IMA origin; (ii) identify the
inferior mesenteric vein (IMV) just lateral to the ligament of Treitz,
make an incision in the mesentery immediately posterior to it, and
develop the plane at this point (see Fig. 31-7), extending it toward the
IMA origin from above; (iii) change to a lateral-to-medial approach.
TIPS
Incise about 1 mm medial to the line of Toldt and think that you are
“releasing” the retroperitoneum off the intact mesocolon.
TIPS
The omentum is not divided, but rather is carefully separated from the
transverse colon by following the embryologic pane. The surgeon and
assistant should take it in turns to reposition their graspers as the
dissection advances along the transverse colon. As one enters the
lesser sac, the superior aspect of the transverse mesocolon is seen,
extending down to the anterior border of the pancreas.
TIPS
If the splenic flexure is very high, an additional 5-mm port inserted in

the LUQ may help achieve the view and tension required to allow safe
mobilization.
Rectal Mobilization
Return the patient to the Trendelenburg position and reflect the small
bowel cephalad.
The assistant uses a bowel grasper inserted via the LLQ port to grasp the
rectosigmoid and elevate it away from the sacral promontory in an anterior
and cephalad direction, displaying the upper part of the presacral space
that had been entered when defining the IMA.
Scissors cautery is used to enter the mesorectal plane, staying in the plane
between the mesorectal fascia anteriorly and the presacral fascia
posteriorly (Fig. 31-10). This by definition ensures that the hypogastric
nerves are preserved. They are usually visible as they pass down into the
pelvis anterior to the sacrum. In patients in whom the planes are difficult
to define, the nerves may need to be released from the back of the
mesorectum so that they “drop back” out of the field of dissection.
FIGURE 31-10 Dissection of the posterior mesorectum from the presacral fascia.
Continue the posterior mesorectal dissection down as far as possible. In

thin patients, this can often be extended to the pelvic floor in this first
approach. Once adequate traction is inadequate, the direction of dissection
needs to be changed.
Next, incise the peritoneum overlying the mesorectal plane on the right of
the rectum, and mobilize the mesorectum laterally by following the plane
from the posterior dissection (Fig. 31-11). Be conscious that there is a
natural tendency for the dissection to drift laterally into the pelvic
sidewall. Keep trying to stay in loose areolar tissue and keep thinking of
“releasing” the surrounding tissues off the mesorectal fascia. Dissection
usually continues to the area of the top of the right seminal vesicle before
traction is lost.
FIGURE 31-11 Incising the right lateral rectal peritoneum.
Now retract the rectosigmoid cephalad and to the right, tenting the left-
sided peritoneum. The assistant can provide countertraction on the left
pelvic sidewall, if necessary.
Incise the left-sided rectal peritoneum, again ensuring the incision overlies
the mesorectal plane and does not drift laterally (Fig. 31-12). The
presacral fascia can be identified as it extends into the lateral endopelvic
fascia on the pelvic sidewall, thereby protecting the nerves and ureters.
The dissection continues as far distally as possible as good traction allows,
and then one changes to further posterior dissection or anterior dissection,
depending on which appears to be limiting the ability to apply traction.
FIGURE 31-12 Incising the left lateral rectal peritoneum.
Continue to work alternately on the posterior dissection and each side

before turning attention to the anterior dissection. Incise the anterior
peritoneum just a millimeter or 2 anterior to the apex of the peritoneal
fold. This places the dissection between the layers of Denonvillier fascia
and allows dissection between the layers, preserving both the anterior
fascia of the mesorectum and the anterior layers of Denonvillier fascia.
This means that the seminal vesicles, vagina, and anterolateral nerve
bundles are protected. For an anterior low rectal tumor, dissect in the plane
anterior to Denonvillier fascia to include it in the specimen, displaying the
vagina or seminal vesicles. For lateral tumors, one side of the fascia may
be taken based on preoperative imaging.
Return to the posterior and lateral dissections to mobilize the rectum to the
anorectal junction. For low resections, it is necessary to dissect the rectum
down to the muscular tube below the inferior extent of the mesorectum
(Fig. 31-13). It is important to confirm that all of the mesorectum has been
dissected off the rectal sleeve, as one can otherwise inadvertently leave
residual mesorectum, particularly posteriorly, which might leave
inappropriately thick tissue, thereby causing the transverse staples to form
incompletely.
FIGURE 31-13 Dissection of the distal rectal tube at the inferior extent of the
mesorectum.
Transection
Before transection, perform a digital examination to ensure one is going to
transect at the correct level. In obese males, one can overestimate how
distal you are, and in thin females, this distance can be underestimated.
Insert a 45-mm endoscopic linear cutting stapler through the 12-mm LLQ
port and advance it into the pelvis. The assistant should retract the
mobilized rectum out of the pelvis under some traction. Using a bowel
grasper, manipulate the rectum so that a view of the distal rectal muscular
tube is obtained.
Pass the jaws of the stapler around the bowel, fully angulate, and advance
so that the bowel lies all the way at the apex of the stapler’s arms. By
catching the jaw on the left side of the pelvis and pushing, the angulation
of the stapler can be increased over what can be achieved with ratcheting
alone.
Make sure to adjust the angle of retraction on the rectum so that it lies
perpendicular to the stapler and ensure the stapler is pushed into the pelvis
and overlying the desired point of transection.
Fire the stapler. Of note, additional firings may be required, but it is
important to come across at a right angle and try to minimize the number
of staple firings, which may be associated with higher rates of
complications.
For very low tumors within 2 cm of the dentate line, an intersphincteric
dissection may be required from below. This will necessitate a handsewn
anastomosis.
Divide the mesocolon beginning adjacent to the cut IMA pedicle. Display
the left colic at its origin and divide it immediately distal to the IMA. This
has two benefits: the potential arcade between the ascending and
descending left colic branches is preserved, and the reach of the mesentery
is increased.
Continue to divide the mesocolon toward the descending/sigmoid
junction, ensuring this proceeds in a straight line. It is important to stop
the division prior to reaching the marginal artery so that the marginal
artery can be tested for pulsatile flow as the specimen is exteriorized.
Place a locking grasper on the proximal rectal staple line.
At the premarked stoma site (usually the RLQ, but sometimes the RUQ
port site in obese patients), make a circular skin incision to the size of the
ileostomy and deepen it to the aponeurosis. Make a vertical 3-cm incision
through the fascia and split the rectus muscle fibers vertically with a Kelly
clamp. Make a 3-cm vertical incision in the underlying peritoneum to
complete the trephine.
In heavier patients, or in those with a large tumor, this will not be adequate
for extraction and so a “keyhole” incision is extended superior to the
ostomy incision, extending the fascial incision appropriately.
Insert a small Alexis wound retractor and pass the stapled end of the
specimen into the wound using the laparoscopic grasper and retrieve it
with a Babcock grasper.
TIPS
The easiest direction to pass the stapler is from a right anterior

approach. When a second or further additional firing of the stapler is
required (often in obese males, where access is challenging), ensure
the jaws are placed just distal to the end of the previous staple line to
ensure there is no ischemic residual corner left (Fig. 31-14). Finally, if
it is difficult to reach with the stapler, have an assistant push the
perineum up toward the stapler, which can help gain 2 or 3 cm.
TIPS
When retrieving the specimen, place a sponge around the rectum and
gently retract while moving it in a circular manner. This prevents
damage to the mesorectal specimen, yet allows retraction through a
small hole. Have a low threshold to extending the incision so the
specimen is not disrupted.
Anastomosis
Identify the divided mesentery and test the marginal artery supply by
dividing the final few centimeters of mesentery with scissors (Fig. 31-15).
Have artery clamps ready to occlude the cut artery. If pulsatile arterial
flow if observed, the artery can be ligated. If not, one needs to transect
further proximally and check for a good pulsatile blood supply.
FIGURE 31-14 Laparoscopic staple gun division of the distal rectum.
FIGURE 31-15 Testing the marginal artery supply at the proximal transection point.
Divide the bowel sharply, perpendicular to its wall, ∼0.5 cm distal to the
divided mesenteric edge.
Grasp either side of the bowel wall with Babcock graspers and insert a
purse-string suture of 2-0 polypropylene, ensuring bites are full thickness
and include serosa, muscularis, and a small amount of mucosa, spaced
∼0.5-1 cm apart depending on the circumference and thickness of the
colon. Insert the first stitch from outside-to-in and continue to pass the
needle from outside-to-in. At the last bite, exit from inside-to-out. Make
sure not to have the bites too deep, or the purse string will not slide easily,
and may not tie tightly.
Insert the head of a circular stapling gun and tie the purse string tightly at
the base. If there are any large epiploicae overlying the proposed staple
line, they can be dissected from the bowel wall and excised. If there is
diverticulosis present, be aware that an epiploica could contain a
diverticulum.
Return the bowel to the abdominal cavity and place several figure-of-eight
Vicryl sutures with Rommel tourniquets until the opening is down to an
appropriate size for the ileostomy. Then re-establish pneumoperitoneum
by twisting the Alexis wound retractor around a port and securing it with a
Kelly clamp.
With the patient in Trendelenburg position, ensure no small bowel loops
are in the pelvis. Using plenty of lubrication, gently insert the circular
stapling gun into the anal canal, taking care not to disrupt the staple line as
the gun passes through the sphincter complex.
With the gun inserted up to the stapled end of the distal rectum, advance
the spike so that it exits just adjacent to the staple line (Fig. 31-16). It is
important not to have a gap between the spike and the transverse staple
line, as if the transverse and circular staple lines do not cross, there may be
an ischemic intervening segment left behind.
FIGURE 31-16 Insertion of the staple gun spike through the distal staple line.
Grasp the anvil by the tube and examine the left colon: ensure the
mesenteric cut edge is straight and that it reaches the pelvic floor without
any tension. Insert the spike into the anvil until it “clicks” and then close
the mechanism, ensuring no other structures are near the staple line (Fig.
31-17).
FIGURE 31-17 Docking the anvil and the staple gun spike.
The bowel should rest on the retroperitoneum and follow the curve of the
sacrum without being under any tension (Fig. 31-18).
FIGURE 31-18 Completed coloanal anastomosis with colonic conduit resting on

sacrum without tension.
Ensure two complete doughnuts are contained in the staple gun.

Occlude the colon at the level of the sacral promontory and reduce the
degree of Trendelenburg positioning. Fill the pelvis with warm saline so
that the anastomosis is completely submerged. Use a bulb syringe, or
flexible sigmoidoscope to examine the staple line for air tightness and
bleeding. Arterial bleeding can be easily clipped endoscopically. Fully
inflate the rectum with gas and observe for any bubbles in the pelvis.
Mature a de-functioning loop ileostomy.
The fascia at the stoma/extraction site should be closed to an appropriate
size with polydioxanone or Maxon sutures.
The “keyhole” incision should be closed with an absorbable subcuticular
suture, leaving the circular incision for the stoma.
TIPS
Before removing the needle, assess the purse string for how tight it is.
If there is any looseness, use this to place a second purse string, just
under the serosa, which always easily makes a tight purse string.
TIPS
If this is difficult, four Allis clamps can be applied to the four

quadrants of the anal verge and retracted to allow easy insertion
through the sphincters.
TIPS
When docking the anvil and spike, grasp the tube of the anvil with a
grasper in the right hand and support the bowel with the left. Once the
spike is inserted, use the right grasper, closed, to press on the back on
the anvil to advance it and “click” it in place, while continuing to
support the colon with the left-handed grasper.
Postoperative Care
care plan.
acetaminophen.
Enterostomal therapy will see the patient on postoperative day #1 to start
to teach about proper stomal care.
Nutritional therapy will also consult with the patient to discuss dietary
management with a new stoma.
Suggested Readings
Asgeirsson T, Delaney CP. Laparoscopic proctectomy: oncologic considerations. Surg Laparosc
Endosc Percutan Tech. 2012;22(3):175-179.
Gorgun E, Benlice C. Robotic partial intersphincteric resection with colonic J-pouch anal anastomosis
for a very low rectal cancer. Tech Coloproctol. 2016;20(10):725.
Mathis KL, Nelson H. Laparoscopic proctectomy for cancer. Ann Surg. 2019;269(4):603-604.
Chapter 32
Transanal Total Mesorectal Excision
SHERIEF SHAWKI
DANA SANDS
MATTHEW F. KALADY
Preoperative Setting: Rectal Cancer Patients

Examination
Digital rectal examination
Flexible and/or rigid proctoscopy
Sphincter evaluation
Clinical tumor staging
Local staging: pelvic magnetic resonance imaging
Particular note of the relation of tumor to the surrounding structures
and the angle between the anal canal and the levator ani to estimate
the direction of mesorectum once passed the puborectalis
posteriorly.
This will help avoiding dissecting in the false areolar plan along the
wall of the rectum.
Evaluation for circumferential resection margin
Distant radiologic staging
Chest and abdomen computed tomography
Additional imaging based on concern for metastatic disease
Serum carcinoembryonic antigen
Multidisciplinary tumor board discussion and treatment plan
recommendations
Stoma marking and education
Mechanical and oral antibiotic bowel preparation
Anesthesia
General anesthesia
Deep muscular blockade is required to achieve proper rectal distension
and appropriate relaxation.
Patient Positioning
Modified lithotomy position with arms tucked at the side
Adjustable stirrups
Adequate padding and securing of the patient in order to support steep
Trendelenburg positioning
Oral gastric tube and Foley catheter
Prior to Sterile Field Preparation

Confirm location of the tumor, mobility, and predicted distal margin.
Determine whether anastomosis will be handsewn or stapled.
For benign pathology, confirm appropriate operative plan, re-evaluate
sphincters.
Rectal enema with diluted povidone iodine is performed.
Sterile Field Preparation and Operating Room Setup

The abdominal and perineal fields are prepped and draped for two team
approach (Fig. 32-1).
FIGURE 32-1 Room setup. Patient is in modified lithotomy position. Abdominal team
is in position with the laparoscopic tower on the left side of screen and the corresponding
monitor on the other side. The perineal team tower is on the right side of the screen, and
corresponding monitor is by the patient’s head in front of the surgeon.
Instruments Needed (See Chapter 31 for the Abdominal

Proctectomy Portion)
Laparoscopic instruments needed
30-degree rigid scope, 5 mm (preferred) or 10 mm
Light cord right-angle adapter (Fig. 32-2)
Allows an improved extracorporeal space for the surgeon for
external hand movements and minimizes collision with the camera
FIGURE 32-2 GelPOINT in place. Note the right-angle adapter with 30-degree
scope to the left; thus, the camera is placed further to the right, resulting in more
space for the surgeon’s hands and minimizing external collision.
Maryland grasper/dissector
Atraumatic bowel graspers
Hook with electrocautery
Suction device
Insufflation:
AirSeal system (SurgiQuest, CT, USA)
Care must be taken to avoid fluid in the tubing of the system that
will result in system malfunction.
Standard insufflation systems may also be utilized, though may result
in billowing of tissues.
Access: GelPOINT access platform (Applied Medical, Rancho Santa
Margarita, CA, USA) (Fig. 32-3)
Regular size channel: 4 cm × 5.5 cm
FIGURE 32-3 Various sizes of GelPOINT access channel. Regular: 4 cm diameter

× 5.5 cm long. Long: 4 cm × 9 cm.
Long channel: 4 cm × 9 cm
Port placement in the Gel Cap (Fig. 32-4)
Three ports with triangulation
FIGURE 32-4 Gel Cap placed with laparoscopic ports position in reverse triangle.
In this case, we used the long 8-mm AirSeal port; hence, the scope was 5 mm, 30
degrees.
Either 8- or 10-mm AirSeal ports can be used depending on the use of

camera.
AirSeal port is a working port for better smoke-suctioning function.
Initial exposure and placement of the access platform is aided by either a
Lone Star retractor (Cooper Medical) or anal eversion sutures.
Purse-String Suture Placement

Placed after careful and precise evaluation of distal margin in relation to
the most distal extent of the tumor, at least 1 cm distal to the distal tumor
edge (Fig. 32-5).
FIGURE 32-5 Defining distal margin in relation to the lowest point of the tumor.
Depending on the location of the tumor, it can be placed in standard

transanal manner under direct visualization, or endoluminally in a
laparoscopic manner via port instrumentation after establishing
pneumorectum.
The latter will require proximal clamping of the colon from the
laparoscopic team to avoid overdistension, which can hinder the
laparoscopic mobilization.
Important Points to Consider When Performing the

Purse-String Suture
Purse-string suture should be circumferential without spiraling.
A circumferential marking using electrocautery may be used for
outlining to avoid spiraling (Fig. 32-6).
FIGURE 32-6 Marking for the purse string to ensure circumferential suture and
avoid spiraling.
Temporary placement of a sponge in the rectum may serve as a

reference point to avoid inappropriate spiraling.
The sponge should be removed prior to tying the knot.
The suture should incorporate near full-thickness tissue, but caution is
advised to avoid too deep of bites, especially when placed distally in the
rectum (Fig. 32-7A-H).
Anteriorly, the vaginal wall could be incorporated if the suture is
placed too deeply.
FIGURE 32-7 A-G. A sequence of endoluminal laparoscopic purse string. No
gapping, deep or greedy bites. H. Purse string could be completed in an open
transanal manner.
Laterally, the endopelvic fascia may be drawn inward, which could

potentially direct the surgeon to the extrafascial plane upon
proctotomy.
Avoid taking too much tissue with each needle pass. This will result in
bunching of the mucosa after tying the purse string.
The resultant redundancy will interfere with proper stretching upon
establishing insufflation, which may render the proctotomy technically
challenging.
It is also important to avoid gaps between needle passes. The inlet of each
new needle pass should be just adjacent to the exit of the prior bite. Upon
insufflation, this gapping may result in leaks and results in deformity of
the lumen, rendering proper proctotomy difficult.
Equidistant with equal depth suture passes is preferred. The depth is just
under the submucosa. When done this way, upon proctotomy and
traversing the muscle layer, the insufflation facilitates retraction of the
muscle fibers, exposing the correct plan for the surgeon.
After the purse string is secured (Fig. 32-8), a thorough washout of the
distal rectum and change of gloves is advisable prior to the proctotomy, as
the bowel is now closed from the viable tumor and minimizes tumor cells
shedding.
FIGURE 32-8 Purse string is tied and completed.
Proctotomy
The proctotomy site is marked with electrocautery, about 1 cm distally to
the purse string. This usually corresponds to the distal end of the radial
mucosal folds that form after tying the purse string (Fig. 32-9).
FIGURE 32-9 A-E. Proctotomy showing entry into the correct plane on the right side
of midline and continuing circumferentially.
Proctotomy is commenced on either side of midline posteriorly.

A full-thickness incision in the posterior rectal wall is more readily
recognized posteriorly and can be used as a guide for the rest of the
circumferential proctotomy (Fig. 32-9B and C).
Distally in the rectum, there is median fibrous raphe in the posterior
midline that causes difficulty in finding the correct plane. Therefore, it
is advisable to commence on either side of the midline initially and
then proceed in the midline.
Once in the right plane, completion proctotomy is undertaken following
the previously placed marks (Fig. 32-9D and E).
This technique may be used for ultra-low rectal tumors that require
intersphincteric dissection.
Intersphincteric dissection is commenced in the usual manner using an
open technique. This ensures proper distal margin and creates a landing
zone for the access channel to be inserted in the anal canal. After finishing
the intersphincteric resection portion, the lumen of the rectum is closed
with a purse-string suture and the pneumopelvis is established (Fig. 32-
10A-F).
FIGURE 32-10 A-F. Intersphincteric dissection after precisely defining distal margin
followed by placement of GelPOINT access channel.
Occasionally, the dissected upper anal canal creates a mass effect and may
obscure laparoscopic vision. In order to have better visualization (after
placement of the gel access channel), upon completing the purse-string
suture, the dissected part of the anal canal is invaginated into the rectal
lumen and the rectal wall is closed with imbricating sutures.
Usually, an intersphincteric dissection leads to plane deeper to the

endopelvic fascia. It is prudent to incise through this fascia returning
to the correct perimesorectal fascia propria to avoid nerves injury and
bleeding when dissecting higher in the pelvis (Fig. 32-11A).
FIGURE 32-11 A. Loose areolar plane between perimesorectal fascia propria and
presacral fascia. B. Dissection should be maintained in this plane. C. Anterior dissection in a
male patient preserving fascia of Denonvilliers. D. Distal anterior rectum dissected from the
prostate.
Dissection
The goal is to separate the perimesorectal visceral fascia from the parietal
endopelvic fascia, staying in the oncologic “holy plane” until connecting
with the transabdominal dissection in the same plane (Fig. 32-11A and B).
A key for successful dissection is to visualize the perimesorectal loose
areolar tissues. Dissection is undertaken and maintained along the
interface between the yellow shiny smooth mesorectum and the white
loose areolar tissue (Fig. 32-11B).
After successful circumferential proctotomy, dissection is carried out in
the correct plane posteriorly and anteriorly (Fig. 32-11C and D).
Traction and countertraction are crucial to expose the appropriate plane.
Subsequently, the lateral attachments (which are relatively more
challenging) are approached and dissected (Fig. 32-12A).
Care should be taken to identify the pelvic nerves and preserve them
laterally (Fig. 32-12B-D).
FIGURE 32-12 Relatively easier exposure of lateral attachments after dissection

in the correct plane anteriorly and posteriorly. A. Left neurovascular bundle. B. Left
neurovascular bundle being dissected. C. Right neurovascular bundle. D. Right
neurovascular bundle dissected.
The entire circumferential progression dissection cycle is repeated once

more advancing proximally. Anteriorly, the extent of dissection is the
peritoneal reflection, that is preferred to remain intact until connection
with the abdominal team (ie, the “rendezvous” or connection between the
abdominal and transanal approaches) (Fig. 32-13A).
FIGURE 32-13 Anterior (A) and posterior (B) dissection planes meeting. It is
preferred to postpone the connection until both teams are ready to approach final portion
together in cooperative manner.
Posteriorly, dissection continues to the fascia of Waldeyer (Fig. 32-13B).

Both anterior and posterior dissections are extended laterally as much as
possible, following the correct plan. This facilitates visualization, allowing
more safe dissection of the lateral stalks (Fig. 32-14A and B).
FIGURE 32-14 Second round of anterior and posterior dissection. A. Peritoneal
reflection. B and C. Easier defining of plane between mesorectum and lateral
attachments.
Connection of Transanal and Abdominal Dissections

The peritoneal reflection is incised and taken down from the laparoscopic
abdominal approach (Fig. 32-15).
FIGURE 32-15 Peritoneal reflection incised, abdominal view.
Similarly, the connection is completed posteriorly (Fig. 32-16).

FIGURE 32-16 Both teams connected posteriorly. Note simultaneous dissection of
both top and bottom teams when safe and feasible.
Lateral attachments are then divided (Fig. 32-17A-D).

FIGURE 32-17 Both teams dissecting lateral attachments. Left side (A:
transabdominal view and B: transanal view). Right side (C: transabdominal view and D:
transanal view).
Both teams work in harmony, retracting and exposing for each other and
dissecting simultaneously when safe and feasible.
Extraction of the Specimen

If transanal extraction of the specimen is to be performed, it is prudent to
assure the specimen size can fit through the pelvic floor hiatus and anal
canal to avoid fracturing the specimen (Fig. 32-18A-D).
FIGURE 32-18 A and B. Transanal delivery of the specimen after placement of
wound protector through the anal canal and levator hiatus. Note the previously placed
suture in preparation for handsewn anastomosis. C and D. Intact specimen anteriorly and
posteriorly removed from the transanal location.
Depending on the size of the specimen, extraction can be done while the
GelPOINT Path is in situ or if it is removed to avoid excessive friction.
In the latter event, we place a wound protector to avoid friction with the
surrounding tissues.
Furthermore, to facilitate delivery of the specimen transanally, the left
colic artery should be divided intracorporeally and the mesentery divided
to, but not including, the marginal artery.
This maneuver will create length and limits the chance of shearing or
avulsing the vasculature and mesentery during extraction via the anal
canal.
If a safe transanal extraction is not feasible, transabdominal retrieval of the
specimen should be performed. Our preference is through a small
Pfannenstiel incision or via the future stoma site.
Anastomosis
Handsewn Anastomosis
The specimen is transected from below under direct visualization (Fig. 32-
19A).
This ensures proper orientation and adequate blood supply.
FIGURE 32-19 A. Transanal transection. B. Eight sutures are in place, and after
confirming orientation and good blood supply of the colonic conduit, a second throw is
now started.
Eight sutures are placed equally spaced circumferentially via the perineal
approach. First bite incorporates the anorectal wall or distal rectal cuff,
including a superficial part of the underlying internal sphincter muscle
fibers.
The sutures are then secured to the draping on the outside and wait for
delivery of the colonic conduit to complete the anastomosis (Fig. 32-
19B).
Once the colonic conduit is in place and properly oriented, the previously
placed sutures are released and passed through the full thickness of the
colon. This is done in an organized and sequential manner taking each
suture one at a time and clamping the ends of the suture without tying.
After completing all eight sutures, they are then sequentially tied. The
tying index finger should push the knot to the anastomotic line rather than
pulling outside to avoid ripping the anastomosis.
Stapled Anastomosis
Distal Purse-String Suture

The upper rim of the remnant rectal cuff should be freed (in full thickness)
from the surrounding tissues (Fig. 32-20). The mobilization from the
surrounding tissues will help avoid incorporating adjacent tissue such as
the vagina in the anastomosis and/or the sphincters and allows for flexible
mobility and incorporation of the rectal wall.
Full-thickness suturing provides anastomotic integrity to avoid delayed
adverse sequelae such as dehiscence.
FIGURE 32-20 Dissected distal rectal rim prior to placing second purse-string
suture.
This dissection can be done transanally with good visualization of the

planes.
The surgeon’s index finger can be introduced transanally and used to
bluntly, yet gently, peel the rectal remnant from surrounding structures.
Alternatively, dissection of the rectal cuff can be facilitated and/or
initiated laparoscopically. A full-thickness purse-string suture is then
placed circumferentially (Fig. 32-21A-D).
FIGURE 32-21 A-D. Sequence of purse string placed in the distal rectal dissected rim
for stapled anastomosis.
The anvil is placed and secured in the colonic conduit by the abdominal
team.
The purse string is tightened securely, and the spike of the end-to-end
anastomosis gun is guided through and anastomosis is completed in
conventional laparoscopic manner.
Alternatively, the distal purse string can be left open, and the stapler
passed through it into the abdomen.
Here, under direct vision, the anvil and spike can be mated, and the
colon brought down into the pelvis under direct vision.
Finally, the stapler is opened at the anal canal, and the distal purse
string secured.
The stapler is closed, and after ensuring that the sphincter is excluded
from the anastomosis, it is fired.
As another approach, a drain is passed through the anastomosis, and the
purse string is tied down around the drain tube (Fig. 32-22A and B).
The spike of the stapler is connected to the drain tube (Fig. 32-22C).
FIGURE 32-22 A. Drain tube is passed through the untied purse string. B. Purse
string is then tied tight. C. The spike of the stapler is then connected to the end of the
tube. D. The tube guides the spike through the purse string. Laparoscopic guidance of
the abdominal team is helpful. E. End-to-end anastomosis stapler is now in position,
and the anastomosis will be completed in usual laparoscopic conventional manner.
The drain is pulled from above and used as a guide to bring the spike
through the purse string (Fig. 32-22D).
The anvil of the colon is then mated with the spike (Fig. 32-22E), and
the anastomosis is completed in the usual manner.
An additional approach has the anvil from the colon passed through from
above, and the purse string is secured (Fig. 32-23A).
The anvil of the colon is then mated with the spike (Fig. 32-23B and
C), and the anastomosis is completed in the usual manner (Fig. 32-24).
FIGURE 32-23 A. The anvil, which was placed and secured by the abdominal
team, is delivered into the rectum, while the colonic conduit is oriented and without
tension. B. The anvil and end-to-end anastomosis gun spike are connected together.
C. Stapler is deployed.
FIGURE 32-24 Stapled anastomosis completed.
The anastomosis is reinforced with 2-0 polyglycolic acid sutures as needed

(Fig. 32-25A and B).
FIGURE 32-25 Enforcement of the anastomosis with interrupted 2-0 polyglycolic acid
sutures. A. Reinforcement of the anastomosis with interrupted 2-0 polyglycolic acid
sutures. B. Completed reinforcement.
Postoperative Care
care plan.
acetaminophen.
Most patients will have received a diverting loop ileostomy, and
enterostomal therapy will be seen on postoperative day 1.
Suggested Readings
Bhama A, Althans A, Steele SR. Perioperative preparation and post-operative care considerations. In:
Attalah S, ed. Transanal Minimally Invasive Surgery (TAMIS) and Transanal Total Mesorectal
Excision (taTME). New York, NY: Springer; 2019.
Keller DS, Steele SR. TaTME for low rectal cancer: pros and cons. Chin J Gastrointest Surg.
2018;21(3):250-258.
Chapter 33
GYN-Onc Considerations for Complex
and Multivisceral Colorectal Disease
MARIAM ALHILLI
ROBERT DEBERNARDO
Background: Gynecologic Organ Involvement by Colon

Cancer
Potential organs involved the vagina, uterus/cervix, ovaries, rectocervical
junction, or vulva/ perineum.
Complete tumor resection has a strong impact on prognosis.
Tumor involvement is difficult to distinguish from tumor-associated
inflammation.
En bloc resection (modified posterior exenteration) is advocated to
avoid tumor dissemination.
Preoperative Considerations
Symptom assessment
Pelvic pain
Vaginal bleeding
Dyspareunia
Postcoital bleeding
Obstructive symptoms
Clinical examination
Thickening and obliteration of rectovaginal septum
Fixation, retroversion, and immobility of the uterus
Speculum examination: vaginal mass
Biopsy suspicious areas of disease
Consider pelvic examination under anesthesia, cystoscopy, and
sigmoidoscopy
Imaging
Magnetic resonance imaging—determine transmural tumor
involvement and lymph node involvement (Fig. 33-1)
FIGURE 33-1 Magnetic resonance imaging pelvis (rectal tumor invading vagina).
Recurrent rectal carcinoma forming a large tumor mass with involvement of
proctectomy bed, vagina, bilateral labia, and mons pubis. A. Sagital image. B. Axial
image.
Positron emission tomography/computed tomography: rule out

metastatic disease
Colonoscopy/sigmoidoscopy
Bowel preparation
Stoma marking
Venous thromboembolism prophylaxis
Antibiotics
Preparation for bilateral ureteral stent placement/cystoscopy
Type and crossmatch of packed red blood cells
Intraoperative Considerations
Equipment
Vessel loops to identify ureters
Cystoscopy and ureteral stents
End-to-end anastomosis (EEA) sizers
Surgical clips
Surgical staplers
Proctoscopy or flexible sigmoidoscopy
Vessel sealing device
Positioning
Low lithotomy position with legs in stirrups
Surgical preparation from the nipple line to the knees
Anatomic considerations (Fig. 33-2)
Avascular spaces
Pararectal
FIGURE 33-2 Pararectal (A) and paravesical (B) spaces.
Paravesical
Presacral
Pelvic lymph node dissection boundaries
From mid-common iliac vessels to circumflex iliac vein laterally
and from midportion of psoas to ureter medially (hypogastric artery
and vein) and obturator fossa anterior to obturator nerve
Para-aortic lymph node dissection boundaries
From the inferior mesenteric artery to the mid-common iliac vessels
Pelvic exenteration types (Fig. 33-3)
Anterior: removal of the uterus, bladder, urethra, and anterior vagina
and sparing of the rectum
FIGURE 33-3 A. Posterior vs. B. Total exenteration.
Posterior: removal of the uterus, cervix, posterior vagina, and

rectosigmoid colon
Total: removal of all pelvic viscera
Extent of surgical resection (Fig. 33-4)
Infralevator:
Resection of levator ani and coccygeus muscles (pelvic
diaphragm)
FIGURE 33-4 Classification of pelvic exenteration: (A) Supralevator
exenteration; (B) infralevator exenteration; and (C) infralevator exenteration
with vulvectomy.
Anus and/or vulva may require removal.

Supralevator:
Performed if tumor does not involve the lower posterior one-third
of vagina and distance between tumor and levator muscles is 2
cm or greater
Technique
En bloc resection of uterus, cervix, and rectosigmoid
A generous midline incision is made, and a self-retaining (Bookwalter)
retractor is placed.
The abdomen and pelvis are assessed. Suspicious lesions are biopsied
and sent for frozen section.
Retroperitoneal space is accessed, and the avascular spaces developed
(Fig. 33-5).
A peritoneal incision is made lateral to the ovarian vessels. The
external iliac vessels are identified.
FIGURE 33-5 Pararectal space.
Ligation of round ligaments as close to the pelvic sidewall as

possible performed.
The ureter is identified.
Incision of the anterior pelvic peritoneum along the pubic
symphysis.
The pararectal, presacral, and paravesical spaces are developed
bluntly, and the cardinal ligament is exposed.
Ligation and division of infundibulopelvic ligaments (ovarian vessels)
(Fig. 33-6)
FIGURE 33-6 Ligation of infundibulopelvic ligaments.
Ureterolysis (Fig. 33-7)

Dissection of ureters off medial leaf of the broad ligaments.
FIGURE 33-7 Mobilization of ureter.
Vessel loop is passed under the ureters and used for lateral traction.
Ureters are skeletonized from the pelvic brim to the level of the
uterine artery.
Mobilization of rectum and bladder (Fig. 33-8)
The peritoneal incision is extended medially to the posterior pelvis.
FIGURE 33-8 Mobilization of rectum and bladder.
The presacral space is developed underneath the sigmoid mesentery,

and the rectosigmoid colon is lifted out of the sacral hollow.
The colon is divided at the appropriate level.
The bladder peritoneum is mobilized, and the vesicovaginal space is
accessed.
Ligation of uterine artery and cardinal pedicles (Fig. 33-9A and B)
The uterine pedicles are skeletonized and ligated at the level of the
ureters.
FIGURE 33-9 A. Ligation of uterine artery. B. Ligation of cardinal pedicle.
The ureters are unroofed from the bladder pillars and are reflected
laterally.
Colpotomy incision: retrograde approach (Fig. 33-10)
The bladder is dissected off the vagina 2-3 cm distal to the cervical
junction.
FIGURE 33-10 Retrograde hysterectomy.
An incision is made in the anterior vagina using electrocautery—this

location is identified using a sponge-stick or EEA sizer in the
anterior vagina.
The colpotomy incision is extended laterally.
The parametrial tissue and cardinal ligaments are divided.
A posterior vaginal incision is made, and the rectovaginal septum is
entered.
Resection of the rectum is dependent on the location of tumor and
involvement of the anus.
Technique: tumor extension below peritoneal reflection
Division of levator muscles—supralevator exenteration (Fig. 33-11)
The anterior and lateral attachments of the levator muscles to the
pubic rami and the obturator internus fascia are divided.
FIGURE 33-11 Supralevator exenteration.
The rectum is lifted anteriorly and upward. The rectal pillars and the
levator muscles are divided from the sacral and coccygeal
attachments.
Perineal phase—infralevator exenteration
When dissection reaches the levator muscles, an incision is made 2
cm lateral to the area of tumor.
A second surgical team outlines the perineal resection (Fig. 33-12).
FIGURE 33-12 Perineal incision infralevator exenteration.
The extent of perineal resection is tailored to the degree of vaginal

or vulvar involvement.
Dissection is carried subcutaneously cephalad until the fascial plane
of the pelvic floor is reached.
The presacral space is entered anterior to the tip of the coccyx.
The specimen is detached and removed vaginally.
Lymphadenectomy
Pelvic lymphadenectomy (Fig. 33-13)
The bifurcation of the common iliac, external iliac, internal iliac
arteries, and veins and ureters is identified.
FIGURE 33-13 Pelvic lymphadenectomy.
Nodal tissue is removed, and vessels are skeletonized from the

midportion of the common iliac artery to the circumflex iliac vein
inferiorly.
Nodal tissue is removed from the midportion of the psoas muscles
laterally to the ureters medially.
Nodal tissue is removed from the obturator fossa anterior to the
obturator nerve.
Para-aortic lymphadenectomy (Fig. 33-14)
The bifurcation of the aorta, the inferior vena cava, the ovarian
vessels, the inferior mesenteric artery, the ureters, and duodenum is
identified.
FIGURE 33-14 Para-aortic lymphadenectomy.
Nodal tissue over the distal vena cava from the level of the inferior
mesenteric artery to the mid-right common iliac artery is removed.
Nodal tissue between the aorta and the left ureter from the inferior
mesenteric artery to the left mid-common iliac artery is removed.
Postoperative Care
Outcomes
High overall postoperative morbidity 11%-50%
Postoperative mortality 0%-7%
Surgical complications
Infection/abscess
Anastomotic leak
Postoperative ileus
Bowel obstruction
Locoregional recurrence rate in patients with R0 resection is 6%.
Risk factors for locoregional recurrence:
Positive lymph nodes
Positive margins
Intraoperative tumor dissemination
Recurrence can be minimized with use of intraoperative radiation
therapy (IORT).
PEARLS AND PITFALLS
Preoperative counseling and discussion of expectations

Lengthy postoperative stay
Changes in sexual function
No guarantee of cure
Possibly that procedure may need to be aborted
Need for vaginal reconstruction
Loss of ovarian function
Surgical evaluation:
Perform examination under anesthesia to determine mobility or
fixation of tumor to pelvic wall.
Gross examination of the abdomen for intra-abdominal disease or
pelvic and para-aortic lymph nodes.
Biopsy of suspicious areas and examination with frozen section.
Preoperative treatment with chemotherapy and/or radiation therapy
may facilitate complete surgical resection.
Consider IORT if margins are found to be positive.
Intraoperative considerations:
Abdominal surgical team should guide the dissection during perineal
phase to ensure margins are adequate.
Management of pelvic hemorrhage
Ligation of anterior division internal iliac artery (Fig. 33-15)
The hypogastric artery (anterior division of the internal iliac
artery) is ligated ∼5 cm distal to the common iliac artery
bifurcation.
FIGURE 33-15 Hypogastric artery ligation.
A right-angle clamp is passed beneath the hypogastric artery,

avoiding the underlying internal iliac vein.
The artery is ligated with a 1-0 or 2-0 silk suture.
Pelvis can be packed with planned return to the operating room in
24-48 hours after resuscitation and stabilization.
Interventional radiology
Use of flaps can reduce the risk of infection and fistula in patients
who are heavily irradiated.
Pelvic floor management
Layered closure of the deep pelvic and perineal tissues is the most
expedient and simplest method to close the perineum omental
pedicle flap to cover pelvic floor—Omentum is removed from
transverse colon and greater curvature of stomach. The left
gastroepiploic blood supply is maintained.
Consider mesh placement (synthetic absorbable—Polyglactin 910).
Pelvic drains below omentum or mesh
Vaginal reconstruction with myocutaneous flap
Postoperative considerations:
Early ambulation
Foley catheter may be left in place for 5-7 days if extensive
dissection of the bladder peritoneum is required. A trial of void is
performed.
Prophylactic anticoagulation
Consider extended duration anticoagulation (28 days).
Strongly consider referral to tertiary center with expertise in
management of colorectal malignancies and multidisciplinary team of
colorectal surgery, gynecologic oncology, urologists, plastic surgeons,
and radiation oncologists.
Suggested Readings
DiSaia PJ, Creasman WT. Clinical Gynecologic Oncology. 8th ed. Philadelphia, PA: Mosby; 2012.
Ramirez PT, Frumovitz M, Abu-Rustum NR. Principles of Gynecologic Oncology Surgery. 1st ed.
Philadelphia, PA: Elsevier; 2018.
Chapter 34
Spinal and Orthopedic Considerations
for Advanced Multivisceral Colorectal
Cancer
LUKAS M. NYSTROM
NATHAN W. MESKO
Indications/Contraindication
Localized recurrence without evidence of distant disease—does this
operation give the patient a reasonable chance at curative intent (especially
for high-level ablations)?
Preoperative advanced imaging—does anatomic distortion from
surgery/radiation, anticipated tissue planes, and tumor location allow for a
reasonable chance at “cure”?
Morbidity needs to be considered—high-level (S1/S2) resections will
create bladder and major potential dysfunction in ipsilateral or bilateral
lower extremities.
If a clean margin resection is not thought possible, we do not
recommend attempting a high-sacrum resection given extreme post-op
functional morbidity consequences.
Involvement of major vessels that would require resection/bypass is soft
contraindication—is it feasible to get a “clean” margin in multiply
operated/radiated tissue?
Overall patient comorbidity burden and health status
Is there local tissue flap coverage available?
Is local radiation therapy necessary (intraoperative radiotherapy or
brachytherapy)?
Anterior approach
+/− Headlamp
Richardson, Deaver, and malleable retractors
Self-retracting abdominal instrumentation
+/− Digital x-ray to localize level
Nerve stimulator/neural monitoring for L5/S1
Irrigating bipolar cautery device (ie, Aquamantys)
Conventional bipolar cautery
Extended/long clamps, forceps, dissection instrumentation
+/− Lighted retractors
Poole suction tip
Silastic sheet
Posterior approach (Fig. 34-1A-D)
+/– Digital x-ray to localize level
FIGURE 34-1 A-D. Prone positioning and draping should include both posterior
thighs so that soft-tissue coverage options may be maximized. This 68-year-old male
was found to have an isolated S3 body rectal cancer metastasis and underwent an S3
hemisacrectomy resection. A pedicled gluteus maximus flap was utilized to fill the
space evacuated by the sacrum/rectum. A hamstring rotational flap is another potential
option as a local rotational flap.
+/− Intraoperative navigation (two techniques)

Can use in conjunction with intraoperative computed tomography
(CT) scanner and 2 mm × 6 mm craniofacial screws utilized as
fiduciary points for registration
Can fuse preoperative thin-slice CT, magnetic resonance imaging
(MRI), and/or CT angiogram imaging and utilize bony landmarks
for registration
Gelpi, Cerebellar, Viper retractors
Blunt Homan and Bennett retractors
Curved and straight osteotomes
Kerrison Rongeur
Nerve hooks, freer elevators, Penfield elevators
+/− K-wires and K-wire driver
+/− Oscillating saw with narrow and reciprocal/sagittal blades
High-speed Midas Rex burr with matchstick tip
Nerve stimulator/neural monitoring for L5/S1
Irrigating bipolar cautery device (ie, Aquamantys)
Gel foam + Pledgets
Bone wax, Surgicel, Fibrillar
Implants (if resecting above S2 and destabilizing sacroiliac joint):
Pedicle screws
Spinal rods
Cross-links
Small fragment (3.5 mm) and large fragment (4.5 mm) screw set
Surgical Approaches
Anterior
Transperitoneal (Workhorse Approach)

Positioning
Supine on spinal flat top table or in lithotomy position—depending on
needs of multidisciplinary team
Approach will be combined with dissection of recurrent tumor with
multidisciplinary team (covered previously).
Safely mobilize the aorta, common iliac, and internal/external iliac
vessels. Oftentimes, this is radiated tissue, and a vascular surgeon can help
with the distorted anatomy.
Identify and protect nerve roots to be spared (L5, S1 especially; any
additional below this level).
Identify and transect/ligate nerve roots/vascular branches to be sacrificed.
It is generally not feasible to see nerve roots from anterior approach
below level of S2.
Identify the site of the planned osteotomy and ligate/cauterize presacral
vessels where they can be identified maintaining a safe margin from the
tumor.
Pack laparotomy sponges or a silastic sheet between vessels, nerves,
vertical rectus abdominis myocutaneous (VRAM) flap, rectal stump, and
so on and the sacral osteotomy site to protect from the osteotome causing
structure damage from “passing point.”
Retroperitoneal (Less Frequently Used)

Positioning
Supine with a bump underlying the ipsilateral hip to gently tilt the
pelvis
Radiolucent spinal flat top table
Dissect from 2 cm lateral to the anterior superior iliac spine toward the
pubic tubercle.
Identify superficial inguinal ring and release external oblique from this
landmark medially.
Identify the spermatic cord/round ligament and the deep inguinal ring.
Release the remaining abdominal muscles (transversus abdominis, internal
oblique) to expose the inguinal ligament. Maintain, if possible, for later
repair.
Identify the lateral femoral cutaneous nerve and either transect sharply or
preserve if possible with minimal traction.
Release the three abdominal layers subperiosteally from the iliac crest to
allow for the necessary exposure.
If necessary, the rectus abdominis may be released from the pubis.
Prior to doing this, identify the inferior epigastric artery and ligate. If
VRAM flap is planned, make sure plastic surgery team is involved in
this decision.
Identify the external iliac artery and dissect proximally to bifurcation of
common iliac artery.
Identify and protect the femoral nerve as it exits the interval between
the iliacus and psoas muscle bellies.
Identify and protect the ureter—this can be aided substantially by
preoperative placement of a ureteral stent.
Find the plane between the peritoneal cavity and the iliacus muscle.
The peritoneal cavity can be reflected medially to expose the lateral
sacral ala.
Posterior
Positioning
Prone on a Jackson spine table with knees dropped into sling to allow
for hip flexion (Fig. 34-2).
FIGURE 34-2 Utilizing a Jackson spine table with a leg “sling” can help to expose
the sacral prominence and allow for easier access to the sacral anatomy, sciatic notch,
and rectum.
Carefully position arms and pad all bony prominences.

If applicable, confirm if using intraoperative C-arm can clear the knees
and arms prior to draping.
May need to plan draping in both posterior thigh locations (plan to
plastic surgery team ahead of time) for potential hamstring or gluteal
flap harvest options
Incision
Localize with 20-guage spinal needle prior to incision, as needed.
Midline incision with length depending on levels. L4/L5 interspace is
approximately the level of iliac crest. Extend incision to tip of coccyx
and extend as necessary.
Dissect to spinous processes and elevate subperiosteal flaps off lamina (if
tumor allows) on both sides to reach lateral margin of sacrum from tip of
coccyx to greater sciatic foramen. These flaps will elevate the gluteus
maximus off the sacrum.
Release the pelvic floor musculature/anococcygeal raphe from the coccyx
and develop plane (if tumor allows) between the lateral sacrum and the
intrapelvic contents on both sides. Attempt to spare the pudendal nerve
and sciatic nerve (if lower level sacral ablation).
Release pelvic floor musculature from the lateral sacrum, including release
of piriformis muscle, and sacrospinous and sacrotuberous ligaments.
Identify the piriformis muscle belly and transect as lateral as possible to
maintain tissue margin for the tumor.
Identify the major contents of the greater sciatic notch, including the
sciatic nerve, and the superior and inferior gluteal vessels (artery and
vein). Protect these structures.
NAVIGATION/LOCALIZATION FOR OSTEOTOMY
Technique
Navigation can assist with complex osteotomies, or in situations where a
close margin is planned to enhance surgical accuracy.
Must plan appropriate placement of infrared/LED sensor to allow for clear
path of visualization between registration instruments and navigation unit.
Anchor rigid landmark sensor (“patient tracker”) to static bony landmark
with threaded Steinmann pins/bracket device—this cannot move until all
osteotomies are completed.
Two technique options are utilized:
Intraoperative C-arm using fiduciary screw landmarks to register (Fig.
34-3A and B)
Need to request intraoperative C-arm unit ahead of time
FIGURE 34-3 A and B. Fiduciary screw placement can help facilitate more
accurate and precise osteotomies when attempting to spare nerve roots. Utilizing
2.0-mm craniofacial screws by placing them in the right S3 (A) and left S4 (B)
lamina anatomy, these screws serve as static landmarks that can be “touched”
during registration. This technique is utilized with intraoperative computed
tomography scan technology.
Requires use of Jackson spine table to facilitate appropriate

positioning of imaging equipment
Need to plan location of bed to operating room entrance
(cumbersome machine to perform tight turns)
Use 2.0-mm craniofacial screws—place five to six screws within
field of imaging
Preoperative thin-slice CT, MRI, and/or CT angiogram imaging fusion,
utilizing bony landmarks for registration (Fig. 34-4A and B)
Several companies offer navigation technology, and preoperative
imaging protocols should be discussed with your individual vendor.
Generally, dedicated CT +/− MRI pelvis imaging that is 1-3 mm
slices is required.
FIGURE 34-4 A and B. Navigation screen shot—a 68-year-old male with an
S3 isolated hemimetastasis, where navigation was utilized to isolated the tumor
(yellow, A) with three separate cuts planned (green, teal, magenta discs), in order
to gain margins and spare the appropriate sacral nerve roots (B).
Register by easily recognized landmarks that correlate between

gross visualization and fusion imaging (ie, posterior superior iliac
spine, spinous processes, transverse processes, iliac crest osteophyte,
etc).
After landmarks or fiducial markers are identified, register by touching the
screw heads (method #1) or bony landmarks (method #2). An appropriate
standard deviation should be no more than 5-6 mm (the smaller the better).
Osteotomes and drills desired for use are attached to sensor and
appropriately registered so that depth, trajectories, and rotations can be
accurately understood.
Tip: It should be noted that any change in the position of the fiducial
marker or rotation of the fiducials resected area will render the original
scan information inaccurate.
NERVE ROOT DISSECTION
Technique
Perform a central decompression of the sacrum at a level above your
planned osteotomy site to carefully expose the cauda equina (Fig. 34-5).
FIGURE 34-5 Following a resection, hemostasis can be achieved using a variety of
agents, such as bone wax, Fibrillar, and Surgicel. This was a 62-year-old female with an
isolated S3/4 metastasis who underwent an S3-level sacrum resection. The S2 nerve
roots have been isolated and spared. The rectal remnant was not involved, and spared.
Identify individual nerve roots and utilize Kerrison Rongeur to track them
laterally to where they exit the sacral foramina anteriorly.
Expose all nerve roots one level above and all below the level of the
planned osteotomy (if dorsal tumor extension allows).
Protect the nerve roots above the level of the osteotomy and label with
vessel loops.
All nerve roots below the osteotomy will be sacrificed. Prior to the
osteotomy, they should be individually ligated as proximal as possible
with 2-0 silk ties. This will prevent leakage of cerebrospinal fluid. Sharply
transect nerve roots with a blade.
Oftentimes, S4 and S5 nerve roots are small, and it is not practical to tie
these off.
Ligate nerve roots proximal to the dorsal root ganglion to minimize severe
neuropathic pain.
OSTEOTOMIES
Technique
Perform the osteotomies as planned, based on preoperative templating of
the necessary tumor margin.
If performing osteotomies from posterior to anterior, the major vessels in
the pelvis should be protected. If a prior anterior approach was performed,
look for your sponge or silastic sheet barrier.
Navigation can assist in ensuring safe depth of the osteotome in
performance of the osteotomies.
Following the osteotomy, trim any prominent residual sacral angulation to
avoid a source of skin pressure and subsequent ulceration.
Bleeding bone surface areas can be addressed with hemostatic agents,
such as bone wax, Fibrillar, or Surgicel.
INSTRUMENTATION/RECONSTRUCTION
Technique
For levels of resection higher than S2, reconstruction of the sacroiliac arch
and continuity of the sacroiliac ligaments/joint should be considered to
determine stability.
High-level resections are rarely utilized in local rectal cancer
recurrence, due to prior radiation causing a difficult healing
environment and morbidity in the setting of an aggressive and recurrent
nonprimary bone tumor process.
Fixation is gained into the lower lumbar levels with pedicle screws and
into the ilium with pedicle screws or iliac screw bolts.
Stabilize with spinal rods connecting the lumbar and iliac segments.
If needing to reconstitute the sacropelvic arch, obtain biologic stabilization
(preferred) through the use of vascularized free fibular autograft in
conjunction with plastic surgery team.
One (hemisacrectomy) or two (total sacrectomy) fibula are harvested from
the lower legs.
The fibula is placed as struts between the lowest remaining lumbosacral
segment and the ilium. Fix into place with 3.5-mm screws.
Microsurgical anastomosis to nearest accessible arterial inflow is
performed by plastic surgery team.
CLOSURE
Technique
Plastic surgery team should be judiciously utilized for flap coverage to fill
dead space following sacrectomy.
If VRAM flap is planned, this needs to be harvested and “dunked” into
the abdomen during the anterior approach.
Layered closure over deep, 10-mm flap Jackson-Pratt or Blake drains,
which should be sewn in to avoid dislodging with bed mobility and
hygiene.
Posterior skin closure with interrupted monofilament (ie, Nylon) suture
If brachytherapy is necessary for a soft-tissue mass protruding dorsally,
coverage can be temporized with a wound VAC (Fig. 34-6).
FIGURE 34-6 If a patient has a soft-tissue mass involving dorsal wall of the sacrum or
musculature, brachytherapy can be considered as an adjuvant therapy to aiding with local
control. White foam is placed in the defect to protect any remaining pelvic contents and
shield from radiation effects. The catheter is sandwiched between the white foam (seen in
the defect) and black foam overlying the catheters, with delayed plastic surgery coverage
completed after a 3-5 days course of radiation therapy.
If wound closed, incisional negative-pressure wound therapy on all

posterior incisions can maintain sterility of surgical site and promote
healing.
Postoperative Care
Strict activity precautions postoperative to prevent pressure on the
flap/incision is necessary.
We otherwise follow our published standardized enhanced recovery
perioperative care plan.
Orogastric tubes are removed prior to extubation.
Diet is advanced as tolerated.
With concomitant stoma construction, our wound/ostomy therapists will
meet with the patient on postoperative day (POD) #1.
Pending the extent of the dissection, urinary catheters are removed on
PODs 1-3. Depending on the level of transection, urology may be
consulted to manage any postoperative urinary issues.
acetaminophen.
Suggested Readings
Koh CE, Solomon MJ, Brown KG, et al. The evolution of pelvic exenteration practice at a single
center: lessons learned from over 500 cases. Dis Colon Rectum. 2017;60(6):627-635.
Lau YC, Jongerius K, Wakeman C, et al. Influence of the level of sacrectomy on survival in patients
with locally advanced and recurrent rectal cancer. Br J Surg. 2019;106(4):484-490.
Sasikumar A, Bhan C, Jenkins JT, Antoniou A, Murphy J. Systematic review of pelvic exenteration
with en bloc sacrectomy for recurrent rectal adenocarcinoma: R0 resection predicts disease-free
survival. Dis Colon Rectum. 2017;60(3):346-352.
Chapter 35
Intraoperative Urology Consultation
HADLEY WOOD
KEN ANGERMEIER
The distal third of the ureter, and more commonly the left-sided ureter, is
most likely to be injured.
Risk factors for injury: large pelvic masses, radiation, chemotherapy,
previous pelvic surgery, and inflammatory processes such as diverticulitis
or inflammatory bowel disease (IBD).
Overall, cystotomy (35%) is the most common iatrogenic genitourinary
injury in a colorectal procedure, followed by incomplete ureteral
transection (29%), complete proximal and distal ureteral injuries (17% and
15%, respectively), urethral injury (3%), and injury to a preexisting ileal
conduit (1%).
Delayed Presentation
Delayed presentation is associated with significant morbidity and
mortality (Fig. 35-1).
FIGURE 35-1 Morbidity and mortality associated with undiagnosed and recognized
ureteral injury, thus emphasizing the importance of detection and early repair. (Blackwell
RH. Kirshenbaum EJ, Shah AS, Kuo PC, Gupta GN, Turk TMT. Complications of
recognized and unrecognized iatrogenic ureteral injury at time of hysterectomy: a
population based analysis. J Urol. 2018;199(6):1540-1545.)
Approximately two-thirds of all ureteral injuries go undetected at the time

of initial injury.
Postoperative presentations of ureteral injuries include sepsis, urinoma
formation, abscess, obstructive uropathy, renal insufficiency, ileus,
peritonitis, and death.
Fistulization is most likely to involve vagina, sigmoid colon, or cecum.
Significant morbidity associated with undetected injuries.
Higher hospital total charges, longer length of hospital stay and greater
incidences of anastomotic leak, renal failure, and wound complications
(Fig. 35-1).
Ureteral injuries/fistulae often coexist with bladder injuries, and therefore,
upper tracts must be evaluated for all bladder injuries with magnetic
resonance urography (MRU), computed tomography urography (CTU), or
retrograde pyelograms to rule in or rule out concomitant ureteral
involvement.
Large proportion of ureteral injuries are missed as these could be partial
injuries, ureteral contusion, devascularization, or thermal trauma and
could manifest in delayed manner.
Safeguards
Ureteral catheters
Lighted ureteral catheters
Intraoperative cystoscopy
Intraureteral indocyanine green (ICG)
Ureteral Catheters
Most common form of primary prevention performed prior to colorectal
surgery used chiefly in low anterior resections (LARs), abdominoperineal
resections (APRs), prior history of radiation, and previous abdominal
surgery.
Employed in ∼4%-5% of all colorectal surgeries (increased incidence from
1.1% in 2004 to almost 4.4% in 2011).
Time factors: 11.3 minutes of added operative duration.
Current dogma: while prophylactic catheters do not prevent injury, they
do result in intraoperative recognition of injury and facilitate in
immediate repair at the time of primary surgery.
Emerging literature suggesting benefit to ureteral catheters, however,
no randomized control trials to date.
Side effects: hematuria, urinary tract injury (UTI), rare: ureteral
perforation, edema, and reflux pain
Lighted Ureteral Catheters

Increasingly utilized in laparoscopic procedures to facilitate ureteral
identification when tactile feedback (eg, robotic surgery) is limited.
No ureteral injuries demonstrated in a large 5-year retrospective cohort
examining the use of lighted ureteral catheters in almost 500 cases of
laparoscopic LARs and left colectomies in the setting of diverticulitis and
malignancy.
Intraoperative Cystoscopy
Can be utilized to evaluate for bladder injury, particularly low trigonal and
bladder neck injuries that may not be well-visualized directly
Can be performed with injection of intravenous (IV) dye to visualize
ureteral jets (eg, fluorescein, indigo carmine, methylene blue)
Five-fold increase in intraoperative detection of ureteral and bladder
injuries
Intraureteral Indocyanine Green

ICG injected into the lumen of ureter and subsequent visualization of
fluorescent green enhanced ureter noted under near-infrared fluorescence.
Main application in robotics, where tactile feedback is limited.
Types of Ureteral Injury

Laceration: complete or partial
Ligation: suture versus stapled
Crush
Thermal injury
Kink
Ischemic/de-vascularization
Periureteral inflammation/fibrosis (extrinsic, as with diverticular
phlegmon)
Intraoperative Consultation for Injury

Preoperative assessment should include a good history review, including
previous radiation, malnutrition, chemotherapy, and assess contralateral
kidney/prior imaging.
Intraoperative assessment should include hemodynamic stability,
availability of family/power of attorney and previous renal disease, and
brief review of entire operative course and anatomy with primary surgeon.
Patient may require repositioning or reprepping, to permit cystoscopy or
access to genitalia for catheterization or cystoscopy.
If fluoroscopy is needed, as with retrograde pyelography to assess ureters
for injury, C-arm access may be impaired by table positioning. Direct
injection retrograde with methylene blue for on-table assessment or
antegrade injection of IV dye may allow for intraoperative identification
without fluoroscopy and repositioning.
Cystoscopy equipment available (including tubing and light source)
Guidewires, open-ended ureteral catheters, double J and single J ureteral
stents, fine scissors (eg, tenotomy), fine-needle drivers (eg, for 4.0 or 5.0
suture), and fine, atraumatic forceps
Intraoperative Management of Ureteral Injury

Urology consultation, if available
Direct inspection of the ureter when injury suspected
Contralateral ureter and bladder should also be examined. Bladder is the
most commonly injured organ in the lower urinary tract.
Assess for relevant comorbidities. For example, does the patient have
impaired renal function? Are both kidneys present and working? Does the
patient have baseline urologic disease, such as urinary incontinence,
bladder obstruction, or atonic bladder? All may impact decision-making
about reconstructive options.
Small or incomplete injuries may be managed with ureteral stenting alone,
although direct repair is preferred for injuries that are directly visualized.
Ureteral Repairs
Most injuries occur in the pelvic ureter; thus, 90% of ureteral injuries can
be managed with three procedures including:
Ureteroneocystostomy or ureteral reimplant
Psoas hitch
Boari flap +/– psoas hitch
Mid-ureteral repairs are mostly managed with ureteroureterostomy, Boari-
psoas hitch, or (more rarely) transureteroureterostomy (TUU).
Upper ureteral repairs may be managed with UU, TUU, or
ureterocalycostomy with or without concomitant nephropexy/renal
mobilization.
Complete ureteral injuries may require ileal ureter replacement
(contraindicated in cases of IBD or previous radiation to the abdomen) or
renal autotransplant.
Ureteral ligation with percutaneous nephrostomy in cases where no
options exist.
Endourologic
Endourologic options can be diagnostic and therapeutic. These may also
be employed when an open repair may not be feasible, given an early post-
op time period when it may be difficult to intervene with open surgical
management or if the patient is unstable and cannot undergo an open
repair (Fig. 35-2).
FIGURE 35-2 Retrograde pyelogram performed on-table demonstrates left distal

ureteral suture ligation. Patient ultimately required release of suture ligature with stenting.
Proximal diversion with occlusion (via nephrostomy tube and a

nephroureteral catheter that is occlusive)
Ureteral stent placement with retrograde pyelogram
Technique
Open Options for Repair
Proximal Ureteral Injury
Given proximal ureteral injuries are rare and require complex repairs, the
authors choose not to discuss the following reconstructions. Repair algorithm
is beyond the scope of this chapter.
Ileal ureter (could be contraindicated in cases of IBD, radiation) (Fig. 35-
3)
FIGURE 35-3 Patient with long-segment ureteral stricture, nonfunctioning bladder,

and solitary kidney. Underwent ileal conduit to renal pelvis. Images demonstrate half of the
anastomosis completed with instruments in the lumens of the ileum (upper) and renal
pelvis (lower).
Autotransplant
Ureterocalycostomy
TUU
Renal descensus with concurrent psoas hitch
Nephrectomy
Mid-ureteral Injury
Transureteroureterostomy
Indication: Most commonly employed in the rare patient with a long-
segment mid-to-distal ureteral stricture and limited pelvic access that
would preclude a ureteral reimplant with a psoas hitch or bladder flap.
Indicated when distal ureter is obliterated or not suitable for repair (Fig.
35-4).
FIGURE 35-4 A 57-year-male s/p left simple nephrectomy following blunt trauma and
subsequently developed right mid-ureteral obstruction following hemicolectomy. Images
demonstrate the right and left ureters mobilized toward the midline (A) and completed
transureteroureterostomy anastomosis (B). (Images courtesy Kenneth Angermeier, MD.)
May be a good option in a patient with long-segment ureteral obstruction

with contralateral “orphan” ureter secondary to prior contralateral
nephrectomy
Contraindications: avoid in patients with history of urothelial malignancy,
patients with urolithiasis who may require further upper tract
instrumentation, infectious disease such as tuberculosis
Mobilization of affected ureter to renal pelvis with care taken to preserve
adventitia
A tunnel may be created in retroperitoneum posterior to mesentery of
small bowel, preferably cephalad to inferior mesenteric artery.
If needed, mobilization of contralateral ureter to bring medially, but no
dissection below iliac bifurcation if possible
End-side reimplant with 4-5.0 absorbable suture, chromic or absorbable
braided (eg, polyglactin)
Posterior anastomosis is performed first, followed by stenting of effected
ureter and then the anterior anastomosis.
Bladder drainage post-op variable depending on the extent of repair,
patient, but typically longer than 48 hours. Stent typically 2-3 weeks,
removed via office cystoscopy
Drain creatinine (Cr) may be obtained if drain output is elevated to check
for urine leak.
Not the primary option and only used in select cases, due to putting both
ureters potentially at risk.
Ureteroureterostomy
Limited mobilization, excision of injured area with spatulation of each end
Primary closure over JJ stent with 4-5.0 absorbable suture, chromic or
absorbable braided such as a polyglactin
Anastomoses can be performed in running or an interrupted manner.
Posterior anastomoses completed first, followed by placement of ureteral
stent and then anterior anastomoses completed
Tissue wrap such as omental or peritoneal may be used around
anastomoses if available.
Bladder drainage post-op variable depending on the extent of repair,
patient, but typically longer than 48 hours. Stent typically 2-3 weeks,
removed via office cystoscopy
Anastomosis performed in a similar manner as TUU.
Distal Ureteral Injury

Ureteral Reimplant or Ureteroneocystostomy with or without
Psoas Hitch
Debride edges of the ureter, remove devascularized tissue.
Mobilize if needed to renal pelvis, but dissection/mobilization should be
limited to only to only what is necessary for tension-free repair to limit
risk of ischemic injury to ureter.
Contralateral bladder pedicle may be ligated to sweep bladder toward
affected ureter.
Perform the colorectal anastomoses and hemostatic evaluation/irrigation
prior to ureteral repair.
Typically refluxing implantation into a cystotomy near dome of bladder
with 4-0 or 5-0 absorbable (Fig. 35-5) suture, such as polyglactin or
absorbable monofilament (eg, polydioxanone suture).
FIGURE 35-5 Ureteroneocystostomy with instillation of saline to maximally distend

the bladder following distal ureteral injury in a patient undergoing hemicolectomy for
diverticular disease.
JJ stenting × 2-3 weeks

Placement of pelvic drain
Foley catheter prolonged pending surgeon, typically longer than 48 hours
Boari Flap +/– Psoas hitch (Fig. 35-6)
FIGURE 35-6 Boari flap raised from left anterior bladder toward the left pelvic brim (A),
followed by fixation to the underlying psoas tendon and introduction of the left distal ureter
through a cystotomy in the back wall of the flap (B). Ureter is shown inserting into the Boari
flap posteriorly (C).
Mid- and distal reconstruction often requires use of this flap to bridge
larger gap (<10-15 cm in length) between the ureter and the bladder.
Mobilize the ureter and bladder as described earlier for
ureteroneocystostomy.
If tension-free anastomosis cannot be achieved, the bladder should be fully
mobilized on the opposite side of the planned flap and requires division of
the contralateral superior vesicle pedicle.
After the bladder is distended with normal saline, measure the distance
from the posterior bladder wall to the proximal cut end of the ureter. The
outline of the flap is marked on the bladder with the flap being at least 4
cm wide at the base and 3 cm at the terminal end (or 3x the diameter of
the ureter) to avoid constriction of the ureter after tubularization. The
length of the flap should equal the length of the ureteral defect plus 3-4 cm
additionally if a nonrefluxing anastomosis is planned. The ratio of flap
length to base width should not be greater than 3:1 to avoid flap ischemia
(Fig. 35-6).
Not the primary option and only used in select cases, due to putting both
ureters potentially at risk.
Fill and clamp bladder. Stay sutures are placed just outside the four
corners of the planned flap.
Outline flap to rotate up toward the ureter with wide base proximal
portion.
Reimplant ureter, preferably through separate cystotomy on posterior
distal aspect of the flap.
Psoas landmarks and hitch details: using an index finger, elevate the
ipsilateral posterior bladder wall toward the psoas tendon and hitch in
place with 2-0 or 3-0 similar monofilament (eg, polydioxanone) in a
vertical orientation to avoid injury to femoral nerves
(genitofemoral/ilioinguinal are lower). The ultimate goal of the psoas hitch
is to relieve tension off the ureteral anastomosis.
Bladder closed in two layers, with 4-0 running mucosal closure and 3-0
interrupted suture through muscularis and adventitia
The peritoneum, perivesicular fat, or omentum may be further mobilized
for an additional layer of coverage over the anastomosis and may be
tacked to the bladder serosa with multiple absorbable sutures.
Cystogram typically 10-14 days post-op for confirmation of integrity
before removal of JJ stent and Foley catheter
Bladder Repair
Bladder filling followed by primary closure in two layers, with 4-0
running mucosal closure and 3-0 interrupted suture through muscularis
and adventitia
Diversion with Foley or suprapubic tube followed by cystogram prior to
Foley removal (typically 7-14 days)
In cases of radiation, IBD, second layer closure with perivesicular fat flap,
the omentum are optimal and prolonged Foley drainage preferred.
Urethral Repair
Defect most commonly mid-prostatic urethra, but can be membranous
urethra or even bulbar urethra (Fig. 35-7)
FIGURE 35-7 Voiding cystourethrogram demonstrates extravasation of contrast from

the proximal bulbar urethra following abdominoperineal resection (APR) and contrast
pooling outside the urethra that subsequently drained through the perineal closure wound.
Location of prostate (p) noted. Fistulae following postradiation APR can be seen
emanating from the prostatic or membranous urethra as well.
Most commonly encountered during APR or very LAR, after radiation,

during dissection of rectum off the prostate between the seminal vesicles
Repair acutely primary closure with flap (omentum or gracilis
interposition) for second layer
Urinary diversion with Foley catheter 3-6 weeks
Delayed presentation, most common with development of rectourethral
fistula
Repair algorithm is beyond scope of this chapter; please refer to specialist
center.
Special Considerations
IBD—fisulizing nature, reoperative nature.
Second layer over closure important (omentum, peritoneal flap,
paravesical pedicle/fat)
Patients with short gut high risk for stones due to metabolic problems and
hyperoxaluria
Thus, procedures such TUU, use of bowel reconstruction in substitution of
ureteral segments, and any operation that involves ureteral reimplant have
implications for fistulization, strictures, and/or upper tract stone
management due to the native pathology stemming from the original
disease process.
Diverticulitis
Bladder wall often thickened from phlegmon, difficult to mobilize, may
limit closure/Boari flap, ureteral reimplant
Radiation
May lead to ischemia and compromise blood supply especially in setting
of postradiation ureteral stricture, thus important to consider two layer
closure
Avoid use of ureteral segments below the pelvic brim if feasible, as these
are often prone to delayed stricture or leak
Postoperative Identification of Ureteral Injury

History and clinical evaluation (consider type of surgery, duration since
surgery, clinical stability, abdominal wall status)
Renal ultrasound or CT to assess for hydronephrosis/obstructive uropathy
Elevated Cr may be due to renal compromise (obstruction) or reabsorption
of urine in the peritoneum, artifactually increasing serum Cr.
Cystogram or CT cystogram in cases of bladder injury
Evaluation of ureters for concomitant injury: CTU, retrograde pyelogram,
MRU
Mag-3 renal scan may help identify the extent of obstruction in partial
ureteric occlusion.
If a urinoma is present, percutaneous drainage of the pelvis may be
required, along with urinary diversion.
For ureteral injuries, endourologic management is optimal in this case, to
avoid re-entry into a recently operated abdomen unless the injury is
identified relatively early (<5 days) (Fig. 35-8).
FIGURE 35-8 Obstructing nephroureteral catheter fashioned by melting the distal end
of a nephroureteral catheter to occlude a leaking ureter after iatrogenic ureteric injury.
If endourologic management is not successful, urinary diversion with

percutaneous nephrostomy tubes allows for healing and delayed
laparotomy and repair.
PEARLS AND PITFALLS
Iatrogenic ureteral injuries are common in colorectal surgery with the

most common injuries involving the bladder followed by the distal
ureter. These injuries may confer a significant morbidity and mortality
to the patient and thus should be dealt with the utmost diligence. Early
identification of UTIs is paramount in minimizing morbidity and
preserving renal function. Definitive repair at time of injury is
associated with excellent outcomes and overall decreased morbidity and
mortality; however, intraoperative recognition is not always feasible
and requires high index of suspicion.
Preoperative placement of ureteral catheters should be considered in
high-risk surgeries, where they can be of assistance with
visualization, detection, and palpation, and facilitate on-table
identification and repair of ureteral injuries.
Inspection of the contralateral ureter along and bladder for any
concomitant injuries that may have occurred is prudent when ureteral
injury is noticed.
Postoperative diagnosis of ureter or bladder injury requires high level
of suspicion, given multitude of symptoms such sepsis, ileus,
absorptive azotemia, oliguria/anuria, flank pain, nausea/vomiting,
acute abdominal pain, ureteral stricture (long term), and fistulization.
JP fluid for Cr
Imaging with urinary drainage phase such as CTU/MRU can be
diagnostic.
In cases where MRU/CTU are contraindicated, cystoscopy with
retrograde pyelogram and attempt at retrograde stenting may
prove both diagnostic and therapeutic, depending on the extent of
injury.
Multiple surgical options for repair of the ureter depending on the
level and mechanism of injury
In patients with bowel disease or previous radiation, special
consideration should be given for closure with flap.
Percutaneous nephrostomies can be employed as temporizing
measure until more definitive surgical management is possible.
Intraoperative identification of injury can be performed by several
means: injecting methylene blue and looking for spillage or waiting
for the Foley to have blue urine, filling and distending bladder and
looking for spillage, cystoscopy and stents or retrograde radiograph.
Postoperative Care
Individual variations exist; however, in general, the Foley catheter, JP
drain (if utilized), and stent remain postoperatively for 1 to several weeks.
Refer to the previous text by injury location to discuss specifics.
Suggested Readings
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Silva G, Boutros M, Wexner S. Role of prophylactic ureteric stents in colorectal surgery. Asian J
Endos Surg. 2012;5(3):105-110.
Speicher PJ, Goldsmith ZG, Nussbaum DP, Turley RS, Peterson AC, Mantyh CR. Ureteral stenting in
laparoscopic colorectal surgery. J Surg Res. 2014;190(1):98-103.
Steele SR, Hull TL, Read TE, Saclarides TJ, Senagore AJ, Whitlow CB, eds. The ASCRS Textbook of
Colon and Rectal Surgery. 3rd ed. Arlington, IL: Springer; 2016.
Summerton DJ, Kitrey ND, Lumen N, Serafetinidis E, Djakovic N, European Association of Urology.
EAU guidelines on iatrogenic trauma. Eur Urol. 2012;62(4):628-639.
Teeluckdharry B, Gilmour D, Flowerdew G. Urinary tract injury at benign gynecologic surgery and the
role of cystoscopy. Obstet Gynecol. 2015;126(6):1161-1169.
PART V
Technical Tips for Specific Situations
Chapter 36
Complex Diverticular Disease:
Colovaginal and Colovesicle Fistula
Repair
MICHELLE F. DELEON
STEVEN D. WEXNER
BRADLEY CHAMPAGNE
Colonoscopy, cystoscopy (for colovesicle fistula), and a vaginal
examination/vaginoscopy (for colovaginal fistula) should be performed, if
possible, to exclude cancer and confirm fistula.
We normally attempt to “cool” patients down with intravenous (IV)
antibiotics and wait 6-8 weeks after the flare to undergo a semi-elective
operation.
Though ureteral stents have not been shown to decrease the rate of ureteral
injury during colorectal surgery, they do allow for earlier detection of
injury. In these cases where ureteral anatomy may be distorted secondary
to inflammation and scarring, we recommend placement of ureteral stents
to aid in detection of the ureter.
Bowel preparation and perioperative antibiotics are routinely given.
Patients should be considered for marking for a stoma (colostomy vs.
diverting ileostomy), depending on the degree of inflammation.
Laparoscopic Approach
Patient Positioning
The patient is placed in the modified lithotomy position (+/− bean bag).
The arms are tucked at the patient’s side, and the bean bag is placed to
suction.
If the patient is too obese to have both arms tucked, the left one remains
out.
An oral gastric tube and a bladder catheter are placed.
Any hair on the abdomen is clipped from xiphoid to pubis and out to the
anterior axillary line.
Surgeon and Monitor Positioning

The primary surgeon stands on the right side of the patient, with the
assistant on the left side.
After all ports have been inserted, the assistant moves to the right side of
the patient, to the left of the primary surgeon.
The primary monitor should be placed on the left side of the patient
toward the hip.
The secondary monitor is on the right side of the patient toward the head
and is used primarily for port placement.
Sterile Surgical Equipment

Gastrointestinal (GI) laparoscopic tray with atraumatic graspers
GI open tray with pelvic retractors (add on for other specialties if further
work is needed)
Knife handle
Adison forceps
Ochsner clamp
Allis clamp
Kelly clamp
Moynihan clamp (short and long)
Babcock clamp (short and long)
Kocher clamp
Tonsil clamp
Dennis clamp
Suction tip
Metzenbaum scissors
Mayo scissors
Harrington scissors
Jones scissors
Needle holder
Monopolar cautery
Bonnie forceps
Appendiceal retractors
St. Mark’s retractor
Included in this tray also long instruments for the pelvic dissection
Laparoscopic and open linear and end-to-end staplers
Energy device
Flexible sigmoidoscope
Hassan, 10-12 mm and 5 mm trocars
0- and 30-degree, 10 and 5 mm laparoscope
Additional instruments are usually needed depending on the combined
part with the proctectomy, gynecology tray, or urology or orthopedic
specials
Technique
Port Placement
Using the Hassan approach, a supraumbilical 10-mm port is placed (Fig.
36-1).
FIGURE 36-1 Port placement for laparoscopic sigmoid resection.
A 12-mm port is placed in the right lower quadrant (RLQ), 2-3 cm

anteromedial to the anterior superior iliac spine.
A 5-mm port is placed in the right upper quadrant, in line with a hand’s
breadth away from the 12-mm RLQ port.
A 5 mm left lower quadrant is inserted for additional retraction.
For a difficult splenic flexure mobilization or in a morbidly obese patient,
an extra 5-mm port may be placed in the left upper quadrant.
These ports should be placed under direct visualization, lateral to the
inferior epigastric vessels and perpendicular to the abdominal wall to
avoid unnecessary torque.
Note: One author (SDW) utilizes a 12-mm infraumbilical Hassan cannula
followed by a right upper quadrant and a RLQ 10-mm port. For a difficult
splenic flexure mobilization or in a morbidly obese patient, a 10 mm left
lower quadrant port may be added.
Procedure Details
Medial-to-Lateral Approach
The patient is placed left side up, in steep Trendelenburg position.
This method allows the small bowel to fall out of the pelvis.
With the aid of gravity, the small bowel is placed in the right upper
quadrant.
The greater omentum is reflected cephalad to expose the transverse
colon.
A small sponge may be placed through the 10-mm port, to aid in minor
diffuse bleeding that is often encountered with inflammatory tissue.
For uncomplicated sigmoid resections, a medial-to-lateral approach is
preferred, though one author (SDW) prefers a lateral to medial.
The “preferred” approach may always not be possible with diverticular
fistula as the sigmoid or the upper rectum is adherent to either the
bladder or the vagina. This situation causes the mesentery to fold on
itself and prohibits adequate retraction to expose the inferior mesenteric
artery.
For this reason, lateral attachments must be released first along with the
colovesicle or colovaginal fistula before approaching the inferior
mesenteric artery medially.
Start by mobilizing lateral attachments away from the fistula and
inflammatory process. This maneuver will guide the surgeon to the correct
plane when approaching the diseased colon.
If there is not significant inflammation, and the fistula is clearly away
from the trajectory of the ureter, the fistula may be taken down with
relative ease. When doing so, err on the side of the colon to avoid
exacerbating the existing defect in the bladder or the vagina.
After this is done, the operation can proceed from medial to lateral, as
optimal traction can now be placed on the inferior mesenteric artery.
Lateral-to-Medial Approach
If the fistula has significant surrounding inflammatory tissue, and the
surgeon cannot be certain the ureter is away from the fistula, a complete
lateral-to-medial approach may be preferred to first identify the ureter
before taking down the fistula.
The colon is grasped with the surgeon’s left hand, drawing it anterior and
to the right.
This exposes the lateral attachments of the sigmoid colon that are
divided using hot scissors.
To ensure the correct plane is entered, the lateral attachments should be
taken just 1 mm medial to the white line of Toldt.
As dissection proceeds, the surgeon will first encounter the gonadal
vessels and then the ureter located just medial.
The avascular plane overlying these structures should be kept intact.
If the fistula is adherent to the pelvic sidewall, the surgeon must trace the
ureter as it travels to the bladder, since it can be pulled up into the fistula.
If the surgeon is still having difficulty after the above maneuvers, he or
she can divide the proximal colon to allow better exposure of the
retroperitoneum and the ureter’s trajectory.
Laparoscopic Division of the Fistula

After the ureter is identified and the surgeon is ready to divide the fistula,
a window should be created behind the fistula to prevent injury to
posterior structures (Figs. 36-2 to 36-5).
FIGURE 36-2 Colovesicle fistula visualized laparoscopically.

FIGURE 36-3 Colovesicle fistula folded on itself, secondary to intramural abscess
extending into left bladder and left pelvic sidewall.
FIGURE 36-4 Using sharp dissection to take down the fistula. Note grasper in
background creating window behind fistula to prevent injury to other structures.
FIGURE 36-5 Use of suction tip for blunt dissection to aid in fistula takedown.
Use of sharp dissection with the scissors and blunt maneuvers with the
suction tip is preferred to help avoid inadvertent injury to nearby
structures (Fig. 36-6).
FIGURE 36-6 Transecting the proximal sigmoid where the ureter had already been
identified to help expose the ureter’s trajectory into the pelvis.
TIPS
An extremely helpful maneuver is the use of blunt dissection and finger
fracturing to dissect through inflammatory tissue.
TIPS
The surgeon should be very cautious and make every attempt not to
violate the retroperitoneum, as doing so may result in mobilization of
the ureter with the colonic mesentery.
Hand Assist
If there is significant difficulty identifying the ureter or safely taking down
the fistula, a hand port can be placed to aid in dissection, before
committing to a complete laparotomy.
This option will limit the incision to a lower midline, especially if the
splenic flexure was already mobilized.
The umbilical port site is extended caudad to accommodate the size of the
surgeon’s hand.
In general, the size of the incision in centimeters is about the size of the
surgeon’s glove.
A 5-mm suprapubic port is added.
A laparotomy pad is placed through the gel port.
This can be used to pack the small bowel out of the operative field,
control any minor diffuse bleeding, and clean the laparoscope.
The camera is placed in the RLQ port, and the hot scissor is placed in the
suprapubic port.
The left hand retracts the sigmoid anteromedially.
As described earlier, the lateral attachments are taken down with
electrocautery.
The gonadal vessels and ureter are identified, and the fistula is taken
down.
If ureteral stents were placed, the surgeon can now palpate for the stent to
aid in its identification and trajectory.
If there is difficulty with visualization and retraction, the surgeon may
alternatively move between the legs and use the energy device from the
left lower quadrant port. The camera is then placed in the suprapubic port.
Often, simply finger fracturing through the fistula will take it down
safely and easily.
With the lateral sigmoid now freed, the operation can proceed in the
standard manner.
Open
If there is still difficulty with identification of the ureter or mobilization of
the colon, an open procedure is indicated.
If possible, the surgeon should try to determine whether or not splenic
flexure mobilization will be necessary.
Because the proximal descending colon and splenic flexure are usually
not involved, the splenic flexure can often be laparoscopically
mobilized, despite significant inflammation in the lower abdomen.
This approach will allow for a smaller, lower midline, or Pfannenstiel
incision and will aid in faster recovery and postoperative pain control.
With the abdomen open, exposure is essential.
Pack the small bowel in the right upper quadrant and extend the
incision (if necessary) down to the pubic bone to get maximal exposure
of the lower abdomen and pelvis.
Similar to hand assist, if ureteral stents were placed, this maneuver
allows the surgeon to palpate the stent to aid in its identification and
trajectory.
The surgeon can then encircle the fistula and use a combination of
finger fracturing and electrocautery to safely take it down (Figs. 36-7 to
36-10).
FIGURE 36-7 Encircling the colovesicle fistula.
FIGURE 36-8 Division of colovesicle fistula with finger fracturing technique.

FIGURE 36-9 Division of colovesicle fistula with finger fracturing technique.
FIGURE 36-10 Colon freed from bladder.

Specific Considerations
Colovaginal Fistula
Finding the plane between the vagina and rectum or sigmoid can be
extremely challenging in the case of a diverticular-related colovaginal
fistula.
Placing a sizer in the vagina can aid in finding this plane.
Vaginal Repair
Primary vaginal repair is not routinely done unless a large obvious defect
is seen.
If needed, resect the inflamed area around the fistula and close the defect
with interrupted or running 2-0 absorbable suture.
Placement of omentum over the area is useful to provide a barrier between
the vaginal repair and the bowel anastomosis.
Bladder Repair
If a large defect is seen in the bladder, the bladder is closed in two layers
with absorbable suture.
A bladder catheter is left in for 5-7 days and taken out after a cystogram
shows no leak.
If there is no obvious defect in the bladder, no repair is done.
If the surgeon is unsure if a bladder defect is present, the bladder can be
instilled with saline ± methylene blue to identify a hole. Similarly,
methylene blue testing following bladder repair is useful.
Efforts should be made to ensure that the colorectal anastomosis is not
immediately adjacent to the site of the prior fistula, bladder repair, or
within a phlegmonous cavity.
Omental Pedicle Flaps

There are no randomized studies evaluating omental pedicle flaps in
diverticular fistula repair to show they have benefit.
In our institution, we attempt to place an omental pedicle flap if the
colorectal anastomosis is lying near the vaginal or bladder defect/repair, or
if tissue quality is poor.
Fecal Diversion
There is no consensus on whether or not a proximal diversion is necessary
for the treatment of diverticular-related fistula.
Most studies are small retrospective reviews that report conflicting results,
with some authors promoting the liberal use of diverting stoma while
others are proponents of a single-stage procedure.
At our institution, we advocate selective use of proximal diversion if the
patient is immunosuppressed, tissue quality is poor, the procedure is
emergent, if there is a positive leak test, if there is excessive blood loss, or
if there have been significant fluctuations in the patient’s hemodynamics.
Drains
Drains are not routinely placed when surgically repairing diverticular-
related fistula.
They may be placed in cases where a significant bladder repair was
performed.
PEARLS AND PITFALLS
Surgery for complex diverticular disease is very challenging, given the

ongoing inflammatory process.
There should be a low threshold for conversion to hand assist or open
procedure if necessary.
Ureteral stents should be used when possible.
An upfront medial-to-lateral approach is usually not feasible. Some
lateral attachments and the fistula must be divided in order to get the
proper retraction required for a medial-to-lateral approach.
Err on the side of the colon when separating the colon from the vagina
or the bladder.
In cases of extensive inflammation, the ureter should be identified prior
to aggressive dissection of the fistula.
Create a window behind the fistula before dividing it. When dissecting
and dividing the fistula, use sharp dissection with scissors or blunt
dissection with the suction device. Alternatively, divide the fistula with
an energy source.
For hand-assist and open procedures:
Blunt dissection with finger fracturing is an excellent way to safely
and effectively takedown the fistula.
The ureters may be palpated if ureteric stents were placed.
If needed, attempt splenic flexure mobilization laparoscopically
before converting to open. This will minimize the incision to a lower
midline or Pfannenstiel. For this reason, routinely mobilize the
splenic flexure as an early step during difficult cases.
Primary bladder repair may be performed if a defect is identified.
There is no consensus for the use of omental pedicle flaps, fecal
diversion, or drains. These strategies should be used at the discretion of
the surgeon.
Postoperative Care
care plan.
Orogastric tubes are removed prior to extubation, IV fluids are minimized,
diet is given day 0.
acetaminophen.
continued, following surgery for deep vein thrombosis prophylaxis.
A bladder catheter is left in for 5-7 days and taken out after a cystogram
shows no leak for colovesicle fistula patients.
The catheter may be removed on postoperative day #1 for colovaginal
fistulas.
Suggested Readings
Feingold D, Steele SR, Lee S, et al. Practice parameters for the treatment of sigmoid diverticulitis.
ASCRS Standards Committee. Dis Colon Rectum. 2014;57(3):284-294.
Wen Y, Althans AR, Brady JT, et al. Evaluating surgical management and outcomes of colovaginal
fistulas. Am J Surg. 2017;213(3):553-557.
Chapter 37
Large Bowel Obstruction
DAVID M. SCHWARTZBERG
DAVID LISKA
Large bowel obstruction (LBO) etiologies include malignancy,
inflammatory conditions (eg, diverticulitis, inflammatory bowel disease),
volvulus, radiation, and pseudo-obstruction.
Consideration should be given to urgent (eg, ischemia, perforation, sepsis)
and elective conditions.
Complete versus partial obstruction often times will guide management.
In the setting of malignant disease, the decision for operative or medical
management may depend on life expectancy, goals of care, and extent of
disease.
Left-sided lesions are more prone to presenting with obstruction than
right.
Left-sided lesions may be treated with resection, diversion, or stenting.
Right-sided lesions are often best treated with resection and
anastomosis, although diversion is occasionally required (eg,
malnutrition, comorbidities, bowel ischemia, peritonitis).
Diversion versus resection also depends on many of the same factors as
above.
Positioning
Modified lithotomy position and Lloyd-Davis position
Arms out or tucked, pending an open or laparoscopic approach
Bilateral ureteral stents (as indicated)
Skin preparation for the abdomen
All extremities should be properly positioned and padded.
The patient pelvis should be placed on the edge of the operative table, with
padding underneath the sacrum.
Orogastric tube, Foley catheter, and appropriate lines and monitors
TIPS
If dense adhesions, consider a lower midline laparotomy or

establishing pneumoperitoneum from an alternative site (eg, Palmer’s
point in the left upper quadrant).
TIPS
With a chronic obstruction or acute/complete LBO in the setting of a

competent ileocecal valve, extensive bowel dilation may cause loss of
abdominal domain and difficulty with laparoscopic visualization.
Placing the patient in a head down position may help with
visualization, although conversion to hand-assist or minilaparotomy
may be required.
TIPS
If there is no significant mismatch, an EEA may be performed.
LAPAROSCOPIC DIVERTING LOOP ILEOSTOMY
Indications
Obstructing colorectal tumor with incompetent ileocecal valve in a patient
with metastatic disease, unresectable primary tumor, or unable to tolerate
formal resection
Specific Equipment
Wound protector (typical size: small, 2.5-6 cm)
One 12-mm balloon trocar (without obturator)
Small silastic drain (to secure the 12 trocar in the wound protector) or
wound protector cap
Two 5-mm trocars
Two atraumatic bowel graspers
5-mm monopolar laparoscopic scissors
3-0 chromic and 3-0 absorbable braided suture and/or surgical marker to
mark proximal and distal orientation of bowel
4-0 absorbable monofilament and steri-strips to close port sites
Small stoma rod
3-0 chromic sutures to mature stoma
Ostomy appliance
Technique
A dime-sized disc of skin is incised with a #15 blade scalpel or
electrocautery at the premarked ileostomy site (Fig. 37-1).
FIGURE 37-1 Skin incision for an ileostomy.
The subcutaneous fat is vertically incised with electrocautery, while right-

angle retractors (Crile retractors) provide exposure (Fig. 37-2).
FIGURE 37-2 Division of the anterior fascia exposing the rectus muscles.
The anterior fascia of the rectus sheath is exposed and incised for 3-4 cm
with electrocautery, while Crile retractors provide exposure.
Once through the fascia, a large Kelly clamp is used to bluntly separate the
fibers of the rectus muscle; and the Crile retractors are readjusted to retract
the muscle, thereby exposing the posterior sheath (Fig. 37-3).
FIGURE 37-3 The rectus muscles are bluntly spread apart to expose the posterior
fascia.
Two tonsils are used to elevate the posterior sheath.

The posterior sheath is divided sharply with a Metzenbaum scissor.
Note the size of the fascia defect should admit the surgeons 1.5 fingers
for ileostomy and 2 for a colostomy.
A finger is placed into the peritoneum and swept for adhesions.
If there are no adhesions, a small wound protector is placed, and a finger
again swept to ensure no bowel or omentum is incorporated into wound
protector.
A 12-mm inflated balloon trocar is placed into the wound protector, and
the silastic drain is used to secure the wound protector around the trocar.
Pneumoperitoneum is established, and the left lower quadrant (LLQ) 5-
mm port placed under direct vision lateral to the epigastric vessels,
followed by a left upper quadrant port.
The abdomen and the pelvis are examined for occult pathology, and
pictures taken to document the tumor burden.
Beware for proximal (ie, right-sided) perforation with an acute left-sided
obstruction and competent ileocecal valve.
If needed, adhesiolysis is performed using monopolar laparoscopic
scissors.
The ileocecal junction is identified, and a loop of ileum approximately 20
cm proximal to the ileocecal valve chosen to be the ileostomy site.
The future-ileostomy site should be tension free when lifted to the
anterior abdominal wall.
At the site selected for the ileostomy, the bowel is marked with
electrocautery or a series of stitches to confirm proximal and distal to
maintain orientation and avoid a twist.
The 5-mm laparoscope is moved to the LLQ port, and a bowel grasper is
then placed in the 12-mm trocar to grasp the bowel while maintaining the
correct orientation.
Pneumoperitoneum is carefully released, and the site of the ileostomy
carefully brought extracorporeally through the wound protector while
meticulously maintaining the proper bowel orientation without any
twisting of the mesentery.
Brown (chromic) and blue (absorbable braided), or long and short, stitches
are placed to mark distal (brown/short) and proximal (blue/long) (Fig. 37-
4).
FIGURE 37-4 Sutures mark the proper orientation of the loop ileostomy.
The laparoscopic bowel grasper is replaced with a Babcock clamp, and the
wound protector carefully released and pulled up and over the bowel and
Babcock.
A small tunnel is created with a Kelly at the bowel–mesentery interface of
the eviscerated bowel, and a small stoma rod placed and temporarily
secured with two Babcock clamps.
The port sites are closed with 4-0 absorbable monofilament, steri-strips,
and nonocclusive bandages.
The ileostomy is opened asymmetrically with the distal limb being just
above the level of the skin and allowing for sufficient bowel length to
spout the proximal limb (Fig. 37-5).
FIGURE 37-5 A. Rod is placed under the loop ileostomy and the distal bowel is
opened. B. Stoma is matured in a Brooke fashion with full thickness of the bowel, serosa
of the bowel and the dermis.
The efferent/distal limb is sutured in three places, full thickness from

bowel lumen (at 6, 4, and 8 o’clock positions) to the dermis, not including
the epidermis.
The afferent/proximal limb is then spouted.
Three sutures are placed, full thickness from the bowel wall (at 12, 10,
and 2 o’clock positions) to the dermis and clamped (Fig. 37-6).
FIGURE 37-6 Stoma maturation.
The back of Adson forceps is used to spout the distal bowel as the three
sutures are tied sequentially.
The stoma appliance is placed.
The stoma rod is removed on postoperative day 2.
LAPAROSCOPIC DIVERTING LOOP COLOSTOMY
Technique
Indications
Obstructing left-sided colorectal tumor with competent ileocecal valve in a
patient with metastatic disease, unresectable primary tumor, or unable to
tolerate formal resection
Specific Equipment
5- or 10-mm 30-degree laparoscope
One 12-mm balloon trocar
Two 5-mm trocars
5-mm monopolar laparoscopic scissors
4-0 absorbable monofilament and steri-strips to close port sites
Long stoma rod
3-0 chromic sutures to mature stoma
Ostomy appliance
Procedure
An infraumbilical incision is made, and a 12-mm balloon trocar is placed
to enter to peritoneal cavity via a Hasson technique.
After obtaining pneumoperitoneum, a right lower quadrant 5-mm port is
placed under direct vision lateral to the epigastric vessels followed by a
right upper quadrant port; both are positioned a handsbreadth from the
umbilical incision.
The abdomen and the pelvis are examined for occult pathology, and
pictures taken to document the tumor burden.
A sigmoid colostomy is preferable over a transverse colostomy, if
anatomically feasible in terms of reach and tumor location.
The most redundant portion of the sigmoid colon is grasped and
medialized by incising the white line of Toldt using monopolar
laparoscopic scissors.
It is important not to overmobilize the colon from its attachments as to
prevent against prolapse.
The sigmoid colon is grasped with a bowel grasper and visualized to be
without tension when reaching the anterior abdominal wall at the level of
the proposed stoma site.
If the patient’s anatomy does not permit creation of a sigmoid colostomy,
a transverse loop colostomy is performed:
The proximal transverse colon is grasped by a bowel grasper and
brought to the proposed stoma site on the anterior abdominal wall.
It is important to use a portion of transverse colon that is not overly
redundant to prevent against subsequent stoma prolapse.
The transverse colon is mobilized from the omentum as needed with
monopolar scissors to ensure a tension-free stoma to the anterior
abdominal wall (Fig. 37-7).
FIGURE 37-7 Entering the lesser sac for transverse colostomy formation.
The bowel graspers are kept on the selected area of sigmoid or transverse
colon to maintain its orientation and ensure no torsion on the colon when
it is brought up as a stoma.
A dime-sized disc of skin is incised with a #15 blade scalpel or
electrocautery at the premarked ileostomy site (Fig. 37-8).
FIGURE 37-8 Opening the skin for the stoma.
The subcutaneous fat is vertically incised with electrocautery, while

right-angle retractors (Crile retractors) provide exposure (Fig. 37-9).
FIGURE 37-9 Division of the anterior fascia.
The anterior fascia of the rectus sheath is exposed and incised for 3-4
cm with electrocautery, while Crile retractors provide exposure.
Once through the fascia, a large Kelly is used to bluntly separate the
fibers of the rectus muscle; and the Crile retractors are readjusted to
retract the muscle, thereby exposing the posterior sheath (Fig. 37-10).
FIGURE 37-10 Exposure of the posterior sheath.
Two tonsils are used to elevate the posterior sheath.

The posterior sheath is divided sharply with a Metzenbaum scissor.
Note the size of the fascia defect should admit the surgeons two
fingers.
As pneumoperitoneum is released, the colon is carefully brought
extracorporeally through the ostomy aperture and delivered to a Babcock
clamp while meticulously maintaining the proper bowel orientation
without any twisting of the mesentery.
A small tunnel is created with a Kelly forceps at the bowel–mesentery
interface of the eviscerated bowel, and a stoma rod is placed underneath
the bowel and temporarily secured with two Babcock clamps.
The umbilical trocar site fascia is closed with a 0-absorbable braided
suture.
The skin incisions are closed with 4-0 absorbable monofilament sutures,
steri-strips, and nonocclusive bandages.
The loop colostomy is matured by incising along the antimesenteric taenia
(Fig. 37-11).
FIGURE 37-11 Dashed line represents the area of opening along the antimesenteric
taenia.
The edges of the bowel are then matured circumferentially by suturing the
cut edge of the colon to the dermis (Figs. 37-12 and 37-13).
FIGURE 37-12 Opening of the colon wall for maturation.
FIGURE 37-13 Cross section of the loop colostomy.
The stoma appliance is placed.

The stoma rod is removed on postoperative day 2, if there is no tension on
the bowel.
LAPAROTOMY WITH SIGMOID RESECTION ON-TABLE

COLONIC LAVAGE, COLORECTAL ANASTOMOSIS, AND
DIVERTING LOOP ILEOSTOMY
Technique
Indications
Obstructing, resectable, sigmoid tumor or stricture with proximal colonic
stool burden
Patient Positioning
Padded operating room (OR) table, arms out or tucked and padded
Modified lithotomy with Yellowfins
Patient strapped/taped to the bed
Appropriate lines, monitors, Foley catheter, and orogastric tube
Specific Equipment
Basic laparotomy tray
Balfour or Bookwalter retractor
Large-bore angiocath for colonic decompression
Wound protector (sizes; large: 9-14 cm, extra-large: 11-17 cm)
16F Foley catheter
Saline irrigation
Rigid proctoscope
Abdominal drains (eg, Jackson-Pratt, Blake, as required)
Staplers
Thoracoabdominal (TA) stapler
31-mm end-to-end anastomosis (EEA) circular stapler
Gastrointestinal anastomosis stapler
Sutures
#0 chromic/Vicryl ties to ligate the mesentery
3-0 absorbable braided suture to oversew staple line
3-0 chromic suture for stoma maturation
#1 looped absorbable monofilament for fascial closure
Skin stapler
3-0 chromic sutures for stoma maturation
Procedure
A midline laparotomy incision is made.
Abdomen is examined for metastatic spread.
Wound protector and abdominal wall retractor are placed for exposure.
To help with exposure, the colon can be partially decompressed using a
large-bore (14 gauge) angiocath.
The angiocath is introduced with the needle at an acute angle through
the antimesenteric taenia of the dilated colon.
The needle is removed, and the cannula is connected to suction to
evacuate the gas from the dilated colon (avoid suctioning of solid stool
as this will clog the cannula).
A purse-string suture is placed around the insertion site and tied down
as the cannula is removed to prevent any spillage.
Note: This may not be possible with the amount and consistency of the
stool. Also, monitor the catheter to ensure it does not kink and obstruct.
The small bowel is packed cephalad.
The sigmoid colon is retracted medially and mobilized in a lateral-to-
medial manner along the white line of Toldt.
The left ureter is identified and protected.
The origin of the inferior mesenteric artery (IMA) is circumferentially
isolated, sweeping the nodal tissue onto the specimen’s side.
The IMA is divided close to its origin with a Metzenbaum scissor between
two Kelly clamps and tied off with 0-chromic ties.
The inferior mesenteric vein and left colic artery are ligated in the same
manner.
The sigmoid colon is further mobilized, and the “holy plane” is entered
behind the fascia propria of the rectum.
Mesorectal dissection proceeds in this plane until a 5-cm distal margin
from the tumor is reached.
At this level, the mesorectum (including the superior hemorrhoidal
vessels) is circumferentially ligated with sutures between Kelly clamps.
A TA stapler is used to staple off the proximal rectum, and the bowel is
then divided on top of the stapler using a scalpel, while occluding the
proximal bowel with a long Kelley or Kocher clamp.
The proximal colonic transection point is chosen at the level of the
descending colon based on the blood supply and lymphatic drainage.
The blood supply of the proximal colon is tested by observing pulsatile
bleeding from the marginal artery before ligating it.
It is imperative to visualize pulsatile arterial flow from the marginal
artery to assure a well-perfused anastomosis.
A Kocher is placed on the specimen side of the descending colon, with an
atraumatic bowel clamp on the proximal descending colon.
The colon is divided between the clamps with a scalpel.
The specimen is examined on the back table, and adequate margins are
assured.
On-Table Lavage
Corrugated anesthesia extension tubing is then secured within the dilated
colon using a hernia tape with the distal end of the tubing being passed off
the table where the outflow is collected.
In preparation for colonic lavage and anastomosis, the splenic flexure and
the hepatic flexure are mobilized.
The cecum is identified, and the appendix grasped.
The mesoappendix is ligated between ties.
An appendectomy is made in the midportion of the appendix.
A 16-F Foley catheter is passed into the lumen and the cecum.
Confirmed by palpation of the cecum and then the balloon is inflated.
The Foley catheter (inserted into the appendix) is connected to a 4-L
bag of saline, and colonic irrigation is initiated (Fig. 37-14).
FIGURE 37-14 Setup for an on-table lavage.
Once the effluent is clear, the Foley is removed, and the TA stapler is used
to perform an appendectomy and the staple line is oversewn.
The descending colon is prepared for a colorectal anastomosis in a side-to-
end manner, which avoids the mismatch in bowel diameter that an EEA
would entail.
A 31-mm EEA stapler anvil is inserted into the colon and pierced through
the antimesenteric taenia approximately 3 cm from the cut edge of the
bowel.
The TA stapler is then fired to close the colotomy, and the staple line is
oversewn.
Adequate reach and orientation of the bowel and mesentery are assured,
and the anastomosis is then performed with the EEA stapler introduced
per rectum and the anastomotic rings are inspected.
A leak test is performed with a flexible sigmoidoscope and the pelvic
anastomosis submerged in saline.
A diverting loop ileostomy is created in selected patients.
TIPS
An alternative method is to perform the colonic lavage only after

creation of the colorectal anastomosis with the effluent collected via a
proctoscope inserted into the rectum.
ENDOSCOPIC DECOMPRESSION OF SIGMOID VOLVULUS

AND DRAIN PLACEMENT
Technique
Indications
Sigmoid volvulus without signs of necrosis or perforation
Equipment Needed
Flexible pediatric colonoscope with CO2 insufflation
Rigid proctoscope
28-F chest tube
Urometer bag
Procedure
The patient must be without signs of pneumoperitoneum or peritonitis.
With the patient in left lateral decubitus position, administer
sedatives/narcotics as per standard practice for colonoscopy.
Patient should be attached to continuous pulse oximetry and cardiac
rhythm monitor.
Perform flexible sigmoidoscopy with minimal CO2 insufflation and reduce
the volvulized segment by gently advancing the scope passed the area with
mucosal swirling.
Carefully inspect mucosa for signs of ischemia.
If ischemia is present, abort procedure and prepare the patient for
emergent exploration and likely a sigmoidectomy.
Once the volvulus is reduced, advance the rigid proctoscope to the dilated
segment of colon.
Remove the flexible sigmoidoscope.
Insert a 28-F chest tube through the proctoscope.
Remove the proctoscope, leaving the chest tube in the colonic lumen to
aid with decompression and prevent recurrent volvulus.
An alternative method is to advance the chest tube alongside the
colonoscope following decompression (Fig. 37-15).
FIGURE 37-15 Decompression of a sigmoid volvulus endoscopically.
Connect chest tube to urometer to evacuate stool and gas.

Obtain abdominal x-ray to assure detorsion of the colon (Fig. 37-16).
FIGURE 37-16 Plain film appearance of a sigmoid volvulus (A) and decompression
(B) with the tube in place.
Transfer patient to monitored care bed and optimize patient medically for
sigmoid resection.
Perform mechanical and antibiotic bowel preparation prior to surgery.
TIPS
This can be facilitated by initially placing the proctoscope over the

flexible sigmoidoscopy and once in position advancing the rigid
proctoscope over the flexible endoscope to aid with visualization and
prevent colonic trauma.
TIPS
Distal obstructions will be prone to stent migration and unrelenting

tenesmus and, in general, are not ideal for stent placement.
ENDOSCOPIC PLACEMENT OF SELF-EXPANDING METAL
STENT FOR PALLIATION
Technique
Indications
Obstructing left-sided colorectal tumor with metastatic disease, unresectable
primary tumor, or unable to tolerate formal resection. In select cases, this can
also be used as bridge to surgery.
Equipment Needed
Flexible pediatric colonoscope with CO2 insufflation
Fluoroscopy
Guidewire
Through-the-scope (TTS) balloon dilators (different sizes)
Self-expanding metal stent (size based on the length of lesion)
Endoscopic clips
Procedure
A digital rectal examination is performed to ensure there is sufficient
length of rectum distal to the tumor to allow for deployment of the stent
proximal to the anorectal ring.
Using minimal CO2 insufflation, the scope is advanced to the obstructing
lesion.
TTS balloon dilators are used to sequentially dilate the obstructed segment
until the scope can traverse the lesion and the length of the lesion is
measured.
Endoscopic clips are used to mark the proximal and distal extent of the
lesion to help guide stent deployment.
An appropriately sized stent is then inserted TTS and under fluoroscopic
guidance (using the clips as markers) is deployed making sure that the
flared ends are proximal and distal to the lesion (Fig. 37-17).
FIGURE 37-17 Placement of an endoscopic stent. Placement of guidewire across the

obstruction (A); distal edge of the stent in place with the lumen now open (B); cross-table
plain film of the stent in place (C); anterior posterior view of the stent in place (D).
A postprocedural abdominal x-ray is obtained.
Postoperative Care
The patient may ambulate and resume a diet as tolerated, although in the
setting of a LBO, an ileus is not uncommon.
There is no need for prolonged antibiotics.
Patients may shower.
Venous thromboembolism chemoprophylaxis
Enterostomal therapy should be consulted for all patients with an ostomy.
An appropriate multidisciplinary evaluation for all patients with
malignancy should be performed.
Suggested Readings
Alavi K, Field CM. Large bowel obstruction. In: Steele SR, Hull TL, Read TE, Saclarides TJ,
Senagore AJ, Whitlow CB, eds. The ASCRS Textbook of Colon and Rectal Surgery. 3rd ed.
Cham, Switzerland: Springer International Publishing; 2016:669-695.
Vogel JD, Feingold DL, Stewart DB, et al. Clinical practice guidelines for colon volvulus and acute
colonic pseudo-obstruction. Dis Colon Rectum. 2016;59:589-600.
Chapter 38
Endometriosis
Management of Deep Infiltrating

Endometriosis of Rectum and Sigmoid
MARIAM ALHILLI
HERMANN KESSLER
Definition—Deep infiltrating endometriosis: solid mass deeper than 5 mm
below peritoneal surface (Figs. 38-1 and 38-2)
FIGURE 38-1 Deep infiltrating endometriosis involving rectovaginal septum, posterior

uterine serosa, and pelvic sidewalls.
FIGURE 38-2 Deep infiltrating endometriosis involving right ovarian fossa and
posterior pelvic peritoneum and rectum.
Location within pelvis

Rectovaginal septum
Rectocervical space
Uterosacral ligaments
Vagina
Ovaries (endometrioma)
Rectum, mesorectum, sigmoid, or mesocolon (Figs. 38-3 and 38-4)
FIGURE 38-3 A. Endometriotic implants involving ascending colon and cecum. B.

Endometriotic plaque involving sigmoid colon and mesentery.
FIGURE 38-4 Magnetic resonance imaging of pelvis showing deep infiltrating
endometriosis involving the rectovaginal septum and rectum.
Indications for surgery

Extensive symptomatic endometriosis (pelvic/abdominal pain)
Infertility
Need to restore organ function
Surgical management
Conservative (shaving or disc excision)
Radical (segmental resection of rectum/sigmoid)
Laparoscopic approach is considered standard of care.
Interdisciplinary treatment involving Urology, Colorectal Surgery,
Gynecology or Gynecologic Oncology
Symptom Assessment
Pelvic pain
Altered bowel habits
Tenesmus
Dyschezia
Rectal bleeding—usually cyclic nature
Postcoital spotting
Dyspareunia
Clinical Examination
Rectovaginal examination
Obliteration of rectovaginal septum
Thickening of uterosacral ligaments or nodularity
Fixation, retroversion, and immobility of uterus
Tenderness of vagina and posterior cul-de sac
Speculum examination—pigmented endometriosis vaginal lesions
Biopsy if superficial
Imaging
Magnetic resonance imaging: soft tissue evaluation to verify location and
extent of disease (Fig. 38-5)
Computed tomography: pelvic mass evaluation, rule-out ureteral
obstruction
FIGURE 38-5 Endoscopic image of endometriosis involving rectal mucosa.
Transvaginal ultrasound
Requires experienced sonographer and high level of radiologic
expertise
Gastrograffin enema
Flexible sigmoidoscopy—to determine the thickness of lesions, extrinsic
bowel compression, penetration of mucosa, and rule-out stricture (Fig. 38-
6)
FIGURE 38-6 Dissection of pararectal and paravesical spaces to expose the ureter
and uterine vessels.
Cystoscopy—to determine trigone involvement

Stoma marking
Bowel preparation
Placement of bilateral ureteral stents (optional)
Venous thromboembolism prophylaxis
Preoperative antibiotics
Intraoperative Considerations
Equipment
Video equipment: camera unit, 5-mm 30-degree laparoscope, light
source, monitors (at least two), recording device
Gas insufflator
Electrocautery
Two Kocher clamps
Plastic rod for ostomies (optional)
3-0 braided absorbable sutures
Five 5-mm trocars (alternative one/two 10-mm and three/four 5-mm
trocars)
Laparoscopic dissection instrument (electrocautery, bipolar energy
device, ultrasonic device)
Laparoscopic suction/irrigation instrument
Laparoscopic 5-mm dissecting device
Laparoscopic scissors
Laparoscopic 5- or 10-mm Babcock clamp
5-mm Maryland dissector
Three 5-mm bowel graspers
Vaginal probe or sponge stick
Surgical clips
Surgical staplers: articulating endoscopic staplers, circular stapler
Cystoscopy
Proctoscopy or flexible sigmoidoscopy
Positioning
Low lithotomy position with legs in stirrups
Positions of surgeons: with pelvic disease often per preference
Radical approach with segmental resection
Indications:
Deep invasion into muscularis
Nodule larger than 3 cm
Involvement of more than 40% of bowel circumference
Presence of multiple nodules
Stenosis/strictures
Sigmoid lesions
Technique
Surgical steps
Diagnostic laparoscopy, identify extent of disease and anatomic
landmarks: ureters, uterosacral ligaments, and assess extent of
involvement.
Adhesiolysis
Enter retroperitoneum and open pararectal spaces bilaterally using
blunt and sharp dissection (Fig. 38-7).
FIGURE 38-7 Ureter is dissected off the broad ligament peritoneum and
skeletonized to the level of the uterine artery.
Ureterolysis (Fig. 38-8)
FIGURE 38-8 A. Placement of the anvil. B. Connection of the anvil to the stapler.
Excise lesions off vagina if present.

Dissect rectum from posterior uterus and vagina.
Enter rectovaginal septum.
Colorectal surgeon involved.
Identify segment of colon and/or rectum to be resected.
Mobilize sigmoid and rectum.
Enter peritoneum above promontory.
Mobilize rectum and sigmoid posteriorly—inferior mesenteric artery
left in place in most cases.
Left lateral mobilization of sigmoid and rectum until beyond
endometrioma.
Transect mesorectum.
Divide the rectum distally using articulating endoscopic stapler.
Create minilaparotomy (usually Pfannenstiel incision)—body wall
protection.
Perform proximal transection of bowel through minilaparotomy.
Implant anvil of circular stapler into colonic stump.
Close minilaparotomy temporarily, reestablish pneumoperitoneum.
Perform bowel anastomosis (Fig. 38-9).
FIGURE 38-9 Laparoscopic repair of enterotomy in two layers. A. Mobilization of

the bowel. B. Closure.
Assess integrity of anastomosis and determine level above anal verge

with flexible sigmoidoscopy (bubble test).
Drain placement.
Optional creation of diverting loop ileostomy.
Conservative, Symptom-Guided Approach—Shaving or

Partial-Thickness Excision
Technique
Shaving—no entry into bowel lumen
Indications
Unifocal disease
No involvement of muscularis, strictly superficial
Lesion smaller than 3 cm
Does not involve more than 40% of circumference of rectal wall
Surgical steps
Identify anatomic landmarks: ureters, uterosacral ligaments, and
assess extent of involvement.
Adhesiolysis
Enter retroperitoneum.
Open pararectal spaces bilaterally using blunt and sharp
dissection.
Ureterolysis
Evaluate lesion size, penetration depth, and circumferential
involvement.
If lesion is limited to serosa → shaving using sharp dissection
(laparoscopic dissecting device).
Place imbricating serosal stitches (3-0 braided absorbable).
Assess bowel integrity with flexible sigmoidoscopy (bubble test).
Drain placement.
Discoid excision—entry into bowel lumen
Indications
Unifocal lesion
Involvement of at least outer muscular layer
Lesion not larger than 3 cm
Does not involve more than 40% of circumference of rectum or
sigmoid
Surgical steps
Identify anatomic landmarks: ureters, uterosacral ligaments, and assess
extent of involvement.
Adhesiolysis
Enter retroperitoneum.
Open pararectal spaces bilaterally using blunt and sharp dissection.
Ureterolysis: evaluate lesion size, penetration depth, and
circumferential involvement.
If full-thickness lesion with penetration deeper than superficial
serosa, proceed with discoid full-thickness excision using
electrocautery, bipolar energy device, or ultrasonic devices.
Place a rectal probe or sizer in the rectum to aid bowel dissection
(optional).
Repair of enterotomy in two layers using 3-0 braided absorbable suture.
Assess bowel integrity (Fig. 38-10).
FIGURE 38-10 Bowel integrity is assessed after enterotomy repair.
Drain placement.
PEARLS AND PITFALLS
Decision regarding type of excision:

Consider the degree of symptoms, prior to medical therapy
Involvement of inner muscularis of transmural involvement →
segmental resection
Multiple nodules → segmental resection
Nodule larger than 3 cm → segmental resection
Single nodule <3 cm → shaving, disc excision of nodule, or
segmental resection
If patient has completed childbearing, perform hysterectomy first to
allow for extra space for dissection of colon and rectum.
Consider en bloc resection of uterus, cervix, and rectosigmoid due to
dense adhesions.
Consider preoperative biopsy to confirm benign endometriosis.
Dissection of obliterated rectovaginal septum.
Placement of rectal probe (end-to-end anastomosis [EEA] sizer) into
rectum and application of downward traction. Placement of EEA
sizer in vagina with placement of upward traction to expose the
rectovaginal septum.
Consider a defunctioning stoma
If anastomosis is below 6 cm from anal verge
May reduce rate of rectovaginal fistula
Reduces rate of clinical anastomotic leakage
Strongly consider referral to tertiary center with expertise in
multidisciplinary management of intestinal/extra-gynecologic
endometriosis
Postoperative Considerations
Outcomes
Significant improvement in well-being and pelvic pain
Improvement in constipation and fecal incontinence after bowel resection
Surgical Complications
GI complications
Rectovaginal fistula: higher rate with colorectal resection versus disc
excision or shaving
Anastomotic leak
Stenosis of anastomosis
Urinary complications
Postoperative voiding dysfunction (neurogenic bladder)
Prolonged catheterization
Ureteral stenosis
Pelvic abscess
Blood transfusion
Fertility and Pregnancy

Resection improves pregnancy rates: ∼40% pregnancy rate after surgery.
Leaving residual endometriosis can affect fertility and pregnancy.
Advise at least 12 months prior to planned pregnancy.
Recurrence
Depends on residual disease
Higher risk after conservative surgery
25% have microscopic implants
Recurrence rate ∼40% after disc excision versus 15% after bowel resection
with positive margins, less with negative margins
Postoperative Care
care plan.
acetaminophen.
Suggested Readings
Jerby BL, Kessler H, Falcone T, Milsom JW. Laparoscopic management of colorectal endometriosis.
Surg Endosc. 1999;13(11):1125-1128.
Renner SP, Kessler H, Topal N, et al. Major and minor complications after anterior rectal resection for
deeply infiltrating endometriosis. Arch Gynecol Obstet. 2017;295(5):1277-1285.
Chapter 39
Trauma of the Colon, Rectum, and
Anus
ERIC K. JOHNSON
SCOTT R. STEELE
Diagnosis/Mechanism of Injury
Colon and rectal injuries may occur in the setting of blunt, penetrating,
and blast trauma. In military and disaster scenarios, it is not uncommon to
see combined mechanisms of injury.
Most colorectal injuries are diagnosed in the operating room (OR) during
laparotomy performed for broader indications.
Penetrating Trauma
Any penetrating injury to the abdomen or the pelvis can potentially result
in colon or rectal injury.
If there is an anterior violation of the abdominal wall fascia (found on
local exploration), the patient likely requires abdominal exploration in the
OR. Laparotomy versus laparoscopy can be utilized based on local
equipment and expertise. Flank injuries are a bit trickier and often require
imaging (potentially triple-contrast computed tomography [CT] scan) to
evaluate.
Hemodynamically unstable patients with abdominal trauma should
undergo brief resuscitative efforts followed by operative exploration
(unless there is an obvious source of hemorrhage outside the peritoneal
cavity that can be controlled). A focused assessment with sonography in
trauma (FAST) examination is helpful in this setting to look for free
intraperitoneal fluid, and diagnostic peritoneal lavage can also be used.
Tip: Do not waste valuable time obtaining a CT scan in this setting.
Remember that a projectile/object may cross body cavities. What starts as
an entrance wound in the thorax may end in the abdomen. Extremities
apply as well. Look for entrance and exit wounds. There should be an
even number of wounds. If there is not, plain film imaging may locate a
projectile or fragment that is still in the body. The path of injury will alert
one to the possibilities of colorectal trauma.
Blunt Trauma
Patients with blunt abdominal trauma can have variable presentations. A
hemodynamically stable patient should undergo axial (CT) imaging to
evaluate abdominal pain, or suspicious patterns of injury. Free fluid in the
absence of solid organ injury and/or free air are suspicious findings that
should be evaluated further, typically with laparoscopy or laparotomy.
One could imagine a scenario where diagnostic peritoneal lavage (DPL)
could help direct management, but a patient with a negative lavage should
still be observed as an inpatient in the setting of the previous CT findings.
Hemodynamically unstable patients with blunt abdominal trauma can be
evaluated with FAST or DPL to aid in decision-making. Positive findings
should prompt immediate operative exploration after brief resuscitative
efforts.
Peritoneal signs on physical examination in the setting of blunt trauma
should prompt additional investigation.
In the stable patient, CT scan is the best choice. Solid organ injury with
hemoperitoneum may cause peritonitis and does not necessarily require
laparotomy.
Suspicious findings, as noted earlier, should prompt operative exploration.
Pelvic Trauma/Potential Rectal Injury

In the setting of blunt or penetrating pelvic trauma, a rectal examination
should be performed. Any evidence of rectal bleeding or a suspicious
pattern of injury should be further evaluated with proctosigmoidoscopy.
This can be performed using a rigid or flexible scope depending on local
resources. This can easily be done in the OR if the patient is there for other
indications.
Tip: Any blood in the lumen of the rectum or visualized injury should
prompt further abdominal exploration with appropriate injury
management, as later outlined.
Standard exploratory laparotomy tray, long instruments may be helpful.
Large self-retaining retractor, Bookwalter, or similar type
Staplers
Gastrointestinal anastomosis (GIA) (linear) staplers—open or endoscopic
variety, the endoscopic staplers can be used in open cases, and sometimes
give the advantage of ease-of-stapler placement in tight spaces.
End-to-end anastomosis staplers—a range of sizes may be helpful, but
attempt to use the largest size that is safely possible.
Thoracoabdominal (TA) staplers—again a range of sizes in length and
staple height may be helpful. There are options that include curved/cutting
TA staplers that can be helpful in tight spaces—especially the pelvis.
Sutures/ties
3-0 Vicryl helpful for closing enterotomies or suture ligating distal
mesenteric vascular injuries
0 and 2-0 Vicryl ties (long)—useful for ligating mesenteric vasculature
Heavy monofilament slowly absorbable suture like polydioxanone, sizes
ranging from 1 to 2-0 depending on the needs or surgeon preference for
fascial closure
Laparotomy pads have numerous packs of the larger variety that are useful
for packing associated solid organ injuries, absorbing blood, and/or enteric
material.
Warmed irrigation fluid—helpful for clearing the peritoneal cavity of
contaminants and blood, and to improve visualization
Suction devices—a Poole suction and Yankauer suction are both useful.
Umbilical tapes—useful as a quick method for measuring the length of
remaining small bowel or for expedient ligature of large intestinal injuries
in the damage control setting
Tip: A skin stapler can similarly be utilized as a temporary closure
technique.
Ostomy supplies
Temporary abdominal closure device—negative-pressure dressings,
patches, Bogota bag, and so on
Patient Positioning and Preparation

If there is a suspected colorectal injury, it is best if the patient is placed in
low lithotomy position. This allows access to the rectum via the anus for
proctoscopy or anastomosis. It also allows the operating surgeon to stand
between the legs if needed—this can be helpful during splenic flexure
mobilization. In the setting of other potential injuries, the use of lithotomy
could be considered controversial. Since it is not completely necessary to
deal with all colorectal injuries, the use of other positions should be
dictated by surgeon judgment and precedence of potential life-threatening
injury.
The abdomen should be prepped widely, we prefer ChloraPrep, but a
standard chlorhexidine, betadine, or alcohol prep could be used based on
surgeon preference. A perineal, or anal prep, should be left to the
discretion of the operating surgeon, as there is no real evidence that this
makes any difference in outcomes.
In patients who show hemodynamic instability, or the potential for
hemodynamic compromise on anesthetic induction, consider a full prep
while the patient is awake so that the operating surgeon is ready to enter
the abdomen immediately upon induction.
CONDUCT OF TRAUMA LAPAROTOMY
Technique
There are four essential components to a trauma laparotomy.
Control of massive hemorrhage through use of packing
Identification of injuries
Control of contamination
Reconstruction—if indicated and possible
Although the detailed description of the conduct of a trauma laparotomy
and control/repair of all possible injuries are well beyond the scope of this
chapter, we will focus on colorectal injuries.
Once life-threatening hemorrhage has been ruled out or controlled/packed,
it is important to control contamination and focus on discovery of
intestinal injuries. The entire small bowel and colon should be examined
under clear visualization to determine the presence of injury. This may
require a large laparotomy incision (though there may be some role for
laparoscopy in special circumstances), and one should not be hesitant to
enlarge an incision to improve exposure. Adequate visualization may
require mobilization of the colon off of the retroperitoneum or
mobilization of the colonic flexures.
Once an injury is identified, it is important to determine the exact location
and severity of the injury, as this will assist in determining the appropriate
management.
Contamination/ongoing spillage from the bowel may quickly be controlled
with application of bowel clamps both proximal and distal to the injury
site, an expedient temporary skin staple closure, by tying the injury off
with an umbilical tape, or by quickly stapling and dividing the bowel with
application of a GIA stapler.
After identification of injuries and control of contamination, one must
determine whether to definitively repair/reconstruct injuries or to perform
and abbreviated or damage control procedure.
If a damage control approach is chosen, some sort of temporary abdominal
closure must be completed.
Injuries of the Colon

Traumatic colonic injuries occur in varying degrees of severity and
through different mechanisms. These two factors, coupled with the
patient’s physiologic state, largely determine how injuries will be
managed.
In the past, left- and right-sided colonic injuries were managed differently.
The best available evidence indicates that these injuries can be managed
similarly. In terms of injury severity, nondestructive injuries
encompassing <50% of the colonic wall and occurring on the
antimesenteric portion of the colon can be managed through primary
repair, using a single- or two-layer approach to closure. The edges of the
injury should be debrided prior to closure. Injuries occurring on the
mesenteric portion of the colon will often have a vascular component and
can be very difficult to repair primarily, given difficulties in exposure. It is
important to exercise judgment when determining whether these injuries
can be repaired or if they require resection.
In destructive injuries, and those encompassing >50% of the
circumference of the colon, resection with or without anastomosis should
be performed. Stellate injuries are too difficult to repair primarily and are
best managed with resection. One should only resect as much colon as is
required based on injury location, and preservation of major vascular
structures is likely the best approach, unless they need to be sacrificed to
obtain length for a tension-free anastomosis or stoma.
Isolated mesenteric injuries (Fig. 39-1)—Mesenteric injuries may result in
segmental colonic ischemia. Although the colon may be intact, a portion
may still require resection because of an absence of reliable blood supply.
If the marginal artery is intact, a more central vascular ligation can often
be performed without sacrificing colon. If there is questionable perfusion
in a segment of colon, there are a couple of options available to the
surgeon. If the institution has fluorescence angiography capability, a study
can be performed and can be helpful in directing subsequent management.
More crude methods such as Doppler study or fluorescein injection with
Woods lamp examination may be helpful, but may not be as accurate in
directing management, though we have no strong evidence to support this
claim.
FIGURE 39-1 An image showing a mesenteric injury secondary to a high-velocity
missile. The mesentery adjacent to the cecum and terminal ileum has been injured near
the location of the marginal artery.
It is important to consider injury mechanism when planning management

of colonic injury. One must consider the amount of energy transfer that
has occurred during injury, since high-velocity or high-energy injuries
may lead to collateral damage that is not immediately apparent (Figs. 39-2
and 39-3). This can be seen in peripheral mesenteric injuries, where there
is no apparent colonic injury, yet 48 hours or so after the time of injury,
the high-energy transfer may result in necrosis and perforation of the
colon wall adjacent to the path of injury. In many cases, injuries associated
with high-energy transfer are best managed with resection with or without
anastomosis. Therefore it is best to take larger (>2cm margins) when
possible to avoid the possibility of leaving behind damaged bowel.
FIGURE 39-2 A large retroperitoneal hematoma is noted after mobilization of the right
colon. This patient sustained a GSW to the back with a high-velocity round. CT imaging
showed the path of the projectile behind the right colon. Exploration was performed, and
the right colon was mobilized. Its appearance was suspicious for a potential cavitation
injury, though no overt damage to the colon was noted. CT, computed tomography; GSW,
gunshot wound.
FIGURE 39-3 Examine the colon for devascularization from a mesentery injury.
Injuries of the Rectum

Injuries of the rectum should be first and foremost considered in their
anatomic context. It is useful to break these injuries down into three
locations:
Intraperitoneal
Extraperitoneal
”No Person’s Land”—those injuries that bridge the intraperitoneal and
extraperitoneal rectum.
For the sake of management, think of the rectum as beginning at the pelvic
brim and terminating at the top of the anal canal.
Intraperitoneal injuries—those involving the upper portion of the
rectum/rectosigmoid above the anterior peritoneal reflection (and not
involving the reflection) should be managed identically to colonic injuries.
See the section on Injuries of the Colon for recommendations.
Extraperitoneal injuries and those that bridge or involve the anterior
peritoneal reflection are typically managed through some combination
employing The Four D’s.
Proximal Fecal Diversion—There is not much debate about the necessity
of proximal diversion in the setting of destructive injuries in this location.
A colostomy should be created with some combination of application of
the techniques mentioned previously. Diversion options include end
colostomy with Hartmann’s pouch, loop colostomy, or what we refer to as
an end-loop colostomy where the distal or afferent end of the stoma is
closed with a TA stapler prior to loop maturation. The stoma should
remain in place until there is demonstrable healing of the injury at which
time it can be closed. This timing will depend on a number of factors,
including the nature of the injury, the patient’s overall health and ability to
tolerate a secondary procedure, and the time elapsed since the last
laparotomy. Although it can be considered safe to reoperate as early as 6
weeks after the initial procedure, a waiting period of at least 12 weeks is
generally recommended. Some institutions describe early or same-
admission stoma closure, but we do not employ this practice.
Confirmation of injury healing via a contrast study or endoscopic
examination or both should be obtained prior to stoma closure.
Drainage—The requirement for drainage is debatable. If drainage is
employed, the most important factor is ensuring that the proper space is
drained. If the injury is exposed from an abdominal approach, then a
closed suction drain can be placed adjacent to the site of
injury/contamination under direct vision and brought out through a
separate stab incision in the abdominal wall. If the injury is not exposed
from an abdominal approach, then a presacral drain can be placed via a
posterior para-anal approach or by image guidance using CT scan if there
is a visible presacral collection or cavity. It is imperative to place the drain
adjacent to the injury or in the injury cavity if a drain is employed;
otherwise, the drain is useless. Drain management is guided by surgeon
judgment.
Direct Repair—Repair of these injuries can be undertaken if they can be
exposed and they are not destructive. Repair can be performed via a
transabdominal approach in one or two layers, or it can be done via a
transanal approach. An endoscopic approach using transanal minimally
invasive surgery or similar technique could be utilized in some
circumstances. There may be some injuries that are suitable for direct
repair with omission of proximal fecal diversion, but there is no high-
quality evidence to support this approach. These patients must be carefully
selected, and this technique should likely be limited to those with low-
energy mechanisms of injury. Many question the need for direct repair at
all, if proximal diversion is employed. It may not be necessary to expose
the injury and close it. In general, if exposure and repair of the injury can
be done without undue difficulty, we would recommend this approach
with employment of drainage and proximal diversion based on surgical
judgment.
Distal Rectal Washout (Fig. 39-4)—This refers to a washout of the rectum
so that there is little chance of ongoing contamination of the pelvis via an
open rectal injury. It is typically performed via the proximal colon prior to
creation of a Hartmann’s pouch or the maturation of a loop colostomy.
The idea is to flush the distal rectum with sterile saline solution effectively
emptying the rectum of all fecal material. It is important for an assistant to
keep the anal sphincter open during washout so that feculent material is
not forced through the injury tract into adjacent tissues. A small wound
protector device can facilitate keeping the anus open. If the rectum is
empty at the time of injury, there is no need for washout. Critics of this
procedure cite concern for flushing contaminated material into the
adjacent tissues, which can lead to pelvic sepsis.
FIGURE 39-4 A patient with extraperitoneal rectal injury being managed with proximal
fecal diversion and distal rectal washout. A catheter has been placed down the efferent
limb of a loop colostomy for irrigation. Note the assistant between the legs holding the
anus open so fluid drains freely.
Ultimately, the use of any combination of, or all of, the abovementioned
techniques rests with the judgment of the operating surgeon.
Damage Control Scenarios

Many individuals who present with traumatic injury to the colon and
rectum have associated injuries and may be hemodynamically unstable.
Depending on the amount of blood loss, severity of their injuries, and the
location of (environment) and time from injury, they may not be in an
acceptable physiologic state to tolerate a prolonged procedure with
definitive management of their injuries.
These patients tend to be hypothermic, acidemic, and coagulopathic—also
known as the lethal triad. It is important to recognize and identify these
factors, and if they are present, to perform an abbreviated surgical
procedure with the goals of controlling life-threatening hemorrhage,
peritoneal contamination, and providing a temporary means of abdominal
closure so that the patient may be warmed and resuscitated in the intensive
care unit and have their coagulopathy corrected.
These goals can be achieved by packing solid organ injuries and stapling
off intestinal injuries. There is no need to restore continuity—just stop the
contamination and move on. Irrigate the peritoneal cavity with warmed
saline and temporarily close the abdomen. Ideally, this should take <1
hour to complete.
Once the patient has been warmed and their acidosis and coagulopathy
have been corrected, they can return to the OR for more definitive
management and reconstruction. The timing of the return to the OR
requires good surgical judgment.
When the patient returns to the OR for restoration of gastrointestinal
continuity and abdominal closure, the method of management can be quite
controversial and is largely driven by judgment. There are several factors
that will impact this decision-making.
Ongoing bowel/tissue edema—If the bowel is significantly edematous,
this may affect the decision to perform an anastomosis and/or abdominal
closure. Often, a patient must return to the OR several times over several
days before abdominal closure is possible. In many cases, fascial closure
is not possible, and an alternative form of closure must be used with a plan
for abdominal wall reconstruction in a delayed manner. In patients with
edematous bowel, it may be wise to simply proceed with creation of a
stoma with a Hartmann’s pouch (long or short). If the small bowel is in
discontinuity, anastomosis needs to be achieved in relatively short order.
A handsewn technique may be preferred in those with bowel edema.
Continued physiologic derangement—In patients who remain unstable or
in whom advanced critical care measures are required to maintain
stability, it is unwise to restore colonic continuity. This includes patients
who have required massive transfusion, those with multiple injuries, and
those with significant comorbidities who may be less tolerant of an
anastomotic leak. Those with severe fecal contamination combined with a
delay in operative treatment may be best managed via fecal diversion
proximal to the site of injury. Again, these decisions are based on an
evaluation of the “big picture” using sound and safe surgical judgment.
Colonic anastomosis after a damage control procedure—This is an area of
controversy, but there are several retrospective studies examining the
outcomes of patients treated in this manner. Although most studies report
that it is safe to perform anastomosis of the colon after damage control, it
is clear that leak rates are much higher than those seen in the elective
colorectal surgical setting. If the patient is doing well physiologically and
can undergo abdominal closure at the first return to the OR, it may be
reasonable to perform colonic anastomosis. In any other setting, extreme
caution should be used when making the decision to restore colonic
continuity.
Is Proximal Fecal Diversion Necessary?

This is a question that has been asked since the beginning of the operative
management of abdominal trauma. Although many claim that the answer
is very straightforward, we would argue that it is not. There is no single
study that adequately captures all types of colorectal trauma patients in all
possible settings to provide an adequate answer to this question. Because
of this, we tend to propose a set of guidelines that can be used by surgeons
to select patients most appropriate for anastomosis versus proximal fecal
diversion.
The following factors should be considered when making the decision to
divert over restoring continuity:
Physiologic/hemodynamic stability
Blood loss requiring massive transfusion (>6 units of packed RBC)
Need for a damage control procedure
Number and severity of associated injuries
Advanced age and/or significant comorbidities
Mechanism of injury—specifically high-energy transfer injuries
Delay in time from injury to care in the OR
Amount of peritoneal contamination (combined with delay in
treatment)
Use of appropriate antibiotic prophylaxis
After considering all of the abovementioned factors, a thoughtful decision
can be made to restore continuity or divert. We would caution caregivers
to consider the consequences of a leak in any particular individual and
plan to err on the side of diversion when the risk of leak is thought to be
high based on these factors.
Postoperative Care
care plan.
acetaminophen.
Ambulation early is encouraged, pending any additional injuries.
Patients with ostomies will have enterostomal therapy consult on day 1.
Suggested Readings
Causey MW, Rivadeneira DE, Steele SR. Historical and current trends in colon trauma. Clin Colon
Rectal Surg. 2012;25:189-199.
Johnson EK, Steele SR. Evidence-based management of colorectal trauma. J Gastrointest Surg.
2013;17(9):1712-1719.
Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: the evidence vs dogma.
Dis Colon Rectum. 2011;54(9):1184-1201.
Chapter 40
Ileal Pouch-Anal Anastomosis (IPAA)
TRACY HULL
Construction of the J and S Pouch

A total proctocolectomy and ileal pelvic pouch has become the gold-
standard operation for ulcerative colitis (UC) and familial polyposis (FAP)
requiring surgical intervention.
It is also offered to select patients with Crohn colitis (CC) without small
bowel or anal disease.
Preoperatively, all patients should have their anal muscle assessed with a
digital examination to ensure they will be able to control the liquid stool
produced from a pelvic pouch.
Considerations for UC
Biologic medications have been utilized almost uniformly in patients with
UC at least over the past 10 years.
This class of medication has been used in combination with other
immune modulators, and patients refractory to medical management
many times are referred to the surgeon in suboptimal overall health.
Therefore, it has become more common to perform a three-stage
procedure.
Patients with dysplasia offer another challenge.
If the dysplasia is in the colon, we would typically perform (ourselves
not the gastroenterologist) many biopsies of the distal rectum and anal
transitional zone and if no dysplasia offer a double stapled pouch.
Considerations for FAP
Before considering a pelvic pouch, perform an endoscopy on the rectum.
If there is a low number of polyps, a colectomy and ileorectal
anastomosis may be considered.
An esophagogastroduodenoscopy with a scope that has side viewing
capability is performed looking for duodenal adenoma.
More importantly, a family history of desmoids and a computed
tomography looking for desmoids should be considered.
A mesenteric desmoid may preclude doing a pouch.
Considerations for CC
In select and motivated patients with CC, we typically would perform a
colectomy.
If there is no small bowel disease and no anal disease for at least 1-2 years
after colectomy, a pelvic pouch can be considered.
Other Perioperative Considerations

Pelvic ureteral stents are selectively used, but not typically needed.
Sterile Instruments and Equipment

10-mm balloon port
3 mm × 5 mm ports, 1 mm × 12 mm port
10-mm 30-degree camera
5-mm laparoscopic blunt-tip bipolar energy device
3 mm × 5 mm laparoscopic atraumatic bowel graspers with locking
ratchets
5-mm laparoscopic scissors with bipolar cautery attachment
Extra-long (bariatric) laparoscopic atraumatic bowel graspers and scissors
available for morbidly obese patients
5-mm laparoscopic Maryland grasper or laparoscopic Allis clamp
End-to-end circular stapler 28-31 mm
Laparoscopic linear stapler 45-60 mm
Bean bag (optional)
Patient Positioning
Begin in the supine position.
After induction of anesthesia, adopt the Lloyd-Davies position: ensure
perineum just overhangs operating table edge, with legs in Yellowfins
stirrups.
Arms should be tucked next to torso, with foam padding used to prevent
any pressure injuries at the hands and pressure points. In obese patients,
the left arm may be left on an arm board.
Knees should be flexed to approximately 30-40 degrees.
Lower the Yellowfins so that the thighs are almost neutral to the torso to
ensure adequate space for laparoscopic instruments to reach the splenic
flexure.
Technique
Double-Staple “J” Pouch

Stage 1—a subtotal colectomy is performed—typically laparoscopically.
For an open procedure, a midline incision is chosen.
Trocars for laparoscopic surgery vary as to the preference and skill set
of the surgeon. Some also use a single port or robot. One choice for
trocars is shown in Figure 40-1.
FIGURE 40-1 Possible trocar placement for laparoscopic surgery.
We vary in our handling of the rectal stump, depending on the degree

of inflammation/status (ie, friability) of the bowel. The traditional way
is to embed it the distal aspect of the incision or the extraction site (if
laparoscopic). That way if the staples do not hold, it avoids a disastrous
pelvic infection (Fig. 40-2).
FIGURE 40-2 The rectal stump is sewn to the undersurface of the extraction site
(laparoscopic) or lower midline incision (open).
Typically, the inferior mesenteric pedicle is left in place.

Another method is to divide the rectum at the sacral promontory,
oversew the staple line, and leave a pelvic and transanal drain.
Stage 2—completion proctectomy and pouch +/− diverting ileostomy
(modified stage 2)
This stage is typically performed ∼4-6 months following the colectomy.
This allows the patient to stop taking steroids and immune affecting
medication and regain their health.
The patient is placed in stirrups or split legs. If a mucosectomy is to be
done, stirrups are chosen.
There is no specific bowel preparation.
The patient should receive preoperative intravenous antibiotics.
If the patient has had oral steroids within 3 months, we will consider
giving a preoperative dose of 100 mg of hydrocortisone.
Our goal is to use the least amount of steroids in the perioperative
period.
The stage can be done open, laparoscopic, combined
laparoscopic/transanal, or robotically, depending on the skill set of the
surgeon.
Trocar placement is similar to what is shown above and often use the
previous sites.
An incision is made over the embedded stump (if applicable). The rectal
stump is mobilized free and replaced in the abdomen.
The ileostomy is carefully taken down to avoid loss of bowel and length. It
is tied off and returned to the abdomen if laparoscopic or packed in the
upper abdomen if open (Video 40-1).
One method to continue access is to place an extra-small wound protector
in the ileostomy site and a small or medium in the suprapubic incision
(Fig. 40-3).
FIGURE 40-3 A wound protector is placed through the stoma site.
A 10- to 12-mm trocar is placed inside the wound protector (Fig. 40-4).
FIGURE 40-4 The 10- to 12-mm trocar is placed through the wound protector.
It is loosened a bit, and a Penrose is tied around the outside the wound
protector. To seal the area, penetrating towel clips (usually two) are placed
on one side, and pneumoperitoneum is established (Fig. 40-5).
FIGURE 40-5 A Penrose drain is placed around the outside and held tight with an
instrument. Penetrating towel clips are placed along the side, which prevents the
pneumoperitoneum from escaping.
Under direct vision, the other 5-mm trocars can be placed (Fig. 40-6).
FIGURE 40-6 All trocars placed and ready to begin.
After incision or trocar placement, all adhesions are lysed, and the
ileocolic pedicle and small bowel mesentery are mobilized beneath to the
duodenum.
To improve reach, the ileocolic artery can be divided being cautious to
avoid injury to the arcade that is close to the bowel–mesentery junction as
that will be the blood supply for the future pouch. This can also be done
just before pouch construction.
Also, if reach is a problem, small incisions can be made over the
peritoneum covering the vessel to allow more mobility (Fig. 40-7).
FIGURE 40-7 To enhance reach, the ileocolic vessel can be divided. However, the
marginal vessel must remain intact. Also, small slits can be made over the perineum to
allow for more reach.
The rectal stump is identified (Video 40-2).

The patient is placed in steep head down, and adhesions are lysed in the
pelvis.
Dissection is begun in a similar manner as when doing a total mesorectal
excision for rectal cancer. The inferior mesenteric vessels do not need to
be ligated flush with the aorta, and the envelope of fat may be more
difficult to dissect in the pelvis if there has been a lot of inflammation, but
essentially dissection is carried out in the presacral space after the inferior
mesenteric vessels are ligated. Hence, the rectal mesentery is removed.
If this is a second stage procedure, all mesentery cephalad is divided.
We ensure we have dissected to the pelvic floor by placing an index finger
in the anus with the other hand in the pelvis or laparoscopically a clamp in
the pelvis, to verify full mobilization of the rectum to the pelvic floor.
When the mobilization is to the level of the pelvic floor, the rectum is
stapled. We use a 30-mm stapler if open with the goal of a 1-1.5 cm anal
transitional zone (Figs. 40-8 and 40-9). For the robotic or laparoscopic
approach, we strive to use the least number of fires with the laparoscopic
linear stapler (Video 40-3).
FIGURE 40-8 The rectal stump is divided at the pelvic floor with a goal of a 1-1.5 cm
anal transition zone.
FIGURE 40-9 A sagittal view of placing the stapler to ensure a short anal transition
zone.
An extraction site is chosen (for laparoscopic surgery), which is usually

the old stoma site or a suprapubic site.
The rectum is removed via the extraction site.
The small bowel is brought onto the abdomen. It is measured to provide a
15-20-cm-limb J pouch. Again, if there is a question of reach particularly
in the open technique, a long instrument can grasp the curved part of the J
and verify reach (Fig. 40-10).
FIGURE 40-10 Reach to the pelvis can see assessed for the planned pelvic pouch by
grasping the small bowel 15-20 cm upstream from the distal most point and pulling down
to the pelvic floor.
TIPS
A quick assessment of reach for a J pouch is done by grasping the

small bowel about 18 cm upstream from the stoma and assessing the
mobility of that point toward the pelvis. In the open approach, the
objective would be easy to reach of this point in the small bowel to the
pubic synthesis. Assessing reach is more challenging in the
laparoscopic approach, but easy mobility of the clamp and small
bowel deep into the pelvis can be ascertained.
TIPS
If there is significant scarring in the rectovaginal space in women, a

sizer in the anus and vagina and positioned to open the space can
improve visualization.
Construction of the J Pouch

For open procedures, drape off the abdomen to avoid spillage.
For laparoscopic procedures, the pouch can be typically constructed
through the ileostomy site.
An enterotomy is made in the curved part of the J. The gastrointestinal
anastomosis (GIA) 100-mm stapler is carefully inserted and fired after
assuring the mesentery is not caught (Fig. 40-11).
FIGURE 40-11 Various stages of construction of the ileal J pouch. An enterotomy is
made in the curved part of the J. It takes two to three firing of the gastrointestinal
anastomosis 100 to complete the pouch. The tip of the J area should not be long. The
spike is brought out the rectal staple line. The gun is mated, and the anastomosis
constructed.
Typically, it takes two to three fires of the GIA to construct the pouch. The
open end at the tip of the J is closed with a 30-mm stapler, ensuring that is
it nearly flush with the end of the GIA staple line to avoid a long tip of J
segment.
3-0 absorbable suture is usually used to oversew the 30-mm staple line as
it tends to bleed. Also, a simple suture is placed in the confluence of the
two limbs to anchor the tip of the J end to the afferent limb. Care is taken
when placing this suture as not to kink or narrow the afferent limb inlet.
Some surgeons prefer to oversew the entire linear staple line with 3-0
absorbable suture in a Lembert manner.
The pouch is insufflated with air or saline to ensure it is water tight and
distends adequately.
A purse string is placed in the enterotomy site at the curved part of the J,
and the head of the gun is placed and tied down (Video 40-4).
Before placing the gun in the anus, four Allis clamps are placed around the
anus to efface the anus and aid in the gentle insertion of the stapler (Fig.
40-12).
FIGURE 40-12 Four Allis clamps can be placed on the anus to efface the anal canal.
This assists in gun insertion with tight anal muscles and a short distance to the staple line.
It is easy to push the gun through the staple line.
It is very easy to inadvertently shove the stapler though tight anal muscles
and through the rectal staple line. These effacement clamps reduce the
amount of pressure needed to go through the anal muscles.
Care is taken intra-abdominally to push the sphincter muscles away from
the short rectal stump and avoid incorporation into the staple line.
The anastomosis is completed in the usual manner, but ensuring that the
pouch mesentery is straight and no extraneous tissue is in the staple line. It
is optimal for the spike to protrude at the underside of the staple line that
assists in avoiding catching vagina or other anterior structures (Fig. 40-
13).
FIGURE 40-13 The spike is extended carefully. Aiming for the spike to penetrate just
posterior to the staple line will assist in keeping anterior structures out of the circular staple
line.
Laparoscopically, it is easy to twist the pouch mesentery 180 or 360

degrees. To ensure the mesentery is straight, all the small bowel should be
on one side (usually the left abdomen) with the cut edge fully viewed from
origin to distal pouch and verified to be straight.
The anvil is mated with the spike. As the stapler is closed, it is important
to guide the pouch into the pelvis as the pouch can turn easily 180 degrees
as the gun is closed (Video 40-5).
The stapler is fired, and doughnuts are checked. We also look for a leak by
doing pouch endoscopy or pumping air in the pouch with saline in the
pelvis looking for bubbles (Fig. 40-14 and Video 40-6).
FIGURE 40-14 The anastomosis is checked by insufflating air in per anus into the
pouch with saline in the pelvis.
A suction drain is placed in the presacral space.

For a three-stage procedure, an ileostomy is constructed upstream. For a
modified two-stage procedure, no ileostomy is constructed.
TIPS
As soon as the stapler is through the anal muscles, the Allis clamps are
removed as they will impede full insertion of the stapler into the short
rectal stump.
Mucosectomy and Handsewn Anastomosis with a J
Pouch
TIPS
The surgeon must keep in mind that the pouch must reach further
through the anal canal.
For patients with dysplasia in the rectum or rectal cancer, a mucosectomy

is performed.
The pouch is constructed in a similar manner, except no purse string is
placed in the curved part of the J.
For the mucosectomy, anal effacement sutures are placed (Fig. 40-15).
FIGURE 40-15 For the mucosectomy, #1 sutures are placed from the anal verge 5-6
cm radially and tied. This effaces the anus to allow better visualization of the anal canal.
Starting at the dentate line, using the electrocautery or scissors, the

mucosa is excised off the muscle (Fig. 40-16).
It is essential to preserve the internal anal sphincter when dissecting.
FIGURE 40-16 Starting at the dentate line, an electrocautery or scissors are used
to remove the mucosa. The surgeon must be mindful to avoid injuring the internal anal
sphincter.
It is crucial to ensure all mucosa is destroyed in the anal canal and

transitional zone. Simply painting the area with the electrocautery on
coagulation will desiccate and destroy viable mucosal cells that may
remain.
2-0 or 3-0 polyglycolic acid sutures are placed through the cut edge in the
eight cardinal positions and pinned out.
The pouch is oriented and advanced down and out the anal area. Typically,
it may be necessary to guide the pouch toward the anus by an abdominal
operator as the anal operator eases the cut edges of the curved part of the
pouch out the anus. We typically use a Babcock to advance the pouch
through the anal canal (Figs. 40-17 and 40-18).
FIGURE 40-17 An abdominal operator may need to guide the pouch through the
distal pelvis.
FIGURE 40-18 The curved part of the J is brought out the anal area. It is grasped
with a clamp if need be to ease it down.
The previously pinned out sutures are placed through the curved part of
the pouch and tied down.
Pouch endoscopy is performed to verify the anastomosis is water tight and
no gaps exist.
A drain is placed into the pelvis.
A loop ileostomy is constructed.
TIPS
Sometimes, a curved GU needle is efficacious in placing the sutures

through and into a tight anal canal. We feel it is easier to place the
sutures from the outside skin toward and through the anal muscle.
TIPS
Four short bursts of running suture are placed to further stabilize the
anastomosis (ie, quadrants on a clock).
S Pouch Construction
An S pouch is considered when reach to the pelvis is a problem.
Originally, this was the pouch of choice when pelvic ileal pouches were
first constructed in the early 1980s.
Due to the increased time needed to construct the pouch and long-term
potential evacuation problems that can develop as the efferent limb can
elongate with age, it is only used when reach of the pouch to the anal area
is a problem.
This can be in the setting of a stapled pouch anal anastomosis, but more
typically is when a mucosectomy is required.
Three 15-cm limbs are positioned in an S manner.
2-0 or 3-0 polyglycolic suture is used to secure the limbs, placed in a
running manner through the serosa.
For men with a long anal canal and a handsewn anastomosis, a longer
efferent limb may be needed (Fig. 40-19), but in general, a 2-cm efferent
limb is utilized (Fig. 40-20).
FIGURE 40-19 Three 15-cm limbs are lined up, and the back wall is sewn in a
continuous manner to begin the S pouch.
FIGURE 40-20 The efferent limb should be 2 cm.
The bowel is incised on the antimesenteric surface (Figs. 40-21 and 40-
22).
FIGURE 40-21 The bowel is incised along the antimesenteric border, and the back
wall completed with a continuous suture of the cut edges.
FIGURE 40-22
A running full-thickness suture is used to secure the back wall. The

running suture may be augmented by interrupted simple sutures.
After the entire back wall has been sutured, the front wall is closed with a
running seromuscular suture. The integrity of the pouch is checked by
insufflating air or saline.
The pouch is advanced into the pelvis (Figs. 40-23 and 40-24).
FIGURE 40-23 Illustration of construction of S pouch. Three 15-cm limbs are lined up
with a 2-cm efferent limb. The back wall is sutured. An incision is then made on the
antimesenteric border following the S configuration. The edges are further oversewn with
a running suture to complete the back wall. The front wall is closed with a running suture.
The completed pouch with a 2-cm efferent limb is shown.
FIGURE 40-24 The S pouch being advanced through the pelvis. Note Babcock
inserted via anus and grasping the efferent limb.
The anastomosis stapled or handsewn, as mentioned previously. The goal,

if a handsewn anastomosis is constructed, is to seat the pouch on the
pelvic floor to avoid kinking during stool evacuation. For a stapled
anastomosis, the goal is a short efferent limb as this will most certainly
elongate over time.
Illustrated are differences in the J and S pouch, and common nomenclature
is shown (Fig. 40-25).
FIGURE 40-25 Illustration of J versus S with nomenclature.
Redo Ilealanal Pouch

An ilealanal pouch can require revision due to multiple causes. The most
common is sepsis/fistula, but twist, contortion, or outlet obstruction are
other reasons.
All sepsis must be cleared as optimally as possible before definitive
surgery is considered. If need be, a loop ileostomy is constructed to allow
the patient to regain health and reduce sepsis. Many times, this can be
accomplished laparoscopically.
Redo pouch surgery is scheduled after the patient has regained their health
and stamina. The patient must be motivated as the surgery can be
extremely debilitating.
The patient is placed in stirrups.
A rectal tube is placed, which will assist in identifying the pouch in the
deep pelvis.
Ureteric stents and Foley catheter are placed.
A midline incision is typically made. If the patient is thin, a low transverse
incision can be considered. We do not advocate to do this
laparoscopically, though has been described.
Adhesions are carefully lysed from proximal jejunum to the pelvis.
Proximal small bowel is packed into the upper abdomen. If possible, a
wound protector and a Balfour/Bookwalter retractor are used. An array of
lighted instruments will be useful for pelvic visualization (Fig. 40-28).
FIGURE 40-26 When constructing an ileostomy to control sepsis with a planned redo
pelvic pouch in the future, the stoma should be about 18-20 cm upstream from the pouch.
FIGURE 40-27 In the future if a new pouch needs to be constructed, that stoma will
become the curved part of the J.
FIGURE 40-28 An array of lighted instruments are essential when performing redo
pelvic surgery.
Depending on the problematic area of the pouch, dissection into the pelvis
is usually easier when starting on the right side at the pelvic brim.
Attempts are made to avoid injury to the pouch wall and mesentery (be
mindful of the location of the pouch mesentery) as many times this pouch
can be reused.
In the deep pelvis, a sizer in the vagina may delineate the pouch vaginal
septum.
Hydrodissection, which means injecting saline into the plane between two
structures, can sometimes assist dissection into the pelvis particularly
anteriorly (Fig. 40-29).
FIGURE 40-29 To aid in separating adhesions in redo surgery, hydrodissection can
be useful. Sterile saline is injected between the two structures in an effort to open a plane.
If there is a fistula or a pocket of debris, when that area is encountered, the

tissue will become hard. That alerts you to an upcoming area of sepsis and
difficult dissection.
Sometimes when deep in the pelvis, amputating the pouch as far distally
as possible and excising all mucosa from the anal route is the easiest.
Anteriorly in a male, care must be taken to locate the bladder and other
anterior structures.
After the pouch is excised, all sepsis is debrided particularly if there has
been a presacral collection. This material will collect fluid and can doom a
redo pouch (Fig. 40-30).
Nearly all redo pouches require a handsewn ileal pouch anal
anastomosis (IPAA).
FIGURE 40-30 After there has been a leak that leads to a collection sitting
against the sacrum, the rind from this cavity must be scraped and excised as much as
possible before a new pouch is placed.
All efforts are made to use the same pouch; however, sometimes
enterotomies or concerns of viability make it necessary to construct a
new pouch.
Typically, from the anal approach, a mucosectomy is performed (Fig.
40-31).
FIGURE 40-31 Outlined is the area of incision for the mucosectomy.
The pouch is advanced down into the pelvis and out the anus, as
described earlier.
Sometimes, there can be a fibrotic ring around the pelvis in the mid-to-
distal pelvis from prolonged sepsis. If this is tight, it will constrict the
pouch and lead to ischemia. A dilator can be used to enlarge this area
(Fig. 40-32).
FIGURE 40-32 There is typically a fibrotic ring around the mid- and distal pelvis.
The ring must be fractured so that at least two fingers easily go through. One way to
break this ring is serially placing larger and larger bougie dilators through in the
manner shown in the illustration.
Posteriorly, radial slits can be made in the circular scar, with the goal
that two fingers will easily go through the radial scar.
A drain is placed in the presacral space before incision closure (Fig. 40-
33). An ileostomy is always used for a redo pouch.
FIGURE 40-33 A drain is placed in the presacral space.
TIPS
If an ileostomy is placed beforehand, it is prudent to consider that it

may need to become the curved part of a J pouch should a new pouch
need to be constructed at the time of definitive repair. Therefore, avoid
placement of the stoma within 18 cm of the top of the pouch and
ideally about 18-20 cm upstream from the pouch inlet (Figs. 40-26 and
40-27).
TIPS
It is paramount that the surgeon has read the operative note for the
initial pouch construction because if the mesentery in the pelvis was
not resected, entering the presacral space between the retained rectal
mesentery and the anterior sacral ligament at the pelvic brim may be
the easiest place to start the pelvic dissection.
Surgical Management of Pouch Complications

When constructing a pelvic pouch, there are many suture and staple lines
where a pelvic pouch can leak or have a fistula. Prevention at the original
operation with meticulous surgery is the best way to avoid a problem.
When the anastomosis is created, ensuring all extraneous tissue (like the
vagina in women) is well out of the staple line is paramount (Fig. 40-34).
FIGURE 40-34 When closing the gun, it is imperative to ensure that the vagina is not
in the staple line.
Leaks do occur, and thoughtful management can many times save the
pouch.
IPAA is the most common place for a leak. Posteriorly is typically where
it will leak. There is usually formation of a sinus or abscess in the
presacral region.
The first step is to set realistic expectations for the patient. Stoma closure
will be delayed, and sometimes, it can take up to a year for the area to
close or to perform redo surgery.
Illustrated are the most common areas of a pouch leak (Fig. 40-35).
FIGURE 40-35 The most common areas where a pelvic pouch will leak. 1. Presacral
sinus/abscess. 2. Tip of the J leak. 3. Ileal pouch staple line leak. 4. Ileal pouch anal
anastomotic leak. 5. Pouch vaginal fistula.
An examination under anesthesia to determine the size and extent of the

presacral cavity is the first step. Tip: Adequate drainage must be achieved.
We do not routinely advocate radiology placing a posterior interventional
radiology (IR) buttock drain. This is uncomfortable for the patient and sets
up a situation where a suprasphincteric fistula can occur that probably will
not heal.
A gastrografin enema also can give a roadmap regarding the size of a
presacral cavity. It is also good for a baseline to evaluate treatment (Fig.
40-36).
FIGURE 40-36 Gastrografin enema showing a posterior leak into the presacral
space.
The cavity is identified (Fig. 40-37).

FIGURE 40-37 Illustration of the presacral collection.
We prefer placement of mushroom drains into the cavity, advancing to the

cephalad extent and suturing them in place (Fig. 40-38).
FIGURE 40-38 A mushroom catheter is placed to the cephalad extent of the cavity.
The mushroom size is determined by the size of the cavity and size of the
hole in the IPAA. We sew the mushroom in place proximal to the area of
sensation in the anal canal.
The patient returns to the operating room (OR) every 4 weeks (±2 weeks)
for re-evaluation. The cavity should decrease in size, and the size of the
mushroom should also be able to be reduced (Fig. 40-39).
FIGURE 40-39 The goal is that the cavity will shrink in size.
The goal is to have this area reduce and close. Sometimes, a sinus remains
and that can be unroofed and allow incorporation of the sinus into the back
wall of the pouch. A gastrografin enema is obtained before stoma closure
to demonstrate resolution of the leak.
Illustrated is a laparoscopic stapler being used to incorporate the sinus into
the back wall of this pouch (Figs. 40-40 and 40-41). A laparoscopic
energy device can also be used to do this function.
FIGURE 40-40 At times, the cavity may shrink and form a sinus. Incorporating the
wall of the cavity into the pouch is one way to deal with this. Illustrated is using a
gastrointestinal anastomosis to do this.
FIGURE 40-41 Schematically, the back wall would look like this illustration.
The tip of the J is the second most common place where the pouch can
have a leak.
This may require IR drainage.
A high index of suspicion is needed, thinking about a leak from this area
when a patient has an abscess that starts at the top of the pelvis.
A leak from the tip of the J almost never heals over time. Also, pouch
endoscopy many times does not reveal the leak, and a gastrografin enema
may not show this leak. Hence, a high index of suspicion is needed to
correctly identify this problem (Fig. 40-42).
FIGURE 40-42 The tip of the J is the second most common place that a J pouch will
leak.
After 3-6 months, the problem is addressed and sepsis has been drained,
and surgery to address this problem can be considered. Sometimes, the tip
of the J leak can be dissected out, the corner freshened, and a suture
closure performed (Fig. 40-43).
FIGURE 40-43 Sometimes, the tip of the J leak can be trimmed back to healthy
tissue, and the edges sewn together.
At other times, the end with the fistula can be restapled (Fig. 40-44).
FIGURE 40-44 Many times, there is more elongation that one would expect, and a
leaking tip of the J can be restapled.
However, sometimes, a new pelvic pouch must be reconstructed for

optimal repair.
A pouch vaginal fistula is another form of a leak from the staple or suture
line of the IPAA (Fig. 40-45).
FIGURE 40-45 A leak from the anterior suture or staple line in a woman may project
into the vagina, perineal area, or base of the labia.
Sometimes when the gastrografin enema is performed in anticipation of

stoma closure, it is discovered.
The distinct characteristics of the fistula determine the method of repair.
Sometimes, a redo IPAA is required.
In these circumstances, a mucosectomy and handsewn IPAA is
performed (Fig. 40-46).
FIGURE 40-46 A mucosectomy and handsewn anastomosis can be used to
repair this type of fistula. The vagina is repaired, and the pouch advanced down to
cover the opening.
It is important to avoid whenever possible having the suture line directly

in line with the repaired vaginal tract as this many times leads to a
recurrence (Fig. 40-47).
FIGURE 40-47 If possible, the anastomotic suture line should not be in line with the
vaginal closure sutures (illustrated to be in line and not desirable). This sets up for a
recurrent leak.
It is also possible that a patient can have a pouch vaginal fistula from
cryptoglandular sepsis from the dentate line (Fig. 40-48).
The treatment options may be different for this type of fistula, so
delineation of the exact internal opening is helpful.
FIGURE 40-48 Sometimes, a fistula can arise from a cryptoglandular origin.
When approaching repair of a pouch vaginal fistula, a seton is typically

placed as the first step (Fig. 40-49) along with drainage of all sepsis.
An examination in the OR may be helpful to delineate the anatomy.
Note the anal everting sutures in the photo.
FIGURE 40-49 Placing a seton for 2-4 weeks can reduce sepsis.
In select patients, transanal mucosectomy and pouch advancement

without entering the abdomen is an option if there is good pouch
mobility (Fig. 40-50). A handsewn anastomosis is performed at the
dentate line (Fig. 40-51).
FIGURE 40-50 In selected patients, a mucosectomy can be performed, the pouch
can be disconnected from the anus and then advanced down to close the fistula—all
from the anal approach.
FIGURE 40-51 Completed pouch anal handsewn anastomosis.
The choice of repair for a pouch vaginal fistula depends on the

surgeon’s experience and overall conditions of the patient. A proximal
loop ileostomy is our standard when we repair this problem.
The efferent limb of the S pouch can cause outlet obstruction constipation
(Fig. 40-52). Even when a short limb is constructed, over times, it may
elongate. Surgery is required to address the long efferent limb or the
patient can become totally obstructed (Figs. 40-53 and 40-54).
Redo surgery usually requires disconnection via the abdominal
approach and redo handsewn anastomosis. More commonly, a
completely new pouch is constructed with the goal being a J pouch.
FIGURE 40-52 Illustration of long efferent limb and the outlet problems this can
cause.
FIGURE 40-53 X-ray showing long efferent limb (Fig 40-53) and intra-op photo of
same pouch with long efferent limb (Fig. 40-54).
FIGURE 40-54
The afferent limb can kink behind the pouch and lead to obstructive
symptoms (Fig. 40-55).
Abdominal exploration and pexy of the afferent limb to the abdominal
wall is our preferred method of addressing this problem.
FIGURE 40-55 A redundant afferent limb can become trapped between the pouch
and the spine, leading to obstructive symptoms.
Pelvic pouch endoscopy is performed routinely depending on the initial

pathology of the resected colon and rectum. Over time, a cancer could
develop in the anal transitional zone, as shown in Figure 40-56. This was
treated with pouch excision.
FIGURE 40-56 Lifelong pouch endoscopy is recommended as a cancer can form in
the anal transition zone, which is demonstrated in the photo.
Postoperative Care
care plan.
acetaminophen.
Enterostomal therapy will see the patient on postoperative day #1 to start
to teach about proper stomal care if a diverting ileostomy is performed.
Nutritional therapy will also consult with the patient to discuss dietary
management with a new stoma.
The drain is typically removed in 1-3 days.
Suggested Readings
Fazio VW, Kiran RP, Remzi FH, et al. Ileal pouch anal anastomosis: analysis of outcome and quality
of life in 3707 patients. Ann Surg. 2013;257(4):679-685.
Holubar SD. Prevention, diagnosis, and treatment of complications of the IPAA for ulcerative colitis.
Dis Colon Rectum. 2018;61(5):532-536.
Lavryk OA, Stocchi L, Hull TL, et al. Factors associated with long-term quality of life after restorative
proctocolectomy with ileal pouch anal anastomosis. J Gastrointest Surg. 2019;23(3):571-579.
Remzi FH, Aytac E, Ashburn J, et al. Transabdominal redo ileal pouch surgery for failed restorative
proctocolectomy: lessons learned over 500 patients. Ann Surg. 2015;262(4):675-682.
Chapter 41
Crohn Disease: Surgical Management
DAVID M. SCHWARTZBERG
STEFAN D. HOLUBAR
Managing Crohn patients is a multidisciplinary endeavor that requires
close collaboration with the referring an inflammatory bowel disease
(IBD) subspecialist gastroenterologist. Understanding the medical
management and how that interplays with surgery is critical to decision-
making.
Formulation of a multidisciplinary care team plan
Thiopurines and biologics, both of which have very long half-lives,
may safely be held perioperatively.
Assessment and active preoperative management by the surgeon of
modifiable risk factors such as
smoking/nicotine cessation
steroids/immunosuppressive medications tapering
management of intra-abdominal sepsis with enteral/parenteral
antibiotics and percutaneous drains
nutritional optimization with exclusive enteral nutrition (Ensure
monodiet) or total parental nutrition
correction of anemia with iron and B12 infusions, folate, and vitamin
C supplementation
Preoperative stoma education and site marking
Optimization of present peristomal and enterocutaneous fistula skin
Prior to embarking on any elective Crohn-related surgery, it is important
to fully assess the extent of the disease. This may include any or all of the
following:
Endoscopy including colonoscopy/sigmoidoscopy/proctoscopy and
esophagogastroduodenoscopy
Contrast-enhanced cross-sectional small bowel mapping with magnetic
resonance enterography, computed tomographic enterography, or
fluoroscopic small bowel follow-through
Ancillary fluoroscopic studies such as water-soluble enema (not
barium), sinograms/fistulograms
Thorough review of prior operative and pathology reports
Perioperative measures should include
Cathartic and oral antibiotic bowel preparation (in the absence of acute
small bowel obstruction)
Parenteral antibiotics at least an hour prior to incision
Pre-incision venous thromboembolism (VTE) prophylaxis
With regard to stress-dose steroids, this historic practice has generally
been abandoned for several reasons.
First, level 1 evidence exists, showing that stress-dose steroids may
be safely omitted.
Second, in the era of enhanced recovery, patients are typically given
intraoperative 8 mg of dexamethasone for prevention of
postoperative nausea and vomiting, which is effectively stress dose.
Procedures: Laparoscopic Surgery for Inflammatory

Bowel Disease
Palliative loop ileostomy, ileocolic resection, redo ileocolic resection,
segmental small bowel or colon resection, total abdominal colectomy, and
total proctocolectomy
Patient Positioning
Padded operating room table, arms tucked and padded
Lithotomy with Yellowfins for most cases; consider split leg as well
Allows for:
Perineal access
Intraoperative lower endoscopy
Stapled end-to-end anastomosis
Upper lateral leg padding to protect the peroneal nerves
Foley catheter should not be allowed to fall into the anus and should be
secured and passed under the inner thigh.
Patient must be secured to the bed with a Velcro strap or wide silk tape.
If the stoma site is not tattooed (ie, marked with ink), it should be marked
with small needle “poke” holes in a circular pattern (as opposed to an “X,”
which is more likely to leave a scar if the stoma is omitted).
Basic laparotomy tray
Kocher and Kelly clamps for mesenteric ligation
Long- and short-needle drivers, Metzenbaum scissors, heavy Mayo
scissors, and DeBakey and Adson forceps
Hand-held electrocautery pencil and Yankauer suction
Basic laparoscopy tray
Multiple 5-mm atraumatic bowel graspers; 5-mm modified endo-
Babcock (preferred)
5-mm electrified endoshears with trigger switch (preferred) or foot
peddle
Wound protector (typical sizes: small, 2.5-6 cm; medium 5-9 cm)
One 12-mm sleeve without obturator
Small ¼-in Penrose (or silastic) drain to secure the 12-mm sleeve in the
wound protector
may also use proprietary rigid wound protector cap
Two to three 5-mm optical trocars
5- or 10-mm high-definition laparoscope, rigid or flexible-tip
(preferred) and insufflation tubing
Using a 5-mm laparoscope allows for “port hopping,” such that the
laparoscope can be placed in any of the ports.
Preferred: 5-mm electrosurgical vessel sealing device for
intracorporeal vessel ligation and also for dealing with thick mesentery
extracorporeally
Optional:
Passive (preferred) or active smoke evacuator
Laparoscopic suction irrigator (especially in phlegmon pelvic cases)
Anti-adhesion barrier (but must not place atop an anastomosis)
Stapled anastomoses (see Chapter 19)
Traditional Cleveland Clinic method for stapled anastomosis
29, 31 or 33 mm circular stapler for end-to-side ileocolic
anastomosis
TA-90 gray load to close the common enterotomy after circular
stapler is fired
Common enterotomy may also be oversewn.
Alternative method
Gastrointestinal anastomosis (GIA)-80 stapler with blue loads for
extracorporal resection and anastomosis
Endo-GIA if intracorporeal resection or anastomosis
TA-60/TX-60 stapler with a blue loads to close the common
enterotomy
In cases of thick bowel wall, green loads should be used.
Note the enterotomy should be measured, and if approaching 6 cm
in length, then consider using a TA-90 gray load stapler.
Sutures (with taper needles)
Traditional Method for Mesentery Ligation and Sutured

Anastomosis
#1 chromic sutures for interlocking suture ligatures for Crohn mesentery
3-0 absorbable braided suture for the anastomosis: crotch stitch, and for
imbrication of the corners and transverse/crossing staple lines
3-0 chromic sutures for stoma maturation
Two running #1 looped absorbable monofilaments for fascial closure
Stainless-steel staples and 4 × 4 gauze, paper tape for skin closure
Alternative Method
Large jaw electrosurgical instrument and supplemental 2-0 absorbable
interlocking monofilament suture for mesenteric ligation
3-0 absorbable monofilament for the back, inner, and front wall of the
anastomosis; for the crotch stitch; and for imbrication of the corners and
transverse/crossing staple lines
Two packs of 3-0 absorbable braided pop-offs for stoma maturation
Two running 2-0 absorbable monofilaments on a ½-in taper needle for the
fascia
4-0 absorbable monofilament and skin glue, without dressings, for the skin
LAPAROSCOPIC TRANSVERSUS ABDOMINIS

PREPERITONEAL PLANE BLOCK
Technique
Specific Equipment
Local anesthetic:
20-mL liposomal bupivacaine plus 30 mL of 0.5% (or 0.25%)
bupivacaine plus 100 mL of injectable saline; increase to 150-200 mL
of injectable saline for open cases
Spine needle with low-pressure extension tubing
23-gauge 1.5-in needle (for infiltrating port sites and ostomy/extraction
site fascia and skin)
Malleable retractor or other flat metal surface for blunting the spinal
needle tip
One or two 10-20-mL syringes; smaller syringes preferred due to ease of
use
PROCEDURE: LAPAROSCOPIC TRANSVERSUS ABDOMINIS

PREPERITONEAL PLANE BLOCK
Prior to performing the transversus abdominis preperitoneal plane (TAPP)

block, the operator confirms no allergy or other contraindication(s) to the
chosen local anesthetic; if long-acting local is used, the patient should not
receive any other local anesthetics for 72 hours.
The TAPP block is typically performed prior to the principle procedure
(preemptive analgesia) as long-acting local anesthetic has a long-onset
time, which is overcome by the addition of bupivacaine to the dilution.
Spinal needle tip is blunted by tapping it against a malleable retractor or
other flat metal surface.
The extension tubing is connected to the blunted spinal needle and to a
syringe prefilled with diluted local anesthetic of choice.
After obtaining pneumoperitoneum, under laparoscopic visualization, the
surgeons finger is used to identify the correct sites for infiltration at the
midclavicular line in each of the four abdominal quadrants; key is to stay
as lateral as the sterile field allows as the nerves bifurcate laterally.
After piercing the skin, the operator feels for two pops; the first as the
needle traverses the external oblique fascia, followed by the second pop of
internal oblique fascia consecutively, thereby gaining access to the TAPP.
A total of 20 mL of local anesthetic is then infiltrated into each of four
quadrants; note the TAPP block works by the local spreading along the
TAPP where the neurovascular bundle lies. If the spinal needle is placed
too superficial, the operator may observe a bleb at the level of the skin,
and the needle should be advanced.
too deep, the operator will observe a preperitoneal bleb, and the needle
should be withdrawn a millimeter or 2.
The remaining local anesthetic is used for port sites (5 mL each) and
ostomy/extraction site fascia and skin infiltration using the 22- or 23-
gauge 1- or 1.5-in needle.
EQUIPMENT LAPAROSCOPIC OR SINGLE-INCISION

LAPAROSCOPIC SURGERY DIVERTING LOOP ILEOSTOMY
Technique
Equipment
One 12-mm sleeve (without obturator)
Small ¼-in Penrose drain to secure the 12-mm sleeve in the wound
protector (preferred) or wound protector cap or a single-incision
laparoscopic surgery (SILS) port
5-mm laparoscopic camera
Two 5-mm optical trocars
5-mm electrified endoshears or a surgical marker tip removed from the
pen
Traditional Method
3-0 chromic and 3-0 absorbable suture to mark proximal and distal bowel
(white up, brown down, respectively)
4-0 absorbable monofilament and steri-strips to close the 5-mm port sites
Routine use of small Marlin stoma rod (removed at 48 h), typically not
sutured in place
Two 3-0 chromic sutures to mature stoma, no Brooking stitches (everting
sutures)
Ostomy paste and appliance
Alternative Method
Two packs of 3-0 absorbable braided pop-offs to mature stoma
All sutures are cut at end.
Highly selective use of Marlin stoma rod or red rubber catheter in cases of
thick anterior abdominal wall and heightened concern for stoma retraction
4-0 absorbable monofilament and skin glue to close skin at 5-mm port
sites, no dressings
Ostomy paste and appliance
Procedures: Laparoscopic or Single-Incision

Laparoscopic Surgery Diverting Loop Ileostomy
Indications
Severe fistulizing perianal Crohn disease, or as rescue therapy for severe
medically refractory Crohn colitis with severe hypoalbuminemia and other
risk factors. The most important concept in constructing an ileostomy is to
ensure all levels of the trephine traverse the layers of the anterior abdominal
wall in-line (Fig. 41-1).
FIGURE 41-1 Ileostomy construction: Vertically aligned trephine.
Traditional Method
A quarter-sized disc of skin is grasped with a Kocher clamp and incised
with a #15 blade at premarked ileostomy site (Fig. 41-2).
FIGURE 41-2 Ileostomy construction: Skin incision.
The subcutaneous fat is vertically incised with electrocautery, while right-

angle Crile retractors provide exposure.
The anterior fascia of the rectus sheath is cleared of fat and divided 2-cm
cranial and 2-cm caudal (Fig. 41-3), with electrocautery as Crile retractors
provide exposure.
FIGURE 41-3 Ileostomy construction: Vertical fascial incision.
Once through the fascia, a large Kelly is introduced through the rectus
muscle; tip on the peritoneum or posterior sheath. The Kelly is opened to
split the muscle, while the Crile retractors are readjusted to retract the
muscle, exposing the posterior layer (Fig. 41-4).
FIGURE 41-4 Ileostomy construction: Muscle-splitting technique.
Two tonsils are used to elevate the posterior layer, which is divided
sharply with a Metzenbaum scissor.
Alternative Method
The premarked ileostomy site is circumferentially infiltrated with local
anesthetic of choice.
A quarter-sized disc of skin is incised with electrocautery, and a core of fat
down to the level of the fascia excised en bloc with the skin (Fig. 41-5),
similar to a lumpectomy specimen.
FIGURE 41-5 Ileostomy construction: Skin incision with “lumpectomy.” A. A quarter
sized disc of skin is removed. B. A wedge of subcutaneous fat is removed to the fascia.
The anterior fascia of the rectus sheath is cleared of fat, local is infiltrated
into the fascia, the fascia grasped with a Kocher clamp, and a small disc of
fascia excised of the underlying muscle with electrocautery (Fig. 41-6).
A disc excision as opposed to a cruciate incision theoretically reduces
the risk of parastomal hernia as it is resistant to the radial forces of
expansion, as compared with a cruciate incision and linear forces
resulting in splitting or tearing of the fascia along the lines of the
cruciate incision.
FIGURE 41-6 Ileostomy construction: Discoid fascial incision.
The size of the fascia defect should admit the surgeons two fingers to the
proximal interphalangeal joints (Fig. 41-7).
FIGURE 41-7 Ileostomy construction: Trephine sizing.
Remainder of Procedure
A finger is placed into the peritoneum and swept for adhesions.
If adhesions, may need an alternative approach to obtaining
pneumoperitoneum, such as placing the 12-mm sleeve through this site
and placing various 5-mm ports and then clearing the adhesions.
If no prohibitive adhesions, then a small wound protector or SILS port is
placed, and a finger again swept to ensure no bowel nor omentum is
inadvertently caught in the wound protector.
A 12-mm sleeve (or SILS ports) is placed into the wound protector that is
held in the wound protector and the ¼-in Penrose drain used to tie the 12-
mm sleeve into the wound protector (Fig. 41-8).
FIGURE 41-8 Ileostomy construction: Trans-ileostomy site laparoscopic access. A.

Close-up of Penrose looped around outside of the clear circular wound protector which
has the trochar sleeve through it. B. A Kelly clamp is clamped flush on the Penrose to
keep tension and keep airtight for establishing pneumoperitoneum.
Pneumoperitoneum is established, and the left lower quadrant (LLQ) 5-

mm port placed under direct vision (Fig. 41-9) after using the 22-gauge
needle to infiltrate local anesthetic down to the level of the peritoneum.
If blood is seen with this “finder” needle, this may represent the inferior
epigastric vessels; therefore, move the planned port more lateral.
FIGURE 41-9 Ileostomy construction: Laparoscopic port placement.
The suprapubic port is placed after the left lower port such that an
atraumatic bowel grasper can assist by holding the peritoneum against the
pressure of the incoming port, as the suprapubic peritoneum in this
position is notoriously lax.
All four quadrants of the abdomen and the pelvis, including ovaries in
women, are examined for occult pathology.
The patient is placed in steep Trendelenburg position, right side up, and
the cecum is identified, the appendix inspected.
The small bowel is examined retrograde using a hand-over-hand technique
in its entirety to the ligament of Treitz, looking for signs of jejunoileitis
(thickened mesentery, creeping fat, strictures, fistulae).
The cecum is again identified, and a small bowel site is chosen back ∼20-
30 cm for the site of the ileostomy.
Note: Enough length should exist between the ileostomy and the cecum
to facilitate future loop ileostomy closure; a more distal stoma will be
too close to the cecum (and may be preferred in cases where colectomy
is planned), while a more proximal stoma will have higher output.
It is critical to avoid an unintentionally malrotated ileostomy, which will
result in maturing the efferent as opposed to afferent limb; thus, the site of
the ileostomy the bowel is marked, either with electrocautery or using a
surgical marker, such that proximal can easily be distinguished from
distal.
The cautery or marker is used to mark two dots proximally (“eyes to
the sky,” ie, proximal/afferent) and a line distally (“the frown is down,”
ie, distal/efferent, Fig. 41-10).
FIGURE 41-10 Ileostomy construction: Orienting marks.
Note the traditional open method was to place a Prolene proximally and
chromic or absorbable stitch distally (“blue/white to the sky, brown is
down,” Fig. 41-11).
FIGURE 41-11 Ileostomy construction: Orienting stitches.
Note an intentionally rotated ileostomy, with the afferent limb placed

inferior, will be more fully diverting relative to a standard loop
ileostomy with the afferent limb superior (Fig. 41-12). This intentional
clockwise rotation should be such that the limb leading into the afferent
limb is inferior and medial (toward the pelvis and ultimately the
ligament of Treitz) and the efferent limb is superior and lateral. This is
the strong preference of the senior author of this chapter to construct
more fully diverting ileostomy.
FIGURE 41-12 Ileostomy construction: A fully diverting loop ileostomy.
If not a SILS case, the laparoscope is moved to the LLQ port and a bowel
grasper is then placed in the 12-mm sleeve to grasp the bowel.
Pneumoperitoneum is carefully released, and the site of the ileostomy
carefully brought extracorporeally through the wound protector in a
nonrotated manner.
The laparoscopic bowel grasper is replaced with a long Babcock clamp,
and the wound protector carefully released and pulled up and over the
bowel and long Babcock.
The efferent limb serosa incised with electrocautery at the prior marked
site (ie, the “frown”) to the mesenteric margins, taking care not to go full
thickness with the cautery and injury the backwall of the ileum.
MATURING THE STOMA
Technique
Traditional Method
If an open case, the Kocher clamps are placed on the fascia and dermis
and pulled medially to ensure a straight trephine tunnel from the skin to
the fascia (Fig. 41-13).
FIGURE 41-13 Ileostomy construction: Assuring a vertical trephine.
A lap pad is placed in the surgeon’s hand.

A small tunnel is created with a Kelly at the bowel–mesentery interface of
the eviscerated bowel, and a small stoma rod placed and temporarily
secured with two small Babcock clamps.
Brown (chromic) and blue (absorbable braided) stitches are placed to mark
distal (brown) and proximal (blue), and a Marlin rod placed and left for 48
hours or until there is not undue tension (Fig. 41-14).
FIGURE 41-14 Ileostomy construction: Marlen rod placement.
Scissors are used to open the bowel on the efferent (inferior) limb (Fig.
41-15).
FIGURE 41-15 Ileostomy construction: Opening the efferent limb.
Three sutures are placed, full thickness from the bowel wall (at 12, 10, and
2 o’clock positions) to the dermis and the afferent limb is sutured in three
places; full thickness from bowel lumen (at 6, 4, and 8 o’clock positions)
to the dermis, not including the epidermis (Fig. 41-16).
FIGURE 41-16 Ileostomy construction: Everting sutures.
The back of Adson forceps is used to spout the proximal bowel as the
three sutures are tied sequentially.
The efferent limb is then sutured to the level of the skin.
Alternative Method
After the bowel is opened using cautery, the efferent limb is then matured
as a small mucus fistula so that any mucus will go into the pouch and not
leak under the ileostomy appliance faceplate.
Short seromuscular Brooke (everting) stitches are placed at the 12, 6, and
3 o’clock position of the efferent limb and then sutured to the 12, 11, and
1 o’clock positions, respectively, subdermally. This constructs a small
Brooked mucus fistula at the 12 o’clock position (Fig. 41-12).
The bowel is then everted over the afferent limb, and small Crile right-
angle retractors are used to maximally evert (“Brooke”) the ileostomy
(Fig. 41-12). Brooking stitches are then placed at the 9, 6, and 3 o’clock
position of the afferent limb and then sutured to the 9, 6, and 3 o’clock
positions, respectively, subdermally.
Full-thickness sutures from the lip of the afferent limb to the dermis at the
10, 8, 7, 5, 4, and 2 o’clock positions complete the loop ileostomy
construction.
The stoma pouching system is placed.
LAPAROSCOPIC AND OPEN ILEOCOLIC OR SMALL BOWEL

RESECTION
Technique
Equipment
Positioning and equipment are same as Laparoscopic Intestinal Surgery
for Inflammatory Bowel Disease.
If no suspicion of ileosigmoid fistula, supine position or split leg is
acceptable.
Additional considerations:
Consider use of ureteral stents if phlegmon is in close proximity to
ureter or any degree of hydronephrosis.
If open, consider large or extra-large wound protector, or Balfour or
Bookwalter retractor system.
Procedure: Laparoscopic and Open Ileocolic or Small

Bowel Resection
Patient is in slight Trendelenburg, while in lithotomy, arms tucked and
chest taped.
After sterile draping, a 3-6-cm periumbilical extraction (question mark
shaped that is more cosmetic) incision is made, a small wound protector
placed, and a 12-mm sleeve secured in place with a ¼-in Penrose (Fig. 41-
17). Note if the ports from the left panel can be removed that would be
ideal.
FIGURE 41-17 Ileocolic resection: Laparoscopic port placement.
Alternatively, if uncertainty exists with regard to the optimal placement

(ie, in cases of ileocecal and sigmoid resections) or length (ie, in cases at
risk of larger extraction incisions), penetrating towel clips are used to
elevate the anterior abdominal wall and gain entrance to the abdominal
cavity and pneumoperitoneum with a 5-mm optical trocar.
Two 5-mm ports are placed under direct vision; one lateral to the left
rectus sheath, taking care to avoid the epigastric vessels; the other in the
suprapubic position (Fig. 41-17).
The patient is placed in steep Trendelenburg and right side up, while the
omentum and the small bowel are swept medially and superiorly.
Ileocolic Resection and Ileocolic Anastomosis

In primary cases, and in cases of short-segment terminal ileal strictures
without significantly thickened mesentery, a medial-to-lateral approach is
used.
The ileocolic pedicle is retracted anterior, and the terminal ileal mesenteric
peritoneum is incised parallel to the ileocolic pedicle.
Ileocolic artery is dissected free from the retroperitoneum in a medial-to-
lateral manner; the right ureter and duodenum are identified as the
retroperitoneal tissues are swept posteriorly.
After skeletonization, the ileocolic artery is then ligated intracorporeally
using a vessel sealing device; the vessel is sealed once without cutting,
then the device is shimmied distally, and finally the vessel sealed a
second-time cut.
Traditionally, the vessel is taken close to the bowel wall; alternatively, an
oncologic-style high-ligation and mesenteric excision (lymphadenectomy)
may be used theoretically to forestall postoperative recurrence.
The medial-to-lateral dissection continues such that the ascending colon to
the hepatic flexure or mid-transverse colon (especially if a redo case) may
be delivered to the anterior abdominal wall after all the lateral attachments
are taken down.
The ileum, ascending colon, and proximal transverse colon are then
eviscerated via the previously placed with wound protector.
In the case of phlegmonous disease/significantly thickened mesentery,
and in order to avoid tearing or cracking a thickened, friable mesentery,
the incision may need to be extended and a medium or even large
wound protector placed, and the mesenteric dissection and ligation may
need to be completed extracorporeally.
Bowel transection
Once the bowel is eviscerated, an appropriate area of soft, pliable
proximal healthy bowel is identified by the “mesentery pinch test” (Fig.
41-18).
FIGURE 41-18 Ileocolic resection: Mesenteric pinch test.
In the case of handsewn anastomosis, the bowels are divided between

two clamps by a scalpel on top of a betadine-soaked gauze.
A Bainbridge clamp is used on the proximally, while a large Kocher
clamp is used on the specimen side (Fig. 41-19).
FIGURE 41-19 Ileocolic resection: Sharp bowel transection between clamps.
Staplers may be used to transect the bowel as well.

Regardless, the bowel should be transected at a 45-degree angle such
that the antimesenteric corner is closer to the mesentery.
The mesenteric dissection continues until a healthy area of the ascending
colon is reached and the mesentery is divided perpendicularly to the colon
wall to preserve distal vascular inflow; adequate perfusion of the colonic
side is confirmed by incising the mesentery and inspection for bleeding.
The colon is then transected between clamps, with a Bainbridge distally
and a large Kocher clamp on the specimen, and divided with a #10-blade
scalpel on a betadine-soaked gauze.
Tip: Dealing with thickened mesentery
In the case of exceptionally thickened mesentery, the superior
mesenteric artery is protected and overlapping large Kelly clamps are
then placed on the specimen side of the mesentery parallel to the bowel,
while overlapping Kocher clamps are placed on the proximal mesentery
(Fig. 41-20) and the mesentery is then divided sharply between the
clamps; #1 chromic or absorbable sutures are then used to ligate the
thickened mesentery, as interrupted horizontal mattress sutures from
the tip of the distal Kocher to the tip of the next Kocher; this ensures
overlapping horizontal mattress sutures.
FIGURE 41-20 Ileocolic resection: Managing the difficult mesentery.
Alternatively, a large (open) vessel sealing device may be used. The

thickened peritoneum overlying the mesentery is incised with
electrocautery, and large bites of mesentery are taken, splitting the
mesentery into two leaves if exceptionally thickened; supplemental 0
absorbable sutures in the traditional manner to control the mesentery.
The specimen is passed off the table along with the Kocher clamps (or
stapled-off ends), preventing stool spillage.
The decision to construct a diverting loop ileostomy is made based on the
number of risk factors present with more than two to three risk factors,
indicating the need for diversion.
Stapled End-to-Side Ileocolic Anastomosis

A 0-prolene purse-string suture is placed into the cut end of the small
bowel, and a 29- or 33-mm anvil (head) is placed into the lumen and
secured.
The EEA circular stapler is introduced into the open lumen of the
ascending colon, and the spike pierced through the colonic wall ∼3-4 cm
distal on the antimesenteric side of the bowel (Fig. 41-21).
FIGURE 41-21 Ileocolic anastomosis: Stapled end to side.
After mating the anvil/head to the gun body, properly closing the gun and
firing the stapler, a finger or Kelly clamp is placed through the open end
of the colon into the lumen of the small bowel and of the colon to ensure a
patent anastomosis, which is also inspected for bleeding.
A TA-90 is fired across the end of the colon to complete the anastomosis.
The mesenteric defect is closed with running 3-0 suture.
Handsewn End-to-End Ileocolic Anastomosis

Blue towels are placed to drape the bowel.
The mesentery is cut perpendicularly to the bowel walls.
Both ends of the bowel are double-checked for adequate blood supply (not
just oozing but small pulsatile, bleeding vessels) and that they are free
from tension.
The bowel is clamped either with a Bainbridge atraumatic bowel clamp or
with an umbilical/hernia tape.
There is often a luminal mismatch between the smaller ileum and the
larger colon (Fig. 41-22).
FIGURE 41-22 A-F. Ileocolic anastomosis: Size mismatch, Cheatle slit construction.
An antimesenteric Cheatle slit is made on the small bowel (Fig. 41-22A-F)

if needed to better match the luminal diameter of the colon. The corners of
the slit are not trimmed.
Traditionally a single layer 3-0 polyglactin suture closure is done.
The mesenteric sides of the bowel are joined with a Turnbull-style back
row with 3-0 absorbable braided sutures (Figs. 41-23 and 41-24). This
is a full-thickness small-to-large bowel (or small bowel to small bowel)
mucosa-to-mucosa horizontal mattress suture with knots on inside to
fully invert the mucosa. Seromuscular sutures are placed marking the
completion of the back row.
FIGURE 41-23 Handsewn ileocolic anastomosis: Turnbull technique, backwall.
FIGURE 41-24 Handsewn ileocolic anastomosis: Turnbull technique with Cheatle

slit.
The anterior row, starting with the corners, is constructed of interrupted
seromuscular sutures (Fig. 41-25) avoiding the mucosa, as to properly
invert the bowel walls.
FIGURE 41-25 Handsewn ileocolic anastomosis: Seromuscular sutures placed on

the front wall.
If desired (but not required), the anterior row is imbricated with second
row of interrupted seromuscular sutures (Fig. 41-26).
FIGURE 41-26 Handsewn ileocolic anastomosis: Turnbull technique, front wall
outer layer.
Two-layer, interrupted outer/running inner, handsewn anastomosis

Bowels are lined up with Alice clamps with the mesentery at the back
corner.
A 3-0 monofilament backwall seromuscular suture is placed and
snapped and placed under tension to retract and align the bowel (Fig.
41-27).
FIGURE 41-27 Handsewn ileocolic anastomosis: Backwall interrupted outer layer,
back corner stitch.
Interrupted vertical seromuscular backwall sutures of 3-0

monofilament, knots outside, starting at the mesenteric corner and
proceeding toward the antimesenteric corner are placed finishing at the
front corner, which is then snapped (Fig. 41-28).
FIGURE 41-28 Handsewn ileocolic anastomosis: Backwall interrupted outer layer,
front corner stitch.
A running full-thickness inner layer using either a single or two 3-0

monofilament with a single knot on the outside, first on the inner
backwall (Fig. 41-29), then using a reversing stitch to transition from
the inner backwall to the inner front wall.
FIGURE 41-29 Handsewn ileocolic anastomosis: Backwall inner running layer.
The running inner front wall (Fig. 41-30) is then finished by

overlapping the first inner stitch by one bite to avoid a gap, and the 2-
mm two ends of the inner layer are tied to each other, completing the
inner layer (Fig. 41-31).
FIGURE 41-30 Handsewn ileocolic anastomosis: Front wall inner running layer.
FIGURE 41-31 Handsewn ileocolic anastomosis: Completed inner running layer.
Finally, interrupted seromuscular front wall of Lembert sutures of 3-0

monofilament are placed, completing the anastomosis (Fig. 41-32).
FIGURE 41-32 Handsewn ileocolic anastomosis: Completed outer interrupted
layer.
The anastomosis is palpated between the surgeon’s fingers in a pinch test

to ensure a patent anastomotic lumen.
The mesenteric defect is typically closed with running chromic or braided
absorbable 2-0 suture, starting at the apex and running toward the
anastomosis.
A sutured intra-abdominal omental pedicled flap is often employed to
cover the anastomosis.
Stapled Side-to-Side Ileocolic Anastomosis

The terminal ileum (left) and colon (right) are stapled off and the bowels
are lined up, antimesenteric corners up, antimesenteric bowel edge in
front, and mesentery in back (Fig. 41-33).
FIGURE 41-33 Stapled side-to-side ileocolic anastomosis: Lining up the bowels
vertically.
Colon and small bowel antimesenteric staple line corners excised with
Mayo scissors, and the arms of transverse liner cutting stapler introduced
into ileal lumen, also known as GIA stapler (Figs. 41-34 to 41-36).
FIGURE 41-34 Stapled side-to-side ileocolic anastomosis: Removing the ileal corner.
FIGURE 41-35 Stapled side-to-side ileocolic anastomosis: Introducing the stapler
vertically.
FIGURE 41-36 Stapled side-to-side ileocolic anastomosis: Removing the colonic
corner.
The bowel is rotated such that the front staple line will be antimesenteric
and back staple line will not incorporate any mesentery or epiploica (Fig.
41-37).
FIGURE 41-37 Stapled side-to-side ileocolic anastomosis: Rotating the bowel to
avoid the mesentery and epiploica.
Stapler locked, pressure held for 20 seconds to reduce tissue edema, then
fired, cutting between staple lines (Fig. 41-38).
FIGURE 41-38 Stapled side-to-side ileocolic anastomosis: Lock, load, fire, cut.
The common enterotomy provides a view into the internal staple lines that
are inspected for hemostasis (Fig. 41-39) and occasionally requires suture
ligation with a 3-0 stitch.
FIGURE 41-39 Stapled side-to-side ileocolic anastomosis: Inspecting for bleeding.
The common enterotomy edges are reapproximated with Alice and/or

Babcock clamps (Fig. 41-40).
FIGURE 41-40 Stapled side-to-side ileocolic anastomosis: Re-approximating the
common enterotomy.
Prior to selecting a stapler, the common enterotomy is measured, and if

approaching 6 cm, then consider using a TA-90 stapler with a gray load,
otherwise a TA-60 or TX-60 stapler (TA, noncutting; or TX, cutting) is
closed, held for 20 seconds and then fired, closing the common
enterotomy (Fig. 41-41). Finally, the excess anastomotic tissue is trimmed
(if not a cutting stapler) (Fig. 41-42); this can be opened as a donut and
inspected for completeness (Fig. 41-43), and the transverse staple line is
inspected to ensure that staples are “hanging-off” each edge of the staple
line, indicating a complete staple line.
FIGURE 41-41 Stapled side-to-side ileocolic anastomosis: Closing the common
enterotomy.
FIGURE 41-42 Stapled side-to-side ileocolic anastomosis: Trimming the donut.
FIGURE 41-43 Stapled side-to-side ileocolic anastomosis: Inspecting the donut.
The anastomosis is palpated between the surgeon’s fingers for patency and
crotch stitches are placed to reduce tension on the staple line where it
naturally pulls apart (Fig. 41-44).
FIGURE 41-44 Stapled side-to-side ileocolic anastomosis: Assessing luminal
patency, crotch stitches.
Note: The tip of the transverse staple line is “crossing” (or more properly,
intersecting) the linear staple line; in addition, this area—furthest from
mesentery (blood supply)—is oversewn (Fig. 41-45).
FIGURE 41-45 Stapled side-to-side ileocolic anastomosis: Inspecting the transverse
staple line, imbricating the corner.
The mesenteric defect is typically closed with running chromic or braided

absorbable 2-0 suture, starting at the apex and running toward the
anastomosis.
A sutured intra-abdominal omental pedicled flap is often employed to
cover the anastomosis.
Dealing with Fistulae

There are several methods for dealing with fistulae intraoperatively.
Fistulae, if part of the resection (eg, ileo-ileal, ileocecal, or ileum-to-
proximal transverse colon), may be left undisturbed and resected en bloc
with the specimen.
If the fistula is an “innocent bystander” loop of bowel, such as ileosigmoid
without Crohn colitis, traditionally, these are transected sharply, and the
defect in the bystander bowel debrided:
If not on mesenteric border, the debrided fistulous tract can be closed
transversely (as a strictureplasty) primarily with absorbable suture if
bowel lumen will not be compromised and tissue quality is healthy.
If, after debridement, the defect is large (>2 cm), extensive
inflammation around the fistulous opening, or at mesenteric border, a
short-segment is resected, with a colo-colonic or colorectal anastomosis
and a flexible sigmoidoscopic air leak test is performed.
The fistula and repair may factor into the decision to perform a
temporary diverting stoma.
Alternatively, fistulae (such as ileo-jejunal or ileosigmoid) may be
managed with a small bowel resection and primary handsewn
anastomosis.
Finally, in innocent bystander bowel without inflammation or induration,
such as ileo-jejunal or ileosigmoid fistulae, a linear stapler may be used to
closer the innocent bystander side of the fistula (however, we do not favor
stapling for this type of repair).
Special Case: Ileo-duodenal Fistula

These fistulae do not mandate an open approach, and a laparoscopic
Kocher maneuver can often be accomplished, especially in thin patients.
Rarely, these can be stapled off laparoscopically and may benefit from a
strategically placed upper midline extraction site.
Typically, the duodenotomy is handsewn closed as a strictureplasty.
Care must be taken when closing the duodenotomy to avoid
inadvertently incorporating the ampulla of Vater or luminal narrowing.
If the defect is large, it may require a handsewn loop
duodenojejunostomy.
A roux-limb would typically be avoided in a patient with Crohn
disease.
SURGERY FOR SMALL INTESTINAL STRICTURES—SMALL
BOWEL RESECTION AND STRICTUREPLASTY PROCEDURES
Technique
Equipment
Basic laparotomy tray with hand-held electrocautery
2-0 and 3-0 absorbable braided or monofilament sutures
Sterile 14Fr Foley catheter with 10 mL of sterile water to identify occult
strictures; sterile stainless-steel calibration spheres may also be used;
historically, a long-intestinal Baker tube was used but are rarely available.
Surgical clips to mark strictureplasty sites
Procedure: Surgery for Small Intestinal Strictures—

Strictureplasty Procedures
Patient is placed in slight Trendelenburg, may be positioned in lithotomy,
arms tucked and chest taped.
The abdomen is entered sharply in the midline using a 4-cm periumbilical
incision.
A wound protector is placed.
If the entire small bowel cannot be eviscerated due to adhesions, then
adhesiolysis is performed either intracorporally (laparoscopic) or via a
laparotomy incision large enough to inspect the entire small bowel.
The entirety of the small bowel should be run, inspected, and measured,
and the number of strictures counted.
Each stricture must be examined for clinical significance (we recommend
addressing all strictures which do not allow passage of a Foley balloon
inflated with 10 cc of fluid).
Strictures that have a lumen patent enough by the following methods may
be left undistributed, while tighter than these must be addressed surgically
with either a strictureplasty (preferred) or resection.
accept the Foley balloon with 10 mL of saline
accept a medium calibration sphere
The Foley balloon or calibration spheres are also used to run the
bowel lumen to detect occult yet clinically significant short, ring-like
luminal strictures.
Short-segment strictures (<10 cm) are managed with Heineke-Mikulicz
strictureplasties.
For strictures over >10 cm, a Finney strictureplasty may be performed.
Heineke-Mikulicz Strictureplasty
Multiple strictureplasties may be performed in close proximity (Figs. 41-
46 and 41-47); however, strictureplasties performed within approximately
less than 5 cm of each other, unless the mesentery is very supple, may
need to be avoided and that segment of bowel may need to be resected and
a primary handsewn anastomosis created (as described earlier).
FIGURE 41-46 Strictureplasty: Heineke-Mikulicz technique.

FIGURE 41-47 Strictureplasty: Multiple Heineke-Mikulicz and a single Finney
strictureplasty.
Once a stricture is identified (Figs. 41-48 and 41-49), a longitudinal

enterotomy is made on the antimesenteric surface, making sure to extend
across the stricture and ∼1 cm onto healthy bowel on either side of the
stricture (Fig. 41-49, upper left panel).
Electrocautery is used to score the serosa along the longitudinal plane.
FIGURE 41-48 Strictureplasty: Techniques to identify occult strictures.
FIGURE 41-49 Strictureplasty: Heineke-Mikulicz technique.
The bowel lumen is entered sharply.

Consider biopsies of luminal ulcers/strictures to rule out occult
malignancy.
Full-thickness stay sutures are placed at the corners of each side of the
enterotomy; they are placed under tension on a hemostat to approximate
the bowel edges (Fig. 41-49, lower middle panel).
Interrupted seromuscular sutures are placed inverting the mucosa and
ensuring serosa-to-serosa apposition, starting in the middle and using the
rule of halves (Fig. 41-49, lower right panel).
After the bowel is reapproximated, it is tested for defects using the closed
tips of DeBakey forceps; defects are then repaired in an interrupted
manner (Fig. 41-50).
FIGURE 41-50 Strictureplasty: Inspecting for defects.
Ensure patency of lumen by pinching the lumen between the surgeon’s

index finger and thumb; if it is too tight, it should be revised by extending
the longitudinal enterotomy (Fig. 41-51) or resected.
FIGURE 41-51 Strictureplasty: Assessing luminal patency.
Note an alternative technique is the stapled Heineke-Mikulicz (which we

do not advocate) that is done similarly to closing the common enterotomy
of an stapled ileocolic anastomosis, using Alice clamps to line up the
enterotomy corners and then closing the defect with a TA-60/TX-60
stapled, green load in the case of chronically thickened bowel.
Proximal temporary bowel diversion is not used routinely, and placement
should not be based solely on the number of strictureplasties, but should
be considered if there are multiple risk factors for anastomotic leak or
poor wound healing.
Finney Strictureplasty
A seromuscular stay suture is placed at the middle of the stricture on the
antimesenteric side, orienting the stricture at the apex with healthy
proximal and distal bowel apposition (Fig. 41-52, top of left panel).
FIGURE 41-52 Strictureplasty: Finney technique.
Electrocautery is used to score an antimesenteric longitudinal enterotomy,

extending across the stricture and ∼1 cm onto normal bowel on either side
of the stricture (Fig. 41-52, left panel).
The back wall is constructed wit a running 3-0 absorbable suture. We
typically lock the suture (Fig. 41-52, middle panel).
The anterior bowel wall is closed with interrupted seromuscular stitches
(Fig. 41-52, right panels).
Note a stapled Finney may also be performed by making a short
enterotomy at the apex of the strictured segment, approximating the two
limbs of the bowel, inserting an appropriate length linear stapled—one
arm into each limb (green load)—and then stapling the two lumens
together as in an ileal pouch. The apex enterotomy can then be handsewn
or stapled closed, and a crotch stitch placed as for a stapled ileocolic
anastomosis.
Isoperistaltic Strictureplasty
A long isoperistaltic handsewn strictureplasty is uncommonly performed
for continuous disease, which is too long for a Finney strictureplasty.
The bowel is divided at the midportion of the segment to be
reapproximated and Cheatle slits constructed at the cut ends (Fig. 41-53).
FIGURE 41-53 Strictureplasty: Isoperistaltic technique, opening the bowel.
The backwall is then reapproximated using a running 3-0 stitch (Fig. 41-
54).
FIGURE 41-54 Strictureplasty: Isoperistaltic technique, running backwall.
The anterior wall is then folded over and reapproximated using interrupted
3-0 sutures (Fig. 41-55).
FIGURE 41-55 Strictureplasty: Isoperistaltic technique, interrupted front wall.
Special Case: Duodenal Strictures

Short strictures of the first through third portions of the duodenum may be
amenable to Heineke-Mikulicz strictureplasty, as described for
pyloroplasty.
Great care must be taken to avoid the ampullary structures.
However, longer strictures and those involving the third and fourth
portions of the duodenum may require gastrojejunal or duodenojejunal
bypass.
For gastrojejunal bypass, due to the risk of subsequent strictures, it is the
author’s strong preference not to use a roux-limb, but a loop of proximal
jejunum, in an antecolic manner.
For duodenojejunal bypass, we prefer a retrocolic configuration.
After a medial visceral rotation and full Kocher maneuver, the proximal
most loop of jejunum that is free of disease is brought through the
mesocolic defect, which occurs between the ileocolic and transverse colic
pedicles.
Great care must be taken not to disrupt the marginal artery.
The unaffected portions of the duodenum and jejunum are lined up, and a
backwall of interrupted 3-0 seromuscular sutures placed (Fig. 41-57).
FIGURE 41-56 Strictureplasty: Stricture of the ligament of Treitz.
FIGURE 41-57 Strictureplasty: Handsewn duodenojejunal bypass, interrupted

backwall.
A mirror image, longitudinal jejunostomy, and duodenotomy are then

constructed with cautery, and full-thickness running 3-0 sutures are placed
and continue anteriorly to close the inner layer (Fig. 41-58).
FIGURE 41-58 Strictureplasty: Handsewn duodenojejunal bypass, running inner
layer and interrupted backwall.
A front wall of interrupted seromuscular 3-0 sutures is then placed.

Great care is taken to not impinge upon the head of the pancreas.
It is the senior authors preference to then place a tongue of omentum atop
the anastomosis and also to close the retrocolic mesenteric defect.
A right upper quadrant (RUQ) drain and decompressive gastrostomy may
be used for gastric decompression, especially in the setting of chronic
gastric outlet obstruction.
The patient is encouraged to take up to four boxes of a clear nutritional
supplement as tolerated per day.
After the ileus resolves, and prior to advancing to a soft diet, a nonbarium
water-soluble upper GI series is obtained.
The RUQ drain is removed after the patient tolerates food, and the G-tube
removed after 8 weeks.
PEARLS AND PITFALLS
Our approach to both primary and recurrent small bowel and colonic
Crohn disease is guided by the following principles:
Small bowel, large bowel, omental, fascial, and sphincter preservation
Long-term surgical planning taking into account the patients prior,
current, and likely future operations.
After comprehensive adhesiolysis, the length of small bowel remaining
in situ should be measured and recorded in the operative
findings/operative report, as should the specimen.
Repair all serosal tears as they are encountered.
Mark with a stitch, but do not repair, enterotomies as they are
encountered, as with further exploration they often become part of the
specimen.
Take advantage of enterotomies to maximally decompress the bowel of
luminal contents in the case of obstruction; similarly, in the case of
massive small bowel or colonic distension, the bowel should be
decompressed early in the case.
Liberal use of
diverting loop ileostomy, low jejunostomy, or high jejunostomy in
order to minimize anastomotic complications and intra-abdominal
sepsis
prophylactic ureteral stents in the case of phlegmonous right lower
quadrant disease impinging on the right ureter, or similarly in
sigmoid disease with pericolonic inflammation/thickened mesentery
omental flaps
Beware altered anatomy in the case of
cachectic patient where it is relatively easy to enter a deeper than
anticipated plane of dissection
obesity, the reoperative abdomen, and in the presence of
intraperitoneal synthetic mesh
The mesentery in Crohn disease can be difficult to deal with, and we
have offered solutions; however, despite optimal technique, the
challenging mesentery will bleed significantly and may lead to
inadvertent loss of additional length of small bowel due to de-
vascularization. The surgeon should make sure the incision is large
enough to obtain manual compression with his or her fingers and hand
above and below the mesentery.
Historically, the mesenteric resection (ie, lymphadenectomy) was not
considered part of the approach to ileocolic Crohn disease but presently
is in favor and being studied in hopes of preventing/delaying
recurrence.
If there is concern over ligation of the superior mesenteric vein or artery
intraoperative, visceral transplant or vascular surgery consultation
should be obtained.
Handsewn anastomosis. For ileo-ileal, ileocolic, and colo-colonic
anastomoses, in general, we prefer a handsewn end to end anastomosis
for several reasons:
Facilitation of subsequent colonoscopic intubation of the neoterminal
ileum; an end to end anastomosis is generally preferred by referring
gastroenterologists for this reason.
Avoidance of small intestinal bacterial overgrowth associated with a
dilated stapled side-to-side anastomosis (Fig. 41-59), especially
when there is distal obstruction.
FIGURE 41-59 Patulous stapled side-to-side anastomosis.
Maximal preservation of bowel length and mesentery in the case of

future re-resection.
Mastery of the technique, as occasionally due to anatomic
constraints, a stapled anastomosis is not technically possible.
At least 50% reduce intraoperative costs per case compared to
stapling.
Resident/fellow education
Luminal size mismatch anastomotic options, including the
antimesenteric “Cheatle” slit that spatulates the ileum to an elliptical
shape. Note the handsewn and stapled end-to-side techniques are
preferred by many of the Cleveland Clinic Colorectal staff.
Postoperative Care
We have recently shown that although IBD patients may be more
challenging to recover on enhanced recovery, due to various factors such
as reoperative/extensive surgery, intra-abdominal sepsis, prior opiate
exposure, and presence of diverting stomas, these patient should routinely
be recovered using best-practice enhanced recovery protocols including
early feeding, and so on.
Postoperative nonsteroidal anti-inflammation drugs, including Ketorolac
and ibuprofen, are routinely used for multimodal analgesia, but are
typically not recommended beyond the surgical recovery period of 4-6
weeks.
After definitive source control of intra-abdominal sepsis parenteral,
antibiotics are limited to 5 days (based on level 1 data—the STOP-IT
Trial).
Crucial to the postoperative care for Crohn patients is the surgeon’s role in
the multidisciplinary approach and communication with the referring
medical doctor. The referring gastroenterologist should receive copies, at a
minimum, the operative and pathology reports.
Crohn patients often ask about resuming medications postoperatively;
although this is typically sorted preoperatively, the two general approaches
are:
For patients who have their “clock reset” surgically and are without
macroscopically active disease, to cease all medical therapy, and for the
referring gastroenterologist to perform a 6-month interval colonoscopy
and then decide on therapy moving forward
For those with aggressive phenotypes (eg, penetrating, diffuse
jejunoileitis), the surgeon and gastroenterologist decide when it is safe
to resume biologic or thiopurine therapy, typically 2-4 weeks
postoperatively.
Patients may need to receive daily oral corticosteroids postoperatively
at a taping dose. Examples of tapering schedules are as follows:
Acute/recent high-dose steroids: Prednisone 15 mg daily for 7-10
days, then 10 g daily for 7-10 days, then 5 mg daily for 7-10 days.
Then stop.
Patients on chronic steroids may require a prolonged taper if they
have symptoms from the taper. In those instances, referral to an
endocrinologist is considered for a cortrosyn stim test.
It is the senior author’s practice to recommend the following perioperative
vitamin supplementation to optimize collagen synthesis and wound
healing, especially in steroid dependent patients:
Chewable multivitamin daily
Zinc 50 mg twice daily
Vitamin 500 mg twice daily
Vitamin A 20 000 units twice daily for 1 week, only postoperatively in
patients receiving steroids
Finally, approximately one-third of postoperative VTE events occur
postdischarge, and it is the senior authors practice to send all cases IBD
patients with inflammation who have undergone more than a simple loop
ileostomy closure home of 28 days of prophylactic enoxaparin. For
patients whose insurance does not cover enoxaparin and who cannot
afford the out-of-pocket expense, prophylactic heparin is an alternative,
while enteric 81-mg aspirin is an emerging alternative.
Suggested Readings
Deerenberg EB, Harlaar JJ, Steyerberg EW, et al. Small bites versus large bites for closure of
abdominal midline incisions (STITCH): a double-blind, multicentre, randomised controlled
trial. Lancet. 2015;386:1254-1260.
Dietz DW, Fazio VW, Laureti S, et al. Strictureplasty in diffuse Crohn’s jejunoileitis: safe and durable.
Dis Colon Rectum. 2002;45:764-770.
Feagins LA, Holubar SD, Kane SV, Spechler SJ. Current strategies in the management of intra-
abdominal abscesses in Crohn’s disease. Clin Gastroenterol Hepatol. 2011;9:842-850.
Gajendran M, Bauer AJ, Buchholz BM, et al. Ileocecal anastomosis type significantly influences long-
term functional status, quality of life, and healthcare utilization in postoperative Crohn’s
disease patients independent of inflammation recurrence. Am J Gastroenterol. 2018;113:576-
583.
Holubar SD, Dozois EJ, Privitera A, et al. Laparoscopic surgery for recurrent ileocolic Crohn’s
disease. Inflamm Bowel Dis. 2010;16:1382-1386.
Michelassi F, Mege D, Rubin M, Hurst RD. Long-term results of the side-to-side isoperistaltic
strictureplasty in Crohn disease: 25-year follow-up and outcomes [published online ahead of
print January 31, 2019]. Ann Surg. 2019. doi:10.1097/SLA.0000000000003221.
Chapter 42
Colorectal Cancer: Management of
Stage IV Disease
MOHAMMAD ALI ABBASS
BRADLEY CHAMPAGNE
Preoperative evaluation using computed tomography scan with
intravenous contrast, magnetic resonance imaging, and positron emission
tomography is crucial for diagnosis and determining the extent of disease.
Our approach for evaluating stage IV colorectal cancer patients and their
operative planning, if feasible, depends on multiple factors:
Urgency of the procedure
Patient-related factors
Sites of metastatic disease
Survival benefit
When evaluating such patients, you have to first identify the presence of
any life-threatening complications of the tumor (ie, bowel obstruction,
perforation, bleeding).
Once ruled out, then the next step is to investigate the patient’s
performance status and their comorbidities, thus deciding whether they are
fit for surgery.
If the patient is stable and fit for surgery, the next step is to identify the
burden of metastatic disease and isolate resectable cases versus widely
metastatic disease, and based on the survival benefit of those cases, the
treatment plan is customized.
Although decisions for treating these patients are made with the aid of a
multidisciplinary tumor board, when operative plans are made, we also
involve our urology and gynecology-oncology partners early on in the
process.
Stage IV disease is a complicated entity; thus, the treatment plan is not
always straightforward.
When thinking of operative management, the following algorithm is
kept in mind to ease the process:
Surgical Approach to Distant Metastatic Disease

In patients with isolated lung metastasis, the primary lesion is always
addressed first with an anatomic resection.
The decision to proceed with metastasectomy before or after adjuvant
therapy is a decision made by multidisciplinary tumor board.
In patients with liver metastasis, there are multiple ways of approaching
the pathology.
In patients with asymptomatic primary and liver metastasis >3 cm,
liver-first approach is preferable.
Primary first is the preferable approach in patients with symptomatic
tumor (ie, bleeding or near obstructing).
Combined approach is a feasible option when the liver resection is
minor and not extending to more than a lobectomy.
Combined Liver Colon/Colon or Rectum Approach

The technical approach is similar to any approach for colon or rectal
cancer, described in other chapters within the textbook; the only difference
is the combined nature of this procedure.
Usually, the hepatic resection or the bowel resection can be done first, but
the most important part of this approach is to leave the anastomosis to the
final part of the procedure to avoid any hypotension or increased use of
pressers that could affect the integrity of the anastomosis.
Surgical Approach to Local Metastatic Disease

Locally invading rectal cancer or recurrent rectal cancer can be an
indication for pelvic exenteration in men when the tumor is invading the
anterior pelvic compartment; in females most of the time, the invasion is
through the vagina or the cervix, and thus a total mesorectal excision with
total abdominal hysterectomy (TAH) and vaginectomy will be the
operation of choice.
Approaching the rectum usually follows the same surgical principles as
primary rectal cancer, following the total mesorectal excision, and the
dissection extends anteriorly in the cases of prostate and bladder invasion
and posteriorly in case of sacral invasion, as shown in Figure 42-1.
FIGURE 42-1 The green plane including an anterior pelvic exenteration plan in males
with anterior rectal tumors invading the prostate and/or the bladder. The red circle
indicates the dissection plane in posterior rectal tumors that are invading the sacrum or
the coccyx. The protection of sacral nerves in stage IV tumors is always secondary to
achieving R0 resections.
Pelvic Exenteration in Men with Locally Invading Rectal Cancer

This will include a proctectomy combined either with local prostate
resection, local bladder resection, or complete pelvic exenteration, which
will end up with an end colostomy and neobladder and a urostomy (Figs.
42-2 to 42-5).
FIGURE 42-2 This is a sagittal image including the dissection plane of anterior tumors
invading the bladder or the prostate.
FIGURE 42-3 Picture of the mesorectal plane at the level of the sacral promontory in
an open case for left lateral rectal cancer invading the prostate, bladder, pelvic wall, and
external sphincter. The best approach starts with good exposure using a Bookwalter
retractor and isolating the left and right ureters with vessel loops.
FIGURE 42-4 Picture of a pelvic exenteration in a male for low rectal cancer, left
ureter isolated with vessel loop.
FIGURE 42-5 Picture of a pelvic exenteration in a male for low rectal cancer, right
ureter is isolated with vessel loops.
Total Mesorectal Excision with Total Abdominal Hysterectomy +/

− Vaginectomy
This included a proctectomy with a TAH with or without a vaginectomy
(see Chapter 33).
In some large tumors that are also invading the bladder, the patient might
also end up with a neobladder and a urostomy.
Posterior Pelvic Exenteration with Sacrectomy

Sacrectomy is done when the tumor is usually posterior and invading the
coccyx or the sacrum, usually those cases include a proctectomy with
sacral resection done but the spine surgery team (see Chapter 34). The
resection plane is usually behind the holy plane and includes the sacrum to
ensure R0 resections, as shown in Figure 42-5.

Gastrointestinal (GI) open tray with pelvic retractors (add on for other
specialties if further work is needed)
Knife handle
Adson forceps
Ochsner clamp
Allis clamp
Kelly clamp
Moynihan clamp (short and long)
Babcock clamp (short and long)
Kocher clamp
Tonsil tip
Dennis clamp
Suction tip
Metzenbaum scissors
Mayo scissors
Harrington scissors
Jones scissors
Needle holder
Monopolar cautery
Bonnie forceps
Appendiceal retractors
St. Mark retractor
Included in this tray also long instruments for the pelvic dissection
Additional instruments are usually needed dependent on the combined part
with the proctectomy, gynecology tray, or urology or orthopedic specials.
Technique
Positioning and Preoperative Considerations
This is a multidisciplinary approach that includes multiple teams involved:
colorectal, urology, orthopedic, and gynecology oncology.
The patient is usually in modified lithotomy position with both arms
tucked to the side in anticipation of the pelvic dissection portion.
Foley catheter and orogastric tube are placed.
If able, a bowel preparation is utilized prior to surgery (not for obstructed
lesions).
Ureteral stents are used on case-to-case basis.
Abdominal and perineal preparation are often utilized.
Patients are marked for a colostomy and ileostomy or bladder conduit
depending on the extent of disease.
Abdominal Portion
The approach is usually tailored on patient-to-patient basis, but, in most
cases, starts with opening the abdomen with a midline incision starting
above the umbilicus to the pubic bone.
Dissection of the bladder from the abdominal wall to obtain full exposure
to the pubic bone
Exploration of the abdomen to rule out further metastatic disease, which
was not established on imaging, if present
Mobilization of the sigmoid colon, which, in our practice, is mostly done
from a medial-to-lateral approach, especially during open cancer cases
We always attempt to identify the ureter by accessing it through the
avascular plane below the inferior mesenteric artery (IMA) pedicle.
Ligation of the IMA pedicle is done either with 0 chromic sutures or using
the bipolar energy device if available.
Once the ureter is identified, the dissection medially is taken all the way to
the splenic flexure keeping in mind the ureter position and avoiding it
being pulled up toward the pedicle plane.
The mesentery is then divided up to the colon wall below the takeoff of
the IMA.
Then we attempt to dissect the mesenteric edge up to the origin of the
inferior mesenteric vein (IMV).
There is no need to spend time on splenic flexure release and taking the
IMV unless there is a reach issue, which is not present usually in these
cases due to the nature of the case (ie, use of an end colostomy).
The sigmoid and descending colon are then released laterally.
Pelvic Portion
The avascular plane is entered behind the sigmoid mesentery and anterior
to the sacral promontory, as shown in Figures 42-6 to 42-10.
FIGURE 42-6 This is a sagittal image including the dissection plane of posterior
tumors invading the sacrum.
FIGURE 42-7 Laparoscopic mesorectal excision starts with identifying the holy plane
anterior to the sacral promontory; this step is important in stage IV tumors that are
combined liver and colon resections that can be done laparoscopically.
FIGURE 42-8 Laparoscopic posterior mesorectal plane dissection started at the level
of the sacral promontory and showing the hypogastric nerves.
FIGURE 42-9 Posterior dissection plane in an open mesorectal dissection showing

the hypogastric nerves and the presacral plane.
FIGURE 42-10 Anterior dissection is always started by applying enough retraction on
the anterior peritoneal reflection and then using the monopolar cautery to open the plane
between the rectum and the prostate or the vagina.
This plane entry anterior to the sacral promontory allows total mesorectal
excision through the holy plane, which avascular usually.
This dissection is also done usually using the electric cautery; in this
portion of the case, it is helpful if the surgeon uses a headlight for better
exposure, but most surgeons find the use of lighted pelvic retractors
helpful and sufficient.
The use of bipolar electric energy in this portion of the case is helpful as
well to minimize bleeding, especially in reoperative or radiated pelvis.
The posterior dissection is usually done and, at this point and the other
team, is usually called in whether its orthopedic surgery assisting in the
sacrectomy or urology or gynecology oncology to allow for simultaneous
resection.
If the lateral pelvic wall is involved, then the dissection is also done en
bloc with the posterior or anterior segment including the rectum; in some
cases, ligation of the internal iliac artery might be needed due to tumor
invasion.
The dissection in either case is usually taken down to the level of the
levator ani from a colorectal standpoint.
At this time, we usually allow enough time for the other team to finalize
their dissection before attending to the perineal portion of the case.
Perineal Portion
In male patients, the dissection is started 4 cm anterior to the anal verge
and extends posteriorly to the coccyx.
In female patients, usually while doing an abdominoperineal resection, the
dissection is started anteriorly just behind the vagina, but in this case, it
depends on the amount of dissection involved and whether a
hysterectomy, vaginectomy, or even a cystectomy is involved.
The dissection is usually lined from midway between the tip of the coccyx
posteriorly and the anal opening and laterally is marked 1-2 cm outside the
perianal skin, thus to the level of the anococcygeal ligament, and
anteriorly is the variable point, as discussed earlier.
Usually, there are branches of the hemorrhoidal artery in the fatty plane
before starting the muscular dissection.
The muscular dissection is done toward the pelvis from below using the
electrocautery.
Once the pelvic cavity is reached from the bottom, using the index finger
of the surgeon, the plane exposing the puborectalis muscle can be easily
retracted to allow easier and more convenient peripheral dissection.
Closure (See Chapter 50)

At this point, we also allow for reconstruction, if needed, for the urologic
portion of the procedure.
Approximation of the pelvic fascia is preferable, when feasible, using a
running 2-0 absorbable suture.
A Jackson-Pratt pelvic drain is placed above the approximated pelvic
fascia to allow drainage of the accumulating fluid due to the large surface
area of dissection of soft tissue.
The site of the marked colostomy is usually matured, as described
thoroughly in other chapters, and the abdomen is closed using four to one
technique with single-strand absorbable suture size 1, the skin is stapled
using a skin stapler.
The perineum is usually closed using absorbable suture.
0 polystrand absorbable suture is used in an interrupted manner.
The perineal skin is closed with interrupted absorbable 2-0 Nylon in a
vertical mattress technique.
Simultaneously, the colostomy is matured using interrupted 3-0 polystrand
absorbable suture; some surgeons prefer to use a Brooke stitch at four
corners of the colostomy, otherwise use the flush technique.
The use of flaps for reconstruction is preferred when there is a large bulky
defect preventing primary closure.
A Penrose drain is left usually below the skin closure.
PEARLS AND PITFALLS
From a colorectal surgery standpoint, the main source of complications

in such procedures are usually due to the perineal wound.
Some surgeons prefer to use tissue flaps to cover the pelvic defect for
closure as, most of the times, those wounds are associated with high risk
of wound breakdown and dehiscence.
Perineal hernias are also noted as a long-term complication.
Systemic complications and venous thrombosis are also seen and also
other complications that that are similar to other abdominal operations.
Palliative Approach to Obstructing Disease

In cases of obstructing disease, the overall picture of the patient and the
disease dictates the therapeutic or palliative option that a surgeon must
proceed with.
In obstructing lesions presenting in patients who are operative candidates
even with metastatic disease, an anatomic resection would be helpful with
either an end ileostomy or colostomy based on the location of the tumor
(right side versus left side).
In obstructing rectal cancer patients who are operative candidates, a
diverting sigmoid loop colostomy should be offered if they are stable.
If they can’t tolerate, we offer a transverse loop colostomy/blow hole to
avoid the situation of closed-loop large bowel obstruction and perforation.
In patients presenting with obstructing colon cancer and are not operative
candidates, we can offer endoscopic stenting, if feasible, but, most of the
times, we end up offering hospice care for such patients who will not
tolerate surgery.
Finally, in patients presenting with obstructing rectal cancer and are not
operative candidates, we offer endoscopic stenting in very few cases, but
mostly, we are ought to offer hospice care.
LAPAROSCOPIC SIGMOID COLOSTOMY
Technique

Basic laparoscopy tray
Knife handle
Mayo scissors: straight and curved
Metzenbaum scissors: short and long
Adson forceps ×2
Short and long forceps with teeth
Forceps (Russian, DeBakey medium)
Straight and curved hemostat
Kelly clamp
Ochsner clamp
Right-angle clamp (Moynihan)
Tonsil clamp
Allis clamp
Babcock clamp
Needle holders
Monopolar energy source
Richardson retractor (medium and large)
Kelly retractor
Deaver retractor (narrow, medium, wide)
Laparoscopic bowel grasper ×3
10- and 5-mm 30-degree camera
Laparoscopic Maryland dissector
Bipolar energy source
12-mm camera port, one 5-mm port
Surgical Technique
In case of obstructing rectal cancer, the best way to bridge patients to
chemoradiation is through a diverting loop sigmoid colostomy.
If the patient is not presenting with typical distension or complete
obstruction, laparoscopic approach might be feasible.
Laparoscopic sigmoid colostomy
The patient is placed in modified lithotomy.
This operation is usually done using two ports, an umbilical camera
port and another port at the marked colostomy site.
We prefer the cut-down technique for entry and placement of the
umbilical camera port.
Another 5-mm port is placed in the colostomy site.
Using a soft bowel grasper, the small bowel is retracted off the field.
This is usually eased by placing the patient in Trendelenburg
position and placing the left side of the table up.
The redundant portion of the sigmoid colon is identified and grasped
using laparoscopic Babcock clamp.
The colostomy site is opened in a circular manner, and the colostomy is
pulled through it usually using a long Babcock clamp.
A transverse colotomy is established, and the colostomy is matured
using 3-0 polystrand suture.
PEARLS AND PITFALLS
The most important step in this operation is to pay attention to the tissue
handling inside the abdomen to avoid an enterotomy or any injury to
other organs that can delay the start of systemic treatment.
When the patient is completely obstructed, the chance of causing an
enterotomy on entry is very high and thus an open approach is
preferred.
BLOW HOLE/TRAVERSE COLOSTOMY
Technique
This is usually done in descending colon obstruction or rectal obstruction
in a sick patient who will not tolerate prolonged surgical intervention.

Basic GI tray
Knife handle
Adson forceps
Ochsner clamp
Allis clamp
Kelly clamp
Moynihan clamp
Babcock clamp
Kocher clamp
Tonsil tip
Dennis clamp
Suction tip
Metzenbaum scissors
Mayo scissors
Needle holder
Monopolar cautery
Surgical Technique
A flat plate x-ray is performed with a marker taped to the abdomen to
identify the dilated transverse colon in the operating room.
The fascia is opened, and the dilated transverse colon will balloon up into
the opening.
Sometimes, this can be challenging due to thick omental fat, but in most
cases, it’s not due to the distended colon.
The omentum is usually divided, and the anterior tinea of the colon is
identified.
The transverse colon is decompressed and the bowel wall is incised.
The wall of the bowel is sewn to the fascia with 3-0 running absorbable
suture (Figs. 42-11 and 42-12).
FIGURE 42-11 Loop blowhole colostomy is usually located in the epigastric region
and is used to decompress the colon in cases of distal obstruction in patients who are not
surgical candidates for R0 resection.
FIGURE 42-12 Maturing a blowhole diverting loop colostomy, longitudinal incision on
the tinea, and four cardinal sutures to help with maturing the stoma.
PEARLS AND PITFALLS
Blowhole colostomy is at high risk for stoma prolapse, but the

procedure is usually fast and not associated with complications.
ENDOSCOPIC STENTING
Technique
Equipment
Colonoscope
10-12Fr, 40-cm introducer sheath
A high-torque angiographic catheter or guiding catheter
Extra-stiff wire to be used in cases with torturous colon
Self-expanding noncovered metal stents
Surgical technique
It is best to use fluoroscopy and endoscopy at the same time, especially
in cases with torturous colon and long-segment stricture or tumor.
This can be done under moderate sedation, and no need for general
anesthesia.
Position can be supine or lateral decubitus.
Insert the introduce sheath to the level of the tumor, and a water-soluble
enema should be performed to confirm both position and length of
stricture area.
Insert the guidewire to the proximal level of the tumor, and this should
bypass the stricture area; if this step is technically challenging, the use
of the colonoscope is helpful to guide the wire through, otherwise this
can be done using fluoroscopy.
Once the length of the stricture and the tumor is assessed, the
appropriate stent and delivery system can be picked.
The stent when deployed should cover the area of the stricture and
should extend both proximal and distal to the strictured area.
After stent deployment, another water-soluble enema should be done to
evaluate patency and rule out perforation.
We usually refrain from any additional balloon dilation to minimize the
risk of perforation.
PEARLS AND PITFALLS

Care should be taken to not place low rectal stents that can cause severe
pain.
Stents are a bridge to definite surgery and can be used for palliation in
short term only due to complications of erosion and migration.
Postoperative Care
care plan, where applicable, depending on the patient’s status.
minimized, diet is given day 0 unless there is a large amount of distension,
and urinary catheters are removed day 1.
acetaminophen.
Suggested Readings
Karagkounis G, Stocchi L, Lavery IC, et al. Multidisciplinary conference and clinical management of
rectal cancer. J Am Coll Surg. 2018;226(5):874-880.
Steele SR, Chang GJ, Hendren S, et al.; Clinical Practice Guidelines Committee of the American
Society of Colon and Rectal Surgeons. Practice guideline for the surveillance of patients after
curative treatment of colon and rectal cancer. Dis Colon Rectum. 2015;58(8):713-725.
Vogel JD, Eskicioglu C, Weiser MR, Feingold DL, Steele SR. The American Society of Colon and
Rectal Surgeons clinical practice guidelines for the treatment of colon cancer. Dis Colon
Rectum. 2017;60(10):999-1017.
Chapter 43
Construction of Intestinal Stomas
HERMANN KESSLER
MARIANE G. M. CAMARGO
ERIC WEISS
Mark the patient’s abdominal wall for a proper stoma site, ideally by a
trained enterostomal therapy nurse, after positioning the patient in supine,
sitting, and standing postures (Fig. 43-1).
FIGURE 43-1 A and B. Stoma site tattoo with Indian ink.
The appropriate location of a stoma on the abdominal wall may be the

most important factor in allowing optimal function of the stoma (Fig. 43-
2).
FIGURE 43-2 The optimal stoma site is located over the rectus sheath, on the flat
surface of the infraumbilical fat mound, away from irregular surfaces such as scars,
incisions, umbilicus, and bony prominences.
Education, teaching, and familiarization of a new stoma by an

enterostomal therapy nurse will help patients accept and manage their
stomas better.

Laparoscopic or open approaches may be used to create stomas, although
the laparoscopic approach is favored, if feasible.
For laparoscopic stoma creation, the following equipment is needed or
should be readily available:
Video instrumentation:
Video camera unit
5- or 10-mm 30-degree laparoscope
A light source
Monitoring and recording devices
A gas insufflator
A suction and irrigation device (have available)
A laparoscopic 5-mm dissecting device
Electrocautery
Kocher clamp
Three Allis clamps
12-mm Hasson or balloon trocar
Two to three 5-mm trocars
Laparoscopic 5- or 10-mm Babcock clamps
5-mm bowel grasper
Plastic rod or red rubber catheter for loop ostomies
3-0 absorbable braided sutures
Available instruments (as needed):
10-mm trocar
Laparoscopic stapler
Laparoscopic biopsy forceps
For open surgery, a standard set for colorectal surgery that has all the
needed instruments for the stoma construction
LAPAROSCOPIC
Technique
Ileostomy
Patient is placed in modified lithotomy position (Fig. 43-3). Surgery is
begun in Trendelenburg position (head-down tilt), and after cannula
insertion, the patient is tilted left side down, which will allow the small
intestine to fall into the left upper quadrant for creation of the ileostomy.
FIGURE 43-3 Position of the equipment and the personnel for ileostomy.
For jejunostomy, patient is placed right side down.

The surgeon initially stands on the side where the stoma will be created,
with the first assistant positioned on the other side.
Technique
The peritoneal access is achieved through the preoperatively chosen
ostomy site, nearly always planned within the rectus sheath. For loop
ileostomy formation, the right lower quadrant site (below the level of the
umbilicus) is generally preferred, but may vary based on the preoperative
marking.
Cannulas are positioned at the proposed stoma site (12-mm
Hasson/balloon trocar) and on the side opposite to the stoma in the mid-
abdomen, lateral to the rectus sheath (5-mm trocar) (Fig. 43-4).
FIGURE 43-4 Positions of the cannulas for laparoscopic ileostomy formation. Use of
optional cannulas (*) with a low threshold if this makes the procedure easier, especially
when adhesions are present.
A disk of skin is excised with a size of 3-4 cm, depending on the intended
diameter for the stoma creation site and the size of the patient and the
thickness of the bowel loop that will traverse the stoma aperture (Fig. 43-
5A and B).
FIGURE 43-5 A and B. Ostomy skin aperture. A circular skin incision is made with a
diameter of ∼3-4 cm.
The subcutaneous tissue is divided vertically onto the abdominal fascia,

right-angle retractors are used (Fig. 43-6).
FIGURE 43-6 The subcutaneous tissue is generally divided down to the anterior
fascia of the rectus muscle, does not need to be removed.
The anterior leaf of the rectus sheath is divided vertically using

electrocautery, and the rectus muscle is spread open along the muscle
fibers, exposing the posterior rectus sheath (Fig. 43-7A and B).
FIGURE 43-7 A and B. Abdominal wall aperture for ileostomy. A. The anterior fascia
is divided in a cephalad to caudal direction, exposing the underlying rectus muscle. B. The
rectus muscle fibers are separated using the retractors or alternatively a blunt clamp,
avoiding injuries of the epigastric vessels.
The peritoneum is entered using an open technique by dividing the

posterior rectus sheath and peritoneum between the two Allis clamps by
scissors or electrocautery, large enough to accommodate insertion of two
fingers.
Three Allis clamps are then used to grasp the edges of the posterior rectus
sheath equidistant from each other.
A 12-mm Hasson balloon trocar is inserted, and the balloon is inflated to
aid in creation of the pneumoperitoneum (Fig. 43-8).
FIGURE 43-8 A 12-mm balloon cannula is inserted.
The patient is then tilted left side up.

An additional 5-mm cannula is inserted on the contralateral side in the left
mid-abdomen under laparoscopic vision (Fig. 43-9).
FIGURE 43-9 An additional 5-mm cannula is inserted on the contralateral side in the
left mid-abdomen.
The camera is inserted through the left mid-abdomen 5-mm cannula, and
the right side is tilted up again.
A segment of ileum ∼10-20 cm proximal to the ileocecal valve is
identified and gently grasped using a laparoscopic Babcock grasper (Fig.
43-10A and B). Identification of the terminal ileum is facilitated by
retracting the small intestines cephalad according to gravity in
Trendelenburg position.
FIGURE 43-10 A and B. The ileum is grasped with a Babcock clamp through the
cannula at the ileostomy site.
If adhesiolysis is required, one or two additional 5-mm cannulas should be

placed in the left side of the abdomen approximately four fingerbreadths
or closer above and below the left mid-abdomen cannula.
The suitable segment of ileum in the intended orientation is gently grasped
using a Babcock clamp and brought up toward the abdominal wall (Fig.
43-11A).
FIGURE 43-11 A and B. A loop of terminal ileum is brought through the abdominal
wall aperture.
Pneumoperitoneum is released by deflating the balloon, and the bowel is
exteriorized through the ostomy site keeping its orientation.
A stoma rod or red rubber catheter may be placed under the loop by
creating a small opening in the mesentery (Fig. 43-11B).
Reinsufflation and confirmation of the proper orientation of the stoma is
performed following the efferent limb distally to the cecum.
The remaining trocars are removed, and the incisions closed and dressed.
The ileum is then opened on top of the efferent loop by a transverse
incision using electrocautery or scissors (Fig. 43-12).
FIGURE 43-12 Loop ileostomy. After opening the distal aspect of the intestinal loop
from one mesentery margin to the other, sutures used to mature the active half of the
ileostomy occupy two-thirds of the skin aperture circumference, while sutures used to
mature the inactive half occupy only one-third of the circumference.
The mucosa is everted, and the ileostomy is “Brooked” and matured using
3.0 absorbable suture (Fig. 43-13).
FIGURE 43-13 Matured loop ileostomy. The efferent limb opening is small and flush
with the skin, while the everted afferent limb occupies most of the aperture and protrudes
above the skin.
PEARLS AND PITFALLS
Alternatively, if no balloon trocar is available, three full-thickness bites

of the posterior fascia are taken just underneath each Allis clamp,
forming a purse-string suture. The two ends of the purse-string suture
are then drawn through a precut 2-in-length 18-Fr red rubber catheter
using a Rummel tourniquet. A 12-mm cannula is inserted, and the
purse-string suture is tightened around the cannula and secured using a
hemostat clamp. A 12-mm cannula is best suited in terms of preventing
leakage of pneumoperitoneum and also allows any instrument to be
inserted through it (Fig. 43-14).
FIGURE 43-14 Insertion of the cannula at the stoma site. A. Three Allis clamps
are used to grasp the posterior sheath in performing the initial cannula insertion using
an “open” technique at the stoma site. B. Three “bites” of the posterior sheath are taken
in preparation for making a “stay” suture for placement of an occluding Rummel
tourniquet at the stoma site. C. Placement of the Rummel tourniquet permits minimal
leakage after cannula placement.
In more complex cases such as in Crohn disease, a thorough exploration

of the small intestines, in addition to stoma formation, is recommended.
In this situation, more cannulas may be required to adequately inspect
the entire length of the small intestines.
Right Transverse Colostomy

begun in slight reverse Trendelenburg position (head-up tilt), and after
cannula insertion, the patient is tilted left side down, which will allow the
small intestine to fall into the left half of the abdomen.
FIGURE 43-15 Position of the equipment and the personnel for right transverse
colostomy.
For left transverse colostomy, patient is placed right side down.

with the first assistant positioned on the opposite side.
Cannulas
Cannulas are positioned at the proposed stoma site (12-mm Hasson
balloon trocar) and on the side opposite to the stoma in the mid-abdomen,
lateral to the rectus sheath (5-mm trocar) (Fig. 43-16).
FIGURE 43-16 Positions of the cannulas for right transverse colostomy formation.
Technique
The procedure is begun at the proposed colostomy site. For right
transverse colostomy formation, the right upper quadrant site (above the
level of the umbilicus) is generally preferred.
The peritoneal access is the same as described in the previous section for
ileostomy.
Cannulas are inserted using an open technique. Once the camera is
inserted and the diagnostic laparoscopy is completed, the second cannula
is placed, and the laparoscope is passed into this cannula.
The right transverse colon is identified and gently grasped using a
laparoscopic Babcock grasper. Identification of the appropriate segment of
the right transverse colon is facilitated by retracting the small intestines
caudally according to gravity in reverse Trendelenburg position and by
moving the greater omentum superiorly.
If adhesiolysis is required, two additional 5-mm cannulas should be placed
in the left side of the abdomen.
Often, the omentum needs to be taken off the bowel segment for better
reach.
The transverse colon should be brought through the abdominal wall as was
previously described for ileostomy, taking care to maintain proper
orientation of the intestine.
Reinsufflation and confirmation of the proper orientation of the stoma is
performed following the afferent and efferent limbs proximally and
distally, respectively.
The steps to complete the procedure are the same as those used for
ileostomy. Most often, the afferent limb of the stoma will lie to the right,
with the efferent limb to the left (Fig. 43-17).
FIGURE 43-17 Loop transverse colostomy.
A plastic stoma rod is then passed beneath the loop.

The colon is then opened along the antimesenteric tenia using
electrocautery. The mucosa is everted, and the colostomy is matured
toward the skin of the abdomen. Often, equal maturation of both limbs is
performed with colostomies.
Sigmoid Colostomy
begun in Trendelenburg position (head-down tilt), and after cannula
insertion, the patient is tilted right side down, which will allow the small
intestine to fall into the right half of the abdomen.
FIGURE 43-18 Position of the equipment and the personnel for sigmoid colostomy.
with the first assistant positioned on the opposite side.
Cannulas
Cannulas are positioned at the proposed stoma site (12-mm Hasson
balloon trocar) and on the side opposite to the stoma in the mid-abdomen,
lateral to the rectus sheath (5-mm trocar) (Fig. 43-19).
FIGURE 43-19 Positions of the cannulas for sigmoid colostomy formation. Use of
optional cannulas with a low threshold if this makes the procedure easier, especially when
lateral adhesions are present.
Technique
The procedure is begun at the proposed colostomy site. For sigmoid
colostomy formation, the left lower quadrant site is generally preferred,
but may vary based on the preoperative marking.
The peritoneal access is the same as described in the previous section for
ileostomy and loop transverse colostomy.
Cannulas are inserted using an open technique. Once the camera is
inserted and the diagnostic laparoscopy is completed, the second cannula
is placed, and the laparoscope is passed into this cannula.
A laparoscopic Babcock grasper is passed through the left cannula to
grasp the sigmoid colon as distally as possible, usually retrieving the
downstream portion of the sigmoid colon from the pelvis. This portion of
the colon usually easily reaches the abdominal wall, but it may be
necessary to mobilize the colon by dividing the lateral attachments along
the white line of Toldt (two additional 5-mm cannulas should be placed in
the right side of the abdomen—Fig. 43-20A-D).
The mobilized sigmoid colon should reach the anterior abdominal wall
to the sight of the proposed stoma.
FIGURE 43-20 A-D. The sigmoid colon is mobilized by dividing the lateral
attachments along the white line of Toldt.
Once the suitable segment of the sigmoid colon is identified and firmly
grasped, the pneumoperitoneum is released, and under removal of the 12-
mm trocar whose balloon has been deflated, it is exteriorized through the
ostomy site keeping its orientation.
A plastic stoma rod is then passed beneath the loop (Fig. 43-21).
FIGURE 43-21 A plastic rod is passed beneath the loop colostomy.
The colon is then opened along the antimesenteric tenia using
electrocautery. The mucosa is everted, and the colostomy is matured
toward the skin of the abdomen (Fig. 43-22A and B).
FIGURE 43-22 A and B. Loop sigmoid colostomy.
Special Consideration—End Sigmoid Colostomy

An end sigmoid colostomy can be performed by dividing the loop with a
linear stapler at the skin level.
The proximal end is brought up after mesenteric division. If the colon
length is too short, then the bowel and its mesentery should be divided
intracorporeally (Fig. 43-23), which will require placing an additional 5-
mm cannula in the right middle abdomen and a 12-mm cannula in the
right lower quadrant.
FIGURE 43-23 Transection of the sigmoid colon intraperitoneally with an endoscopic
stapler.
If the stoma is being created after a rectosigmoid resection, special care

must be taken:
Presence of adhesions may require three or four cannulas for the
procedure.
The inferior mesenteric artery or the left colic area has a “high”
probability to have been sacrificed; therefore, the marginal vessel may
be the only blood supply to the intestine all way to the pelvis.
Open Technique
Ileostomy
End
Incision: midline laparotomy
Select the target small bowel segment, ensuring full mobilization of the
mesentery and lysis of all adhesions to allow tension-free reach beyond
the abdominal wall.
With blunt forceps dissection, create an opening through the mesentery,
place a gastrointestinal anastomosis stapler through this aperture, and fire
the stapler.
Division of mesenteric vessels may be necessary to obtain adequate reach.
Identification of mesenteric vessels can be assisted by transillumination of
the mesentery with a light source, providing guidance on which vessels to
preserve or sacrifice to sustain stomal perfusion.
A cylindrical stoma trephine is created at the previously marked stoma
site, just as described in a previous section.
Passage of one or two fingers through the completed trephine gently
dilates and confirms trephine size (Fig. 43-24). If necessary, the trephine
diameter can be further enlarged by making a radial skin incision at the
skin level or extending either anterior or posterior rectus sheath incisions.
FIGURE 43-24 Two fingers are passed through the completed stoma trephine to
ensure adequate sizing.
The selected bowel segment is carefully delivered through the properly

sized trephine with assistance of a Babcock clamp. To avoid stoma
retraction, 5-6 cm of small bowel and corresponding mesentery should be
completely pulled through and be left above the level of the skin (Fig. 43-
25).
FIGURE 43-25 An adequately mobilized, tension-free, length of small bowel is

eviscerated through the stoma trephine.
The stoma should be assessed for tension, viability, and mesenteric

bleeding.
Once all remaining abdominal wounds are closed and protected from
topical contamination, use electrocautery to excise the stapled end of
bowel.
The end ileostomy is matured to ideally protrude 2-3 cm, and multiple
sero-subcutaneous inverted interrupted absorbable sutures are used to
suture the everted bowel wall to the skin in a “Brooke” manner (Figs. 43-
26 and 43-27).
FIGURE 43-26 Primary stoma maturation. Absorbable sutures pass through the full
thickness of the bowel wall, but only through the skin dermis. Full-thickness skin sutures
may lead to needle tracts lined with mucus secreting small intestinal mucosa. These
secretions may prevent secure adherence between an appliance and the peristomal skin.
FIGURE 43-27 Primarily matured stoma. Ideally, the stoma protrudes 2-3 cm above
the skin to prevent contact of the corrosive stoma effluent with the skin.
Occasionally, thick or fatty mesentery may require careful debulking,

while maintaining blood supply to allow complete bowel wall eversion.
PEARLS AND PITFALLS
Adequate blood supply to the enterostomy is essential; supply is aided

by maintaining a tension-free placement and ensuring that the
mesentery is free of tension.
Mobilization at the base of the mesentery is critical to ensure
preservation of the collaterals.
Division of the mesentery, close to the bowel, may result in better
length but worse ischemia and result in a devascularized stoma.
The Brooke ileostomy should be of sufficient length from the
abdominal wall so that enteric succus will fall easily into the ostomy
bag with minimal skin contact.
“Brooke” sutures also incorporate a seromuscular purchase of the bowel
at the skin level that fixes the everted structure at the skin. Sutures
should carefully be placed through the dermis, but not the epidermis, to
avoid mucosal cellular implants that have been reported to migrate
along suture lines and colonize the epidermis with ectopic mucosal
islands. Such dermal mucosal islands are thought to secrete mucus on
the peristomal skin and interfere with stoma appliance adhesion.
Loop
Incision: midline laparotomy
Select the target small bowel segment, ensuring full mobilization of the
mesentery and lysis of all adhesions to allow tension-free reach beyond
the abdominal wall.
A fine-tipped clamp is passed to create a small defect at the bowel wall–
mesentery interface, and a thin Penrose drain or umbilical tape is passed
underneath the bowel.
A 3-4-cm-diameter stoma trephine is made at a previously marked site
using the previously described technique.
The Penrose drain is then used to safely pull the loop of bowel through the
stoma trephine while minimizing trauma to the bowel (Fig. 43-28).
It is important to ensure that there is no twisting of the mesentery, so it
may be useful to identify the afferent and efferent limbs of intestine
with sutures in different colors or a marking pen.
FIGURE 43-28 A narrow Penrose drain is passed through a mesenteric defect

and used to gently pull the target loop through the stoma trephine.
The Penrose drain may be exchanged for a plastic stoma rod.

Following closure and protection of all abdominal wounds, a transverse
incision is made on top of the efferent limb of the bowel wall. The
mesenteric portion of the bowel wall is left intact and is not divided (Fig.
43-12).
Absorbable sutures are used to secure the defunctioned segment to the
dermis. The remaining “hood” of bowel is then everted with the blunt
back end of an Adson clamp or small right-angle retractors and sutured to
the dermis (Fig. 43-13).
PEARLS AND PITFALLS

As with end small bowel stomas, the proximal bowel limb should
protrude 2-3 cm from the skin when finished, allowing a watertight fit
between the stoma appliance and the peristomal skin, whereby
decreasing postoperative stoma-related skin complications.
The stoma rod is typically removed after 1-3 days once adhesions have
formed, assuming there is no tension between the rod and skin.
Although loop stomas are often considered temporary, they should be
constructed durably in the event that distal intestinal continuity cannot
be restored.
The use of intra-abdominal antiadhesives may be considered to decrease
adhesions and, possibly, ease subsequent reversal at temporary ostomy
sites.
Colostomy
End
Incision: limited midline incision, depending on marked stoma location
Technique is similar as the one already described for small bowel stomas,
but unlike the relatively mobile small bowel mesentery, the colonic
conduit and mesentery may require substantial mobilization depending on
the level of diversion.
An end sigmoid colostomy may not require significant mobilization due to
the redundant nature of the sigmoid loop; however, a proximal end
descending colostomy may require full mobilization of the splenic flexure
with high vascular ligation to obtain sufficient reach.
Once the segment of colonic conduit is chosen and prepared, a 3-4-cm-
diameter stoma muscle–splitting trephine is fashioned at the site of
previous marking using the previously described techniques.
The colon is passed through the stoma trephine with a Babcock clamp and
eviscerated.
The surgeon confirms a pink, well-perfused stoma rests comfortably for 3-
4 cm above the skin level without tension or retraction.
Following closure and protection of abdominal wounds, the colostomy is
opened everted and sutured to the skin to produce a colostomy that is
ideally protruding 1-2 cm. Typically, the solid nature of colostomy
effluent is not toxic to surrounding skin, and a lengthy stoma eversion is
not necessary (Fig. 43-29A and B).
FIGURE 43-29 End colostomy. A. Sutures are placed in four quadrants and held with
hemostats. B. Tension is placed on the quadrant sutures using hemostats. The blunt end
of a forceps is used to evert the bowel wall.
PEARLS AND PITFALLS
An end colostomy may require a larger trephine depending on the

bowel caliber and mesentery thickness.
Epiploic appendices may be excised to ease colon passage through the
abdominal wall trephine.
Once matured, the colostomy should be evaluated to confirm adequate
perfusion with a pink-glistening mucosa.
The colonic conduit should be treated like an anastomosis by
eliminating tension with adequate colonic mobilization and assuring
adequate perfusion.
Confirming pulsatile blood flow from the marginal artery during
colonic division helps to assess adequate perfusion of the colostomy.
Similar to above, avoid dividing the mesentery adjacent to the bowel
and focus on proper mobilization to gain length to avoid ischemia.
Loop
Incision: same as for end colostomy, but potentially larger
A loop colostomy is typically fashioned from the nonperitonealized
sigmoid or transverse colon, although any segment of colon can be used
with adequate mobilization.
After identifying the target segment of colon, an assessment of reach and
mobilization is performed, ensuring the colon loop reaches several
centimeters above the previously marked stoma site without tension.
Use forceps to bluntly dissect the opening through the mesentery at the
loop apex.
After creating an ∼3-4-cm-diameter trephine using aforementioned
techniques, the colon loop is gently pulled through the trephine.
Place a plastic rod through the aperture in the mesentery, position the rod
transverse to the incision, and thereby prevent retraction of the colon loop
back into the abdomen (Fig. 43-30).
FIGURE 43-30 Plastic rod beneath the loop colostomy.
Following closure and protection of abdominal incisions, the loop

colostomy is matured by incising the colon along the tenia of the bowel
and maturing the cut edge of bowel to the skin circumferentially (Fig. 43-
31A and B).
FIGURE 43-31 A and B. Maturing loop colostomy.
PEARLS AND PITFALLS
The matured loop colostomy may be quite large depending on the

bowel caliber, mesenteric thickness, and postoperative edema.
As with loop small bowel stomas, loop colostomies may be temporary
or permanent and should always be constructed durably if stoma
reversal is inadvisable.
As with loop small bowel stomas, use of intra-abdominal antiadhesive
products may be considered with temporary loop colostomies to
potentially ease future reversal.
Suggested Readings
Beck DE. Stomas and wound management. Clin Colon Rectal Surg. 2008;21(1):3-4.
Erwin-Toth P. Ostomy pearls: a concise guide to stoma siting, pouching systems, patient education and
more. Adv Skin Wound Care. 2003;16(3):146-152.
Erwin-Toth P. Prevention and management of peristomal skin complications. Adv Skin Wound Care.
2000;13(4 Pt 1):175-179.
Erwin-Toth P, Barrett P. Stoma site marking: a primer. Ostomy Wound Manage. 1997;43(4):18-22, 24-
25.
Fleshman JW, Beck DE, Hyman N, et al. A prospective, multicenter, randomized, controlled study of
non-cross-linked porcine acellular dermal matrix fascial sublay for parastomal reinforcement in
patients undergoing surgery for permanent abdominal wall ostomies. Dis Colon Rectum.
2014;57(5):623-631.
Hocevar BJ. WOC nurse consult: nonhealing peristomal ulcer. J Wound Ostomy Continence Nurs.
2009;36(6):649-650.
Hocevar BJ. WOC consult: peristomal bulge. J Wound Ostomy Continence Nurs. 2011;38(4):428-430.
Martin ST, Vogel JD. Intestinal stomas: indications, management, and complications. Adv Surg.
2012;46:19-49.
Chapter 44
The Difficult Stoma
HERMANN KESSLER
MARIANE G. M. CAMARGO
Risk Factors for the Difficult Stoma
Preoperative Variables
Preexisting conditions at surgery that cannot be influenced and associated
with difficult ostomy placement are as follows:
High body mass index
Old age
Emergency surgery
Inflammatory bowel disease (IBD)
Previous abdominal scars or incisions
Abdominal wall hernias
Skin problems
Operative Variables Encountered during Surgery

Variables encountered during surgery that affect the available length of bowel
and reach of mesentery to allow for a tension-free stoma creation and
sufficient blood supply or perfusion:
Obesity
Large pannus
Foreshortened or thickened mesentery secondary to inflammation
Mesenteric fibrosis
Short bowel syndrome
IBD
Special factors aggravating exteriorization of the ostomy are as follows:
Peritoneal adhesions from previous extensive abdominal surgery
Carcinomatosis
Desmoid tumors
Ostomy Siting
Always mark the patient preoperatively, even in the holding area or
emergency room (see Fig. 44-1).
FIGURE 44-1 The “stoma triangle”: Umbilicus, anterosuperior iliac spine, and pubic
symphysis.
Rely on the help of enterostomal therapist.
When talking to the patient, recognize the impact on their quality of life,
answer questions, and provide education about stoma care and alleviate
fears.
Ideal preoperative siting:
5 cm of flat skin: keeps flat even with position change. This will
prevent leakage and pouching problems.
Marking should begin with identification of the “ostomy triangle”
bounded by the anterior superior iliac spine, the pubic tubercle, and the
umbilicus (Fig. 44-1). The stoma is placed at the center of this triangle
on either side, through the rectus muscle.
Traditionally, an ileostomy is placed on the right side and a colostomy
on the left. However, if “conventional” placement leads to stoma
tension, the surgeon may need to choose an alternate site.
Siting method:
Start supine.
Raise head or cough help to identify rectus muscle.
Identify creases: sit, bend over, or stand.
Identify belt line and where pants lay.
Confirm that the patient has the ability to see and touch the stoma.
Special circumstances:
Disabled: mark in position they spend majority of time.
Brace: mark with brace on.
Radiation: avoid prior or future radiation fields.
Two stomas: site at different levels (ileal conduit higher than
colostomy).
Burns: may not be able to wear belt/protective garment
Patient Positioning
Patient is generally in modified lithotomy position.
Endoscopic access to bowel should be available.
Intraoperatively, a decision may be necessary to use a different bowel
segment for ostomy creation.
Often, the open approach is indicated (previous abdominal surgeries,
adhesions, friable tissue, comorbidity, insufficient overview expected).
Equipment and Supplies

Laparoscopy:
Video instrumentation: video camera unit, 5-mm 30-degree
laparoscope, a light source, monitoring and recording devices
A gas insufflator
A suction and irrigation device
A laparoscopic 5-mm dissecting device
Adequate sterilizing and disinfecting devices
Electrocautery
Kocher clamp
12-mm Hasson balloon trocar
Three 5-mm trocars
Laparoscopic 5-mm Babcock clamp
5-mm bowel grasper
Plastic rod for loop ostomies
3-0 absorbable braided sutures
Potential instruments: 10-mm trocar, laparoscopic staples, laparoscopic
biopsy forceps
Colonoscope should be present in operating room.
For open surgery, a consolidation set for colorectal surgery has all the
needed instruments for the stoma construction.
Abdominal Wall Defects

There may be no surgical solution for the best-eligible spot of stoma
creation.
A multidisciplinary team with a hernia specialist and/or plastic surgeon for
abdominal wall reconstruction may be helpful.
Obesity
Special challenges:
Copious subcutaneous tissue of thick abdominal wall: This makes it
difficult to pass stoma through.
Distance that bowel needs to traverse can increase if local area changes
position with ambulation.
Obese mesentery and large omentum contribute to difficult stoma
exteriorization.
Higher risk of postoperative complications
Higher risk of stoma-related complications (Fig. 44-2)
FIGURE 44-2 Obese patients with retracted stoma.
Tips for Obese Patients

If an elective ostomy creation can be deferred in an obese patient, weight-
loss surgery to be considered.
Separate fat from fascia and then pass ostomy in two steps (open surgery).
Subcutaneous lipectomy
Ellipse of skin and subcutaneous tissue removal
Abdominal wall modification:
Modified abdominoplasty or abdominal wall contouring
Liposuction
Use an upper quadrant of the abdomen as a stoma site (Fig. 44-3A and B):
subcutaneous tissue is thinner and anchored to the costal margins,
reducing shifting and mobility of thick subcutaneous tissue with
ambulation; distance between vascular origins and the proposed stoma site
is usually shorter, providing better arterial supply.
FIGURE 44-3 A. Upper quadrant siting of the stoma in an obese patient; (B and C) it
is important to identify the line of sight, because patient cannot see below it, and identify
creases and folds.
Avoid placing the stoma in a large fold (Fig. 44-3C).
Shortened Mesentery
The shortened mesentery is often a result of fibrosis, adhesions, or
inflammation and can be further complicated by fragility of soft tissue and
bowel itself, often resulting in challenges with reach. Examples include:
Patients with central obesity
Patients with a history of desmoid tumors
IBD
Previous laparotomies
Previous peritonitis
Prior external beam radiotherapy
Previous history of bowel resection: intestinal ischemia, necrotizing
enterocolitis, omphalocele, or gastroschisis
ILEOSTOMY
Technique
Maximizing the mesenteric length:
Division of the terminal ileum as close to the cecum as possible.
Ligation of the ileocolic artery at its origin, vascular supply via
preserved collaterals of mesoileum (Fig. 44-4).
FIGURE 44-4 Ligation of the ileocolic artery at its origin.
Dissection of the base of the small bowel mesentery to the third portion
of the duodenum.
Creation of windows in the small bowel mesentery overlying the
superior mesenteric artery (first, inject the mesentery with saline to
lessen the chance of injuring the main feeding vessel) (Fig. 44-5).
FIGURE 44-5 Creation of windows in the small bowel mesentery overlying the
superior mesenteric artery.
Division of the immediate peristomal mesentery for 5 cm or less.

Rectus abdominis muscle-splitting incision (∼3 cm aperture).
Suture cut edge of the ileum to the dermis and not the epidermis, to
prevent mucosal implants (2.5-cm spout for easy pouching) (Fig. 44-6).
FIGURE 44-6 Intestinal mucosal implants along parastomal needle tracks—to be
avoided.
Creation of an end-loop ileostomy (when the intestinal segment providing

the best reach is located proximally to the proposed end ostomy site) (Fig.
44-7).
FIGURE 44-7 Creation of an end-loop ileostomy.
Creation of a loop-end ileostomy in discontinuity (Fig. 44-8) (when an

everted loop ostomy cannot be created when the proposed segment will
not reach the anterior abdominal wall without undue tension despite
freeing of the small intestine mesentery to the duodenum). The distal
corner end may be matured out the inferior aspect (Fig. 44-8A) or divided
and placed in or under the fascia (Fig. 44-8B).
FIGURE 44-8 A and B. Creation of a loop-end ileostomy. The afferent limb is brought
to the skin as an end ileostomy after dividing the mesentery at an appropriate distance.
Elongated division of the anterior rectus fascia, rectus muscle, and

posterior sheath to minimize the risk of vascular compression (Fig. 44-9).
FIGURE 44-9 An 8- to 10-cm incision is placed through the peritoneum and posterior
fascia.
An extra-small wound protector can be used as a delivery device,
facilitating passage.
A long, flexible mesenteric support rod, which can be attached to a
ureteric filiform catheter, may be used for mechanical support (severe
obesity, carcinomatosis, dense adhesions that prevent adequate
mobilization, or in cases of extensive bowel resection) (Fig. 44-10).
FIGURE 44-10 A. A long mesenteric support rod is inserted through the skin away
from the ostomy, (B) passing through the subcutaneous tissues as well as the mesentery
and again back to the skin.
COLOSTOMY
Technique
Techniques that can be used to gain the length of a colostomy focus on
release of all tethering structures and have to respect vascularization.
Potential steps are:
Takedown of lateral peritoneal attachments
Splenic flexure mobilization
Hepatic flexure mobilization
Release of omental attachments
Early ligation of inferior mesenteric artery and branches at various levels
when needed for descending colon length (previous clamping
encouraged); allows for evaluation of adequacy of blood flow from middle
colic artery
High ligation of inferior mesenteric vein
Creation of windows in the colon mesentery.
Additional maneuvers that can be used include:
Division of the peristomal mesentery for 2 cm or less; only feasible with
adequate submucosal collateral blood supply; depending on individual
vascular anatomy, marginal artery may be ligated and can provide
additional 2 cm of length
Supraumbilical placement for obese patients with large and thick
abdominal walls (easier to inspect compared to a lower abdominal
ostomy)
Creation of an end-loop colostomy
Panniculectomy to excise fatty tissue and reduce the substantially
thickened abdominal wall and its large amount of intervening adipose
tissue, may shorten the distance between peritoneum and skin
Use of an extra-small wound protector as a delivery device (Fig. 44-11)
and a long flexible mesenteric support rod (Fig. 44-12), as described for
ileostomy
FIGURE 44-11 Passage of the transected colon through a thick abdominal wall
facilitated by a wound protector.
FIGURE 44-12 A long, flexible mesenteric support rod passing through the
subcutaneous tissues as well as the mesentery and again back to the skin.
Postoperative Ostomy Complications and How to

Prevent Them
Postoperative ostomy complications:
Wide range reported 10%-82%
Most often occur early—within 30 days
Include poor siting, parastomal hernia, prolapse, retraction,
ischemia/necrosis, peristomal skin issues, and mucocutaneous
separation
Due to older age, poor nutritional status, higher American Society of
Anesthesiologists score, immobility, obesity, respiratory comorbid
conditions, diabetes, smoking, and malignancy
STOMAL COMPLICATIONS
Ischemia
Early postoperative ostomy ischemia and necrosis are very serious and
potentially life-threatening complications.
Its degree can be mild and transient (Fig. 44-13), from minor trauma
during ostomy construction to full-thickness necrosis (Fig. 44-14).
FIGURE 44-13 Ileostomy: Marginal ischemia.
FIGURE 44-14 Ileostomy: Deep ischemia.
Its causes range from inadequate arterial blood supply to venous

congestion.
Evaluate ostomy if dark or grayish:
Examining the ostomy mucosa with a glass test tube and light.
Gently scoring the mucosa with a needle, looking for adequate
perfusion.
Flexible endoscopy of stoma can help to determine the extent of
ischemia.
If a demarcated segment is superficial to the fascia, a delayed revision can
be performed. If the necrotic involvement extends below the fascia,
immediate revision is performed as this segment can retract and lead to
peritonitis and intra-abdominal sepsis.
A “Bishop collar” stricture may develop as a late complication of no or
delayed maturation of the ostomy (Figs. 44-15 and 44-16). Almost always,
an end ileostomy with mucosal ischemia results in a fibrotic ring of the
mucocutaneous junction, which may require revision later.
FIGURE 44-15 Ileostomy stricture: “Bishop collar.”

FIGURE 44-16 A. Ileostomy stricture: “Bishop collar.” B. Ileostomy stricture revision.
Stoma mobilization. C. Ileostomy stricture revision. Excising the constricting scar tissue.
Peristomal Hernia
Peristomal herniation occurs as bowel traverses a large ostomy aperture.
It is an incisional hernia and thought to occur more often with colostomies
than with ileostomies.
Factors contributing to its development: obesity, a large fascial aperture,
weakened abdominal wall from previous incisions, placement of an
ostomy outside the rectus muscle, malnourished patients,
immunosuppression, chronic cough (chronic obstructive pulmonary
disease; Figs. 44-17 and 44-18).
FIGURE 44-17 Paracolostomy hernia.
FIGURE 44-18 Paracolostomy hernia. Ectopic stoma site outside the rectus sheath.
In the acute postoperative period, the development of a hernia is obviously

a technical problem, the fascial trephine being made too large. This should
be repaired immediately, usually reopening of the midline incision for
adequate exposure for bowel reduction.
Patients who are asymptomatic or who cannot tolerate reoperation may be
best served with an abdominal binder.
Indications for surgery include:
Incarceration
Nonfitting appliance
Difficulty with irrigation
Skin excoriation
Chronic pain
Enlarging hernia
Cosmetic countenance in some cases
Technique
Treatment options include enterostomal therapy, possibility for early
reversal of the stoma, and, in cases not possible, revision of stoma.
The surgical management of parastomal hernia can be categorized into
three main approaches:
Primary local fascial repair (high recurrence rate) (Figs. 44-19 to 44-
21)
FIGURE 44-19 Incision options for primary repair. If primary repair is going to be
attempted, the skin incision should be made either just outside the mucocutaneous
border or outside the plate of the stoma appliance.
FIGURE 44-20 Primary repair. With the hernia sac resected and the fascial edges
cleared to healthy tissue, the fascial is closed primarily with simple interrupted or
figure-of-eight #1 Prolene or polydioxanone sutures.
FIGURE 44-21 Completed primary repair. The fascia is reapproximated so that
the tip of a Kelly clamp can be inserted between the stoma and the repair. This
prevents obstruction while making the repair tight enough to prevent recurrence.
Relocation of the stomas to the contralateral side with repair of the

hernia
Repair of the hernia with prosthetic mesh (Figs. 44-22 to 44-26)
FIGURE 44-22 Local repair of parastomal hernia with prosthetic mesh overlay.
FIGURE 44-23 Intra-abdominal parastomal hernia repair with underlay keyhole

technique.
FIGURE 44-24 Intra-abdominal parastomal hernia repair with underlay
Sugarbaker technique.
FIGURE 44-25 Intra-abdominal parastomal hernia repair with laparoscopic

“keyhole.”
FIGURE 44-26 Intra-abdominal parastomal hernia repair with laparoscopic
Sugarbaker techniques with “double-crown” tack technique.
The incision used for repair must consider the surrounding area normally
used for pouching. If possible, it should be left undisturbed.
Prevention techniques include:
Trans-rectus stoma
Small trephine
Prophylactic mesh
Tunneling (Figs. 44-27 and 44-28)
FIGURE 44-27 Retroperitoneal tunneling of an end ileostomy with suture pexy of
the peristomal mesentery.
FIGURE 44-28 Retroperitoneal end ileostomy. A. The tunnel is bluntly created
between the cut edge of the white line of Toldt and the anterior abdominal wall fascial
defect. B. The ileostomy is passed through the tunnel to the fascial defect. C. The
small bowel mesentery is secured to the cut edge of the peritoneum.
Pexy of the distal limb of loop stomas (Fig. 44-29)

FIGURE 44-29 Suture pexy of the distal limb of a loop colostomy.
Stoma Prolapse
Most often occurs with colostomies, and the first decision revolves around
the need for the ostomy. If continuity can be restored, it should be done. If
the ostomy cannot be closed, then local repair can be performed.
Stomal prolapse is often associated with a parastomal hernia (Figs. 44-30
and 44-31).
FIGURE 44-30 Prolapsed stoma.
FIGURE 44-31 Prolapsed stoma with necrosis.
Predisposing factors include:

Patient related:
Obesity
Increased intra-abdominal pressure
Spinal cord injury
Bowel redundancy
Emergency surgery
Surgeon related:
Improper placement
Oversized trephine
Excess bowel mobilization
Technique
Prevention:
Preoperative marking of an appropriate stoma site, ideally through the
rectus abdominis muscle.
Fixing the mesentery to the anterior abdominal wall to prevent prolapse
(Fig. 44-32).
FIGURE 44-32 Mesenteric fixation. The mesentery of an end stoma is secured to

the peritoneum, in addition to the fascia and subcutaneous fat.
Passing an end ileostomy through a retroperitoneal tunnel, created

between the cut edge of the white line of Toldt and the anterior
abdominal wall fascial defect (Fig. 44-28).
The size of the fascial defect should thus be minimized. Smaller defect
acts to impede the transmission of abdominal pressure around the
mucocutaneous suture.
As stoma prolapse is often associated with parastomal hernia, the
addition of mesh at the time of permanent stoma creation may reduce
both complications.
Laparoscopic stoma formation, mobilization of the bowel to be
exteriorized is facilitated, not requiring enlargement of the fascial
defect, as with the trephine method.
Nonoperative management:
Ostomy appliance adjustment
Add support belt or truss
Sugar for incarceration
For surgical treatment:
If parastomal hernia is present, hernia repair dictates the approach.
If there is no parastomal hernia, a local stomal revision is enough to
address the problem (Figs. 44-33 to 44-37).
Stoma is incised at the mucocutaneous junction and mobilized from
the subcutaneous tissue, after which an appropriate length of excess
bowel is resected. A stoma is then recreated in the usual manner,
taking care to fix the stoma to the fascia to prevent recurrent
prolapse.
FIGURE 44-33 A and B. Stomal prolapse with necrosis—local repair. A full-
thickness incision is done circumferentially.
FIGURE 44-34 Stomal prolapse with necrosis. Ligation of mesentery and
adhesiolysis.
FIGURE 44-35 A and B. Stomal prolapse with necrosis. Eversion of
prolapsed bowel.
FIGURE 44-36 Stomal prolapse with necrosis. The prolapsed and devitalized
distal limb is divided and closed with a stapling device.
FIGURE 44-37 The stoma is refashioned as an end ileostomy, leaving the

stapled distal limb within the peritoneal cavity.
At times, ostomy relocation may be needed, especially if the fascial
aperture is very large and repair cannot be accomplished easily or the
original ostomy is in a suboptimal site.
Parastomal Varices
Abnormal anastomoses between peristomal and subcutaneous veins
surrounding an ostomy (Fig. 44-38)
FIGURE 44-38 Ileostomy: Caput medusae.
Treatment options:
Suture ligation
Sclerotherapy
Mucocutaneous disconnection (in an emergency setting)
Definitive treatment: portosystemic shunt, transjugular intrahepatic
portosystemic shunt procedure
Stricture
It is usually the result of ischemia of the ostomy.
In the case of Crohn disease patients, recurrent disease is the likely cause.
Other causes include previous radiation therapy or external compression
(eg, constricting skin or fascial opening).
Follow if stoma is temporary, repair if stoma is permanent.
Usually, local cutaneous excision followed by stoma advancement is a
good option (Figs. 44-39 to 44-43).
FIGURE 44-39 Stomal stricture.

FIGURE 44-40 Stomal stricture repair. Peristomal skin incision.
FIGURE 44-41 Stomal stricture repair. Stoma advancement.

FIGURE 44-42 Stomal stricture repair. Excision of distal strictured bowel segment.
FIGURE 44-43 Stomal stricture repair. A. Absorbable sutures inserted. B. Rematured
end colostomy.
Stomal relocation or skin flaps reserved for patients with local skin
problems. Dilatation of the stricture rarely provides lasting improvement.
Retraction
Ostomy retraction (Fig. 44-44) can occur due to:
Inadequate mobilization of a bowel segment
FIGURE 44-44 Loop ileostomy: Recessed stoma after removal of support rod.
Poor location or fixation

Steroid dependence
Obesity
Occasionally, this can still be pouched with minimal problems using
concave stoma plates and belts and with weight reduction.
When pouching becomes an issue, surgical correction by revision is
warranted.
Fixation sutures are placed at the mesentery–fascial interface and the
mesentery–subcutaneous fat. The ostomy is then matured to the dermis.
An alternative technique includes creation of a loop-end ostomy.
Suggested Readings
Steele SR, Lee P, Martin MJ, Mullenix PS, Sullivan ES. Is parastomal hernia repair with
polypropylene mesh safe? Am J Surg. 2003;185(5):436-440.
Strong SA. The difficult stoma: challenges and strategies. Clin Colon Rectal Surg. 2016;29(2):152-
159.
Chapter 45
Complex Abdominal Wall
Reconstruction and Parastomal Hernia
Repair after Colorectal Surgery
CHARLOTTE HORNE
AJITA PRABHU
GENERAL PERIOPERATIVE CONSIDERATIONS
Patient Assessment
Indications for parastomal hernia repair include obstructive symptoms,
persistent uncontrolled pain, and difficulty with pouching.
The first two indications obviously necessitate repair.
Issues with ostomy appliances are not trivial and can have significant
lifestyle limiting and financial consequences due to patient concerns for
accidental leakage as well as the cost of frequently changing ostomy
supplies. Even if asymptomatic otherwise, we will offer repair.
This approach was studied by Kroese et al., and although 21% of
patients in the watchful waiting group required surgical intervention,
there was no difference in rates of emergency surgery as well as
postoperative morbidity in those who crossed over to the surgical
therapy group.
As recurrence rates of a parastomal hernia after repair approach 20%,
employing a nonoperative approach is reasonable and has not been
shown to be associated with increased morbidity. These patients should
be adequately counseled about symptoms of incarceration.
Initial assessment of a patient deemed to require a parastomal hernia repair
always includes evaluating the patient for possible ostomy reversal.
Presence of concomitant midline hernias, multiply reoperative
abdomens, or other factors that may have been previously limiting to
reversal may no longer be absolute or relative contraindications to
reversal, and a reversal should always be performed when possible.
The next step in preoperative evaluation is to assess medical
comorbidities, such as the presence of malignancy, need for ongoing
chemotherapy or radiation, overall life expectancy, weight, smoking
status, and other significant medical comorbidities.
Recurrence after parastomal hernia repair in morbidly obese patients is
associated not only with an increase in recurrence but also with
postoperative morbidity.
All patients are counseled about the importance of smoking cessation,
and cessation is verified with urine nicotine testing.
Uncontrolled diabetes is well known to increase the risk of wound
morbidity.
Preoperative evaluation in diabetic patients includes routine
assessment of HbA1c.
Glycemic optimization, even 60 days prior to surgical intervention,
has been shown to decrease postoperative morbidity.
Our goal HgbA1c prior to scheduling parastomal hernia repair is <8
as this has been shown to be associated with a significant decrease in
postoperative surgical site infection.
For patients with inflammatory bowel disease, optimal surgical results
are achieved by ensuring disease is adequately controlled.
If biologic agents are necessary to achieve disease control/remission,
these medications are continued.
These patients may also require the use of steroids to achieve
disease control/remission. When possible, patients should be
maintained on the lowest steroid dose required.
TIPS
For patients who are currently asymptomatic or minimally

symptomatic, it is feasible to employ a watchful waiting approach.
TIPS
In patients with a body mass index (BMI) > 40 kg/m2, we routinely

counsel patients on the importance of weight loss with a goal BMI of
<35 kg/m2 to decrease postoperative recurrence and overall
TIPS
Patients with HgbA1c >8 are referred back to their primary care
physician or endocrinologist for better blood glucose control prior to
surgery, and elective surgical intervention is not offered until that goal
is achieved.
Operative Approach
TABLE 45-1 Proposed algorithm for preoperative planning of parastomal hernia repair.
There are many different approaches to the repair of parastomal hernias,
including primary repairs, stoma relocation as well as both laparoscopic
and open techniques.
Patient factors, previous operations, type of stoma, and other
concomitant hernias dictate appropriate operative approach.
Although primary suture repair is associated with minimal operative
morbidity, recurrence rates approach 69% postoperatively.
Common laparoscopic approaches include the keyhole repair and the
Sugarbaker repair. These approaches involve the intraperitoneal placement
of mesh.
In general, the laparoscopic approach is associated with decreased
surgical site infection.
Analysis of these techniques shows a lower recurrence rate with the
Sugarbaker repair.
In our practice, patients without prior parastomal hernia repairs,
absence of associated midline hernia, and smaller hernia defects and
those who do not have multiply reoperative abdomens are the ideal
candidates for a laparoscopic approach.
Numerous techniques have been illustrated for the open repair of a
parastomal hernia.
Here we present approaches based on reinforcement of the defect with
mesh, as we consider this to be standard of care for elective cases.
The mesh may be placed in an onlay manner around the stoma in the
prefascial plane; it may be placed posterior to the rectus abdominis
muscle in the retrorectus or preperitoneal plane, or it can be placed
intraperitoneally in an underlay manner.
The onlay technique is beneficial as it does not require a laparotomy;
however, recurrence rates with this technique are the highest at ∼15%.
Both the retrorectus and preperitoneal repair require a laparotomy for
appropriate hernia reduction and mesh placement.
These techniques are associated with an overall low recurrence rate,
7% and 9%, respectively, and low postoperative wound morbidity of
∼2%-4%.
Our preferred technique for open parastomal hernia involves stoma
takedown and relocation on the contralateral side of the abdomen
when possible with placement of mesh in the retrorectus plane.
Placement of mesh in the retrorectus plane avoids complications
associated with intraperitoneal mesh, including extensive adhesions
and erosion.
Re-siting the stoma is ideal as it moves the ostomy to a location of
healthy abdominal wall, allowing for reinforcement of the old fascial
defect as well as the new fascial defect. Still, this approach is
associated with a recurrence rate as high as 11% in the first 13 months
of repair, which serves to highlight the challenging nature of
parastomal hernia repair in general.
TIPS
We strongly recommend against suture repair, unless emergent

operative intervention is necessary or there are strong
contraindications to mesh placement.
TIPS
Simple stoma relocation in the absence of mesh infection is associated
with an unacceptably high risk of recurrence and is, therefore, not
recommended.
TIPS
We do not utilize the onlay technique in our practice due to the high
recurrence rate and risk of mesh infection.
Patient Preparation
Patient optimization prior to undergoing parastomal hernia repair is
critical as these operations can be lengthy due to extensive intra-
abdominal adhesions, previous mesh placements, and stoma management.
Prior to undergoing repair, all patients undergo cross-sectional imaging
(usually a computed tomography) prior to repair as the presence of
concomitant hernias will determine operative approach. We routinely
obtain all operative reports from prior operations when possible.
Patients are evaluated by a certified stoma nurse for preoperative stoma
marking. Preoperative site marking allows the patient to be evaluated in
both the sitting and standing positions, and significant skin creases can be
assessed to ensure the new ostomy is in the most optimal location.
In our practice, we routinely relocate the stoma if possible, during an open
parastomal hernia repair; therefore, identification of an appropriate site
preoperatively provides the patient with an easily manageable stoma
postoperatively.
We do not routinely have patients perform a bowel prep prior to surgery,
as we have found that patients undergoing hernia repair in a contaminated
setting with bowel prep have a higher incidence of surgical site infection
requiring procedural intervention.
Mesh Choice
Appropriate mesh choice is often dictated by whether laparoscopic or open
approach will be utilized.
When parastomal hernias are repaired laparoscopically either an expanded
polytetrafluoroethylene (ePTFE) mesh or a barrier-coated lightweight
polypropylene mesh is utilized.
We routinely use barrier coating mesh—it prevents tissue ingrowth on
the peritoneal surface, reducing adhesions forming to the bowel.
In an open approach, both biologic and synthetic mesh have been used.
Although there have been concerns about synthetic mesh in the
proximity of the stoma and increased risk of wound morbidity in
contaminated hernia cases, multiple studies have shown that a medium
weight polypropylene mesh is both safe and effective in parastomal
hernia repair.
TIPS
When barrier mesh is placed, care must be taken to account for mesh
contraction that can enlarge the keyhole defect if a keyhole approach
is utilized.
Laparoscopic Parastomal Hernia Repair

Laparoscopic parastomal hernia repair is an attractive option for
parastomal hernias and has been shown to have decreased postoperative
pain as well as a decreased incidence of postoperative wound and mesh
infection (3.8%) and recurrence (17.4%).
The keyhole technique and the Sugarbaker technique are the most
commonly used approaches.
A laparoscopic Sugarbaker approach has been shown to have the
lowest postoperative recurrence rate of 10.2%; however, complications
with mesh erosion into the ostomy can be devastating.
As the Sugarbaker approach requires a significant amount of bowel
length to be mobilized, patients with ileal conduits or transverse
colostomies may not be candidates for this approach due to the location
of the ureters or a shortened mesentery.
The keyhole technique has been shown to have a moderately higher
recurrence rate of 27.9%, likely due to the contraction of the ePTFE
mesh reinforcement that enlarges the slit over time.
In both techniques, the stoma is left in situ.
Laparoscopic stoma relocation is not currently routinely done.
Candidates for a laparoscopic approach include those without concomitant
midline defects, no previous history of prior parastomal hernia repair, and
those with smaller parastomal hernia defects.
Cross-sectional imaging is routinely performed in patients thought to be
appropriate candidates for a laparoscopic approach to evaluate for other
hernia defects and any other intra-abdominal pathology.
Laparoscopic Technique
Positioning
In both the keyhole and Sugarbaker techniques, patients are placed supine.
Arms are tucked to facilitate laparoscopic dissection as often the surgeon
and the assistant stand on the same side of the operative table.
All patients received appropriate antibiotic prophylaxis, and prophylactic
heparin is administered prior to incision.
The stoma is oversewn from skin to skin using a 0 permanent braided
suture.
A gauze and sterile dressing are then placed over the stoma to prevent
spillage of enteric contents and minimize contamination during the
procedure.
The patient can be placed in mild Trendelenburg and rotated so the side
with the ostomy side mildly elevated to allow for better visualization.
Port Placement
Appropriate port placement is essential to facilitate adhesiolysis and mesh
placement.
As patients may have significant abdominal wall adhesions, and to
facilitate mesh placement, ports should be placed as lateral as possible.
We routinely place a total of three ports, two 5-mm and one 12-mm port,
with an additional port added, if necessary, to facilitate retraction and
mesh fixation (Fig. 45-1).
FIGURE 45-1 Port placement: Ports are placed on the contralateral side of the
abdomen to the ostomy when feasible. We routinely use a 12-mm port and two 5-mm
ports. (From Appearance of an ostomy. (n.d.). Retrieved June 10, 2018, from
https://www.fascrs.org/patients/disease-condition/ostomy-0.)
Adhesiolysis
Access is gained in the abdominal quadrant furthest away from the stoma
when possible. Our preference is to gain access to the abdomen via an
open cut-down approach; however, other methods of entry can be
effective.
Overall, choice of abdominal entry technique is at the discretion of the
operating surgeon, being cognizant of a high likelihood of intra-abdominal
adhesions.
Subsequent ports are placed on the contralateral side of the abdomen to the
ostomy.
If access cannot be gained in the abdomen contralateral to the ostomy,
we routinely place the initial port as far from the stoma as possible to
facilitate adhesiolysis.
Initial dissection begins with adhesiolysis performed sharply to prevent
inadvertent thermal injuries to the bowel; however, energy devices can be
utilized to facilitate hemostasis.
Adhesiolysis is performed to completely clear the abdominal wall
circumferentially around the hernia defect for mesh placement.
Adhesiolysis is deemed complete when there is adequate space to place
an appropriately sized piece of mesh.
The hernia contents are reduced into the abdominal cavity.
This is done via adequate laparoscopic dissection but may require
gentle pressure on the abdominal wall.
This maneuver should be performed with atraumatic graspers, and the
operating surgeon should avoid excessive traction on the mesentery as
this can tear the mesenteric vessels during reduction.
Ensure that only one loop of bowel, the stoma, is exiting through the
hernia defect.
After the hernia has been reduced, the size of the hernia is measured.
We prefer to measure the hernia defect intracorporeally by placing a
ruler within the abdomen to measure the greatest length and width of
the defect.
Another approach is to mark the widest and longest aspects of the
defect using spinal needles placed through the abdominal wall and to
measure intracorporeally with a braided suture, which is then
removed and held against a ruler to determine the dimensions of the
defect.
The appropriate piece of mesh is large enough to provide at least 5
cm of overlap in all directions.
TIPS
If performing a Sugarbaker repair, interloop adhesions will also have

to be lysed so that the bowel can be lateralized for mesh placement.
Keyhole Mesh Preparation

Since the stoma will remain in situ, the mesh has to be slit to allow for
adequate coverage of all sides of the fascial defect, while accommodating
the ostomy.
We prefer to prepare our mesh prior to introduction into the abdominal
cavity as the cardinal stitches placed facilitate appropriate positioning,
although techniques were the mesh is introduced and then slit has been
described.
A slit in the mesh is made in one end to allow for placement around the
stoma.
To provide enough lateral coverage around the ostomy defect, this slit
must extend approximately one-third away from the lateral edge of the
mesh.
Ending the slit with a cruciate incision allows for enough room to
accommodate the ostomy but keeps the overall mesh defect small, which
is necessary to prevent recurrence (Fig. 45-2).
FIGURE 45-2 Mesh preparation: A cruciate cut is made one-third of the diameter of
the mesh. Next, five cardinal transfascial sutures are placed as shown. Knots should be
tied on the rough side of the mesh. ePTFE, expanded polytetrafluoroethylene. (From Criss
CN, Krpata DM, Prabhu AS. Laparoscopic repair of parastomal hernia. In: Rosen MJ, ed.
Atlas of Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:63-80;
with permission.)
Intra-abdominal manipulation of the mesh can be technically challenging.

To facilitate mesh placement and ensure appropriate orientation of the
barrier-coated mesh, five cardinal anchoring, nonabsorbable sutures are
placed on each corner of the mesh as well as on each side of the split.
After the sutures have been placed in the mesh and tied, the mesh is
then subsequently rolled with the coated side facing inward and
introduced into the abdomen using the 12-mm trocar.
Mesh Fixation
After the mesh is introduced into the abdomen, the medial and lateral stay
sutures are used to anchor the mesh against the abdominal wall.
Care must be taken to ensure the coated side of the mesh faces the viscera
and the slit opens downward on the stoma defect.
Mesh fixation begins with anchoring the mesh lateral to the ostomy first.
Working lateral to medial allows the operating surgeon to maintain
adequate visualization of the defect and appropriate tension on the mesh.
Mesh placement may be optimized by a spinal needle to determine the
appropriate location of the mesh extracorporeally.
The superior stay suture and the stay suture on the lateral side of the slit
are pulled through the abdominal wall using a suture passer after the mesh
is appropriately positioned (Fig. 45-3).
FIGURE 45-3 Mesh fixation: The sutures are pulled out and secured in the order as
shown. The most lateral suture is grasped first to ensure adequate lateral coverage
(suture 1). Next, the medial suture (2) is brought through the abdominal wall orientating
the mesh so the cruciate incision is directed caudally. Lastly, the superior suture (3) is
passed through the abdominal wall and tied. (From Criss CN, Krpata DM, Prabhu AS.
Laparoscopic repair of parastomal hernia. In: Rosen MJ, ed. Atlas of Abdominal Wall
Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:63-80; with permission.)
The stitches are then subsequently tied.

We find tacking the lateral mesh first versus tacking the entirety of the
mesh at the end of positioning to be a better approach as anchoring one
half of the mesh facilitates further mesh positioning.
Also, if medial adjustments need to be made to ensure appropriate
coverage, these can be done at this time.
As described in both laparoscopic ventral hernia repair and parastomal
hernia repair literature, tacks should be placed 1 cm from the edge with
1cm spacing between tacks.
The same steps are subsequently repeated with the medial aspect of the
mesh.
Lastly, the gaps between the stoma and the mesh are closed using a 2-0
nonabsorbable stitch.
The mesh is also secured to the colostomy with seromuscular bites using
the 2-0 nonabsorbable sutures (Fig. 45-4).
FIGURE 45-4 Tacking of mesh: The mesh is tacked to the abdominal wall
circumferentially with tacks placed 1 cm from the edge of the mesh and 1 cm apart. (From
Criss CN, Krpata DM, Prabhu AS. Laparoscopic repair of parastomal hernia. In: Rosen
MJ, ed. Atlas of Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier;
2017:63-80; with permission.)
Laparoscopic Sugarbaker Technique
In this approach, the stoma’s loop of bowel is lateralized and the mesh is
placed in one contiguous piece over the ostomy exit site, forming a type of
hammock or sling through which the ostomy loop passes.
This approach requires a significant amount of mobilization of the bowel
as it must be lateralized enough to accommodate a piece of mesh large
enough to provide coverage of the parastomal defect.
This may not be feasible in patients with ileal conduits as the insertion of
the ureters may limit mobility as well as in patients with transverse colon
colostomies due to the central location of the mesentery.
Lateralization of the Ostomy

After adhesiolysis is complete and the parastomal hernia is reduced, the
hernia defect is measured intracorporeally, and an appropriate size of
barrier-coated mesh is selected to provide a 5-cm overlap of the defect.
The bowel is then lateralized and secured to the abdominal wall using a 2-
0 nonabsorbable suture with seromuscular bites as this allows for
assessment of the angulation of the bowel prior to placement of the mesh
(Fig. 45-5).
FIGURE 45-5 Completion of hernia repair: Transfascial sutures anchor the mesh to
the abdominal wall with tacks placed between cardinal transfascial sutures. (From Criss
CN, Krpata DM, Prabhu AS. Laparoscopic repair of parastomal hernia. In: Rosen MJ, ed.
Atlas of Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:63-80;
with permission.)
Four cardinal transfascial sutures are placed on the corners of the mesh
with the knots present on the rough side of the mesh and then introduced
into the abdominal cavity via the 12-mm port.
The mesh is then appropriately positioned inside the abdomen.
We begin with the inferior lateral transfascial suture to ensure adequate
lateral coverage.
Using a suture passer, the cardinal suture is retrieved from the abdomen
and pulled through the abdominal wall.
Next, the superior lateral transfascial suture is retrieved.
These sutures are then held on tension to ensure adequate lateral
coverage of the defect and to determine whether there is significant
angulation of the bowel at the lateral aspect of the edge that may result
in erosion.
After appropriate positioning is confirmed, the sutures are subsequently
tied.
The remaining medial transfascial sutures are retrieved, and all are tied.
Two rings of tacks are placed.
An outer layer is placed 1 cm from the edge of the mesh with 1-2 cm
between each tack.
A subsequent inner layer is placed next to the stoma exit site, taking
extreme care not to injure the ostomy (Fig. 45-6).
FIGURE 45-6 Laparoscopic Sugarbaker repair: The bowel is lateralized, and the
mesh is fixated to the abdominal wall using two rows of tacks. A. Mesh secured to the
anterior abdominal wall. B. Sagittal view with the transfascial sutures in place. (From
Criss CN, Krpata DM, Prabhu AS. Laparoscopic repair of parastomal hernia. In: Rosen
MJ, ed. Atlas of Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier;
2017:63-80; with permission.)
PEARLS AND PITFALLS
Ports should be placed as lateral as possible to facilitate adhesiolysis to

ensure adequate coverage with the mesh.
A Foley catheter or endoscope can be introduced into the stoma to
facilitate adhesiolysis and ensure accurate identification of anatomy.
2-0 Vicryl sutures can be placed around the mesh in a scroll-like
manner to maintain the rolled configuration of the mesh. These also
facilitate mesh placement by keeping mesh secured during positioning.
Additional transfascial sutures can be placed to decrease long-term
recurrence.
Open Parastomal Hernia Repair
Preoperative Evaluation
Parastomal hernias are repaired with an open surgical approach if there is
a known midline incisional hernia associated with the parastomal hernia; if
there have been previous parastomal hernia repairs with intraperitoneal
mesh; if the patient has any complications with the ostomy including
difficulty pouching, prolapse, or significant peristomal skin changes; or if
there is a high likelihood of dense intra-abdominal adhesions due to
numerous previous laparotomies.
All patients undergo preoperative cross-sectional imaging to assess for
concomitant midline hernias and for parastomal hernia anatomy.
As in patients undergoing a laparoscopic parastomal hernia repair, we
routinely counsel patients on preoperative weight loss if their BMI is >40
kg/m2, ensure compliance with smoking cessation, and optimize other
medical comorbidities prior to undergoing parastomal hernia repair.
In our practice, we often re-site the ostomy to the contralateral side of the
abdomen.
This is done because it allows for a smaller trephination as well as
facilitates a smaller cruciate incision to be made in the mesh. It also
allows for reinforcement of both the previous ostomy site and the new
ostomy site with mesh.
Of note, the use of prophylactic mesh placement with initial colon
resection and ostomy creation has been evaluated extensively.
Although some studies show a decrease in parastomal hernia formation,
there are also randomized controlled trials that report no difference in
outcomes at 1 year.
Although there is still no consensus as to whether a long-term benefit
exists, we routinely reinforce both the new ostomy defect and the old
defect with mesh.
Stomas may also need to be re-sited if there is a large concomitant ventral
hernia defect, due to the lack of adequate muscle at this current location.
Patients may also benefit from stoma relocation due to persistent stoma
leakage and pouching problems. However, if the skin is of good quality,
the patient is satisfied with its location, and the muscular defect is not very
large, we will alternatively perform a retrorectus keyhole repair with the
ostomy left in situ, where the mesh is slit from laterally to medially to
accommodate the ostomy.
The tails of the mesh are then reapproximated using nonabsorbable
monofilament suture to avoid re-herniation laterally.
Patients are routinely evaluated by qualified stoma nurses and marked
preoperatively to ensure the new stoma location avoids any natural skin
folds, waistbands, or areas with a significant amount of subcutaneous
tissue.
It may not be technically feasible to relocate the ostomy in ileal conduits
or in transverse colostomies as the ureters or mesentery may limit mobility
of the ostomy.
In these situations, the stoma may be taken down and re-sited through
the same stoma aperture or the ostomy is left in situ during the
dissection, and a retrorectus keyhole type repair is performed, as
described earlier.
Operative Approach
Our preferred technical approach in parastomal hernia repair is an open
repair with a transversus abdominis release with mesh placed in a sublay
position.
This approach allows for a significant amount of mesh overlap,
avoidance of direct mesh contact with the abdominal viscera as well as
closure of the primary parastomal defect.
It has been shown to have a low recurrence rate with minimal
Patients are placed in the supine position with the arms out laterally.
To prevent contamination from stoma effluent during the procedure, the
stoma is oversewn from skin to skin at the beginning of the case using a 0
permanent polyfilament suture and then covered with a sterile gauze and
dressing, except in patients with urinary conduits.
Urinary conduits are prepared by placing a Foley catheter to allow for
urinary drainage.
All previous incisions are marked.
The operation begins with a midline laparotomy, taking down all
abdominal wall adhesions with care taken to ensure the abdominal wall is
not violated.
We perform a complete adhesiolysis of interloop adhesions to facilitate
stoma relocation. Complete adhesiolysis also verifies that previous
anastomoses, if present, are laid in an anatomically correct orientation.
Next, the parastomal hernia defect is reduced, and the stoma is
subsequently transected with a linear stapler directly against the
abdominal wall to prevent contamination, and the remaining stump is then
dissected away from the mucocutaneous junction and discarded or sent for
pathology.
The next step of the operation is to address the large concomitant midline
hernia defect. Numerous different surgical approaches can effectively
address this problem.
Repair can be achieved by reinforcement with a mesh onlay or placement
of the mesh in an underlay position.
Our preference is a retrorectus repair with or without transversus
abdominis release to achieve optimal hernia repair.
Advantages of this repair include significant medialization of the rectus
abdominis muscle to allow for a tension-free closure.
It also creates enough space to accommodate a large piece of mesh that
allows for reinforcement of the old ostomy site, the midline defect(s),
and the new stoma site.
Furthermore, onlay repair bears the additional risk of wound morbidity,
which is somewhat obviated by a retrorectus approach.
After adhesiolysis has been completed and adequate small bowel length
has been established for stoma relocation, we begin our retrorectus
dissection.
This dissection begins by incising the posterior sheath just lateral to the
medial border of the rectus muscle.
The posterior sheath is dissected free of the rectus muscle. When
encountering the area where the stoma was, a defect will be present in
the posterior sheath (Fig. 45-7).
FIGURE 45-7 Retrorectus dissection: After the ostomy has been taken down, the
retrorectus dissection will demonstrate a defect in the posterior sheath and anterior
fascia that will require closure. A. Diagram. B. Intraoperative Photograph. (From
Winder JS, Pauli EM. Open parastomal hernia repair. In: Rosen MJ, ed. Atlas of
Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:124-149;
with permission.)
In order to prevent enlarging this defect and to maintain the appropriate

plane, we dissect in the retrorectus space, both above and below the
area of the defect. Once this is accomplished, we continue the
dissection laterally in the cephalad and caudal aspects and attempt to
then encircle the defect.
Once the cephalad and caudal dissection planes have joined posteriorly,
dissection continues lateral to medial until the defect has been fully
dissected free.
At this time, if posterior sheath closure is not feasible without undue
tension or there is not adequate space for an appropriately sized piece
of mesh, we proceed with a transversus abdominis release.
After an adequate myofascial release has been completed on both sides of
the abdomen, the posterior rectus sheath and previous stoma defect in the
posterior rectus sheath are subsequently closed using 2-0 Vicryl suture in a
running manner.
Next, an appropriate exit site for the stoma in the posterior sheath is
marked (Fig. 45-8).
FIGURE 45-8 Ostomy positioning: The stoma has been brought through the posterior
sheath. The surgeon must ensure that the mesentery lies flat and that the stoma is not
twisted when pulling it through the posterior sheath.
We make this assessment when the posterior sheath is almost completely

closed to allow for the creation of a straight passage through the posterior
sheath, abdominal wall, and skin.
Care must be taken to avoid any kinking of the ostomy and its mesentery
as this could result in ischemia or issues with stoma function.
We make the smallest defect possible in the posterior sheath to
accommodate the ostomy and then complete the closure of the posterior
sheath.
Again, extreme care must be taken to ensure that the ostomy has adequate
length to pass through the posterior sheath, mesh, and abdominal wall; that
it is not twisted; and that the mesentery lies flat.
After the posterior sheath is closed, the mesh is placed in the sublay
position.
Lightweight polypropylene mesh in contaminated cases has been
shown to have low recurrence rates without a significant increase in
postoperative wound morbidity.
The hernia defect is then measured, and an appropriately sized piece of
mesh is selected.
The mesh can either be placed in a diamond configuration or square
configuration, but care must be taken to ensure appropriate lateral
coverage over the previous ostomy site.
Often, if the ostomy must remain in situ, a square configuration affords
more lateral coverage and facilitates a keyhole configuration of the
mesh.
Using slow-absorbing monofilament transfascial sutures, the mesh is
secured superiorly at the xiphoid and inferiorly at the pubis.
Two or three lateral transfascial fixation sutures are placed bilaterally
using a suture passer passed through small stab incisions in the skin at the
level of each suture.
Prior to tying these, all sutures are held on tension to ensure the mesh is
under an appropriate amount of tension and adequate lateral coverage has
been achieved.
With tension on the transfascial sutures, the abdominal wall is medialized,
and an appropriate site for the stoma to pass through the mesh is marked.
Next, a cruciate incision is made in the mesh to allow just the bowel and
its mesentery to pass through (Fig. 45-9).
FIGURE 45-9 Stoma positioning through mesh: The mesh has been placed and
secured superiorly and inferiorly. An appropriate stoma site is planned with the lateral
mesh held on tension, and small cruciate incision is made in the mesh.
As mesh contraction is a common phenomenon, the incision should

remain as small as possible as it is likely to enlarge with time.
With the abdominal wall medialized, the exit site for the stoma is chosen.
Dissection is carried through the skin and subcutaneous tissue to the rectus
muscles, which are retracted laterally, and a longitudinal incision is made
in the anterior fascia that is just large enough to accommodate the bowel.
The stoma is passed through the mesh and the abdominal wall.
Again, meticulous attention to the ostomy is required to ensure that the
path it traverses through the mesh, fascia, and subcutaneous tissue is as
straight as possible as kinking of the stoma can lead to erosion or
possible stoma necrosis (Fig. 45-10).
FIGURE 45-10 Ostomy siting: The stoma is then brought up through the
abdominal wall and skin. The lateral transfascial sutures are then tied. We place two
closed suction drains in the retrorectus space on top of the mesh. The anterior rectus
sheath and the stoma defect are subsequently closed using figure-of-eight slow-
absorbing monofilament suture. The deep dermis is closed with a 3-0 chromic suture,
and the skin is subsequently closed using a 4-0 absorbable suture. The ostomy is
matured in a standard manner at the end of the case.
Parastomal Hernia Repair with the Ostomy In Situ

In the event that the stoma cannot be relocated, the stoma can be managed
one of two ways.
First, the stoma can be taken down and re-sited at the same ostomy site.
If this is technically feasible, the steps of the dissection and creation
of the stoma are the same as if the stoma was being relocated.
The other approach is to leave the ostomy in situ.
A keyhole incision is made in the mesh to accommodate the stoma
and then two edges of the mesh are reapproximated using
monofilament permanent suture to prevent a lateral recurrence.
It is in these situations that placing the mesh in the square
configuration may increase lateral coverage of the defect.
If the ostomy has been taken down, the defect in the anterior rectus
sheath should be closed to a diameter that only allows passage of the
ostomy.
Postoperative Care
Patients with satisfactory hemodynamic and ventilatory status are
extubated at the completion of the case.
If the parastomal or midline defects are large and are associated with a
significant amount of bowel herniated outside the abdomen, abdominal
closure can result in elevated airway pressure, and these patients remain
intubated for 24 hours postoperatively.
While in the past we used an elevation of plateau pressures of 6 mm Hg or
more as criteria to keep our patients intubated, we continue to evolve in
our management of patients with tight abdominal closures and currently
allow for greater elevations in plateau pressures while still extubating our
patients.
Indeed, we have found that in some cases, it is preferable to prioritize
maintaining airway pressures over achieving tight midline closures and err
on the side of wide overlap with the mesh and partial or incomplete
closure of the midline anterior rectus sheath, also known as a bridging
repair.
Pain is managed with a multimodal approach utilizing intraoperative
transversus abdominis plane blocks, intravenous acetaminophen, and a
patient-controlled analgesia pump.
We prefer not to utilize epidurals due to the high rate of urinary
retention and prolonged need for a Foley catheter to prevent reinsertion
as well as the need to hold prophylactic anticoagulation for their
removal.
Patients routinely receive Lovenox for deep venous thrombosis
prophylaxis postoperatively unless there is a patient-specific
contraindication. This is administered daily starting the night of surgery.
For patients with chronic kidney disease, we prefer heparin dosed three
times a day to twice a day.
PEARLS AND PITFALLS

All patients should undergo preoperative cross-sectional imaging to
delineate anatomy and assist with operative planning.
In the event that the posterior sheath cannot be closed, the hernia sac or
falciform ligament can assist with a tension-free closure. If there is no
fatty tissue available to bridge the posterior rectus sheath closure, a fast-
absorbing mesh (Vicryl) can be used instead.
Routine re-siting of the ostomy is preferred to reinforce both old and
new parastomal defects with the mesh.
Meticulous attention to the path the ostomy and its mesentery takes
through the posterior sheath, mesh, and abdominal wall is essential to
prevent stoma necrosis.
Robotic Parastomal Hernia Repair

The robot has many technical features that may prove advantageous in its
use for the repair of parastomal hernias.
The increased range of motion of the robotic arms as well as the ease of
intracorporeal suturing are some features that may facilitate dissection,
mesh placement, and overall repair of these defects.
Recently, the robot has been used increasingly in the repair of large
abdominal defects and has been shown to be associated with a decreased
length of stay. The utilization of the robotic platform in repair of
parastomal hernias associated with ileal conduits has been shown to be
technically feasible in a small series of patients.
Overall, a robotic approach may be useful; however, this approach is still
in its infancy, and although the theoretical feasibility and technical
advantages prove encouraging, further data are required to determine
appropriateness in parastomal hernia repair.
SUMMARY
Parastomal hernias remain a complex challenge to the general surgeon.
Both patient factors such as patient comorbidities, body habitus, initial
indication for ostomy and its location, multiply reoperative abdomens, and
the potential need for further treatment of the initial disease process must
be taken into consideration when deciding on an appropriate operative
approach for the patient.
Watchful waiting is a reasonable approach for patients who are
asymptomatic or minimally symptomatic. Patients with obstructive
symptoms, significant pain, or issues with pouching should be considered
for operative repair.
Preoperatively, patients are counseled on the importance of smoking
cessation and weight loss if indicated. As it is our practice to re-site the
stoma if technically feasible, we employ the assistance of a certified
ostomy nurse to facilitate decision-making for the new ostomy location.
For patients without concomitant midline hernias and smaller defects and
those likely to have minimal intra-abdominal adhesions, a laparoscopic
approach is technically feasible.
For patients with multiple previous abdominal operations, those with
previous hernia repairs, or those with associated ventral hernia defects, an
open approach is indicated.
In the laparoscopic approach, we prefer to use a barrier-coated lightweight
polypropylene mesh. In the open approach, the optimal mesh choice is still
under investigation. Either a both a large pore monofilament
polypropylene mesh or a biologic porcine-derived acellular dermal matrix
can be utilized.
Suggested Readings
Antoniou SA, Agresta F, Garcia Alamino JM, et al. European hernia society guidelines on prevention
and treatment of parastomal hernias. Hernia. 2018;22(1):183-198.
Birgitta ME, Hansson MD, Slater NJ, et al. Surgical techniques for parastomal hernia repair. Ann Surg.
2012;225(4):685-695.
Carbonell AM, Criss CN, Cobb WS, Novitsky YW, Rosen MJ. Outcomes of synthetic mesh in
contaminated ventral hernia. J Am Coll Surg. 2014;217(6):991-998.
Carne PW, Robertson GM, Frizelle FA. Parastomal hernia. Br J Surg. 2003;90(7):784–793.
Hansson BM, Slater NJ, van der Velden AS, et al. Surgical techniques for parastomal hernia repair: a
systematic review of the literature. Ann Surg. 2012;225(4):685-698.
Hotouras A, Murphy J, Thaha M, Chan CL. The persistent challenge of parastomal herniation: a
review of the literature and future developments. Colorectal Dis. 2013;15(5):202-214.
Kroese LF, Lambrichts DPV, Jeekel J, Kleinrensink GJ, Menon AG, de Graaf EJR, Bemelman WA,
Lange JF. Non-operative treatment as a strategy for patients with parastomal hernia: a
multicentre, retrospective cohort study. Colorectal Dis. 2018 Jun;20(6):545-551.
Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel
approach to posterior component separation during complex abdominal wall reconstruction. Am
J Surg. 2012;204(5):709-716.
Petro CC, Prabhu AS. Preoperative planning and patient optimization. Surg Clin North Am.
2018;98(3):483-497.
Raigani S, Criss CN, Petro CC, Prabhu AS, Novitsky YW, Rosen MJ. Single-center experience with
parastomal hernia repair using retromuscular mesh placement. J Gastrointest Surg.
2014;18(9):1673-1677.
Rosen MJ, Reynolds HL, Champagne B, Delaney CP. A novel approach for the simultaneous repair of
large midline incisional and parastomal hernias with biological mesh and retrorectus
reconstruction. Am J Surg. 2010;199(3):416-421.
Chapter 46
Kock Pouch (K-pouch)
SHERIEF SHAWKI
Patients should be counseled extensively about the expected function,
needs, and potential revisions or failures that may be required with the
operation.
ETS (enterostomal therapy nurse) will educate and mark the patient for the
appropriate place.
Patients should undergo a mechanical bowel preparation with oral
antibiotics.
Prior to surgery, the patient is given intravenous (IV) antibiotics and
subcutaneous heparin.
Patient Positioning
Patients are positioned in Lloyd-Davies position with stirrups (Yellowfins
or similar); alternatively, a split-leg table may be utilized.
Access to the perineum should be readily accessible in cases where
resection of a rectum or pouch is a concomitant part of the procedure.
The patient’s arms may be out or tucked at their sides bilaterally and
padded appropriately to avoid nerve injury.

Ureteral catheters may be utilized, when appropriate.
Standardized laparotomy set with open instruments
Wound protector
PI-55 mm reusable noncutting linear stapler with green load ×3
3-0 Vicryl sutures
2-0 Ticron sutures
Water tube
JP drain
Technique
An open midline incision is performed along with generalized abdominal
exploration.
Extensive lysis of adhesions should be performed from ligament of Treitz
to the terminal ileum.
This includes intraloop adhesions, especially in the terminal ileum, to
facilitate construction of the pouch.
Pouch Creation
Begins with planning the length needed for pouch and the valve.
Starting from the terminal ileum, ∼15- to 18-cm-long efferent limb is
marked. This is the future nipple valve and exit conduit (Fig. 46-1A-C).
Depending on the body habitus of the patient, additional centimeters
may be needed to pass the efferent limb through the abdominal wall.
FIGURE 46-1 A. Intraloop adhesions are lysed, and the bowel is prepared for
pouch creation. B. Bowel is laid out in proper configuration. C. Measurements taken
prior to create the K pouch.
The excess will be resected at the end flush with the anterior abdominal
wall.
This is followed by three loops of small bowel, which will become pouch
reservoir; each measures ∼15 cm (Fig. 46-1B).
The three limbs are aligned together. A seromuscular suture is taken to
oppose adjacent loops and keep them oriented (Fig. 46-2).
FIGURE 46-2 Seromuscular sutures taken to oppose adjacent two of the three loops
of bowel.
The future enterotomy on the small bowel is marked with electrocautery

for its entirety (Fig. 46-3).
It is important to keep the middle enterotomy in the middle of the
bowel (ie, antimesenteric).
FIGURE 46-3 Future enterotomy is marked with electrocautery. Note the two
outer loops are slightly medial and the middle loop should be directly antimesenteric.
The outer two enterotomies are slightly medialized, but still keeping
enough bowel for the anastomosis.
The bowel is incised along the previously placed marks (Fig. 46-4A-C).
FIGURE 46-4 A. Opening of the enterotomy. B. Depiction of the three limbs and the
enterotomy. C. Enterotomy continues along the bowel.
An outer seromuscular layer of the posterior wall of the pouch is

undertaken. This is done in a running manner, using 3-0 absorbable suture
(Fig. 46-5).
FIGURE 46-5 Seromuscular outer posterior layer finished.
The second inner layer of the posterior wall of the pouch to approximate
the mucosa is completed using 3-0 polyglycolic acid suture in running
manner (Fig. 46-6A and B).
FIGURE 46-6 A. Depiction of the inner layer. B. The posterior inner layer is
completed.
Valve Creation
The valve is constructed by intussuscepting the proximal portion of the
efferent limb, exiting the pouch into the pouch cavity.
The length of this valve is about 5-6 cm, requiring a piece of bowel 10-12
cm long.
The bowel is then telescoped into the pouch gently and gradually.
Occasionally, it takes several attempts to position the valve in a
satisfactory position (Fig. 46-7A-C).
FIGURE 46-7 A. Initial intussusception of the valve utilizing a Babcock clamp. B.
Creating the valve by intussuscepting 5-6 cm of bowel. C. Using the back of a forceps
to aid in intussusception.
Cautious scarring the peritoneal surface of the bowel mesentery of

nipple valve segment with electrocautery can also be used to promote
adhesions between opposing surfaces.
TIPS
We find that using a ring forceps to gently dilate the bowel will help
with the intussusception.
TIPS
Prior to intussusception, in case of bulky mesentery, stripping of the

mesenteric peritoneum and fat while saving the blood supply
facilitates intussusception and promotes adhesions between opposing
surfaces.
Valve Fixation
Using a transverse anastomosis (TA) noncutting linear stapler, two parallel
rows of staples are then deployed across the nipple valve one on each side
of the folded mesentery of the intussuscepted segment.
Caution should be exercised to identify the mesentery of the
intussusceptum and avoid it to prevent ischemia and necrosis of the
valve (Fig. 46-8A-D).
FIGURE 46-8 A. Initial firing of the noncutting linear stapler along the lateral
portion of the bowel to fix the valve. B. Second firing of the stapler on the opposite
side. C. Application of the stapler and cross section demonstrating the first two rows.
D. The stapled valve.
Closure of the Anterior Wall of the Pouch

The anterior wall of the pouch is closed commencing at the apex of the
pouch.
Using 3-0 absorbable stitch, with interrupted 2-0 nonabsorbable sutures,
the anterior wall is closed over the nipple.
Sutures will incorporate part of the nipple valve anchoring the valve to the
pouch wall (Fig. 46-9A and B).
FIGURE 46-9 A. Closure of the anterior wall over the nipple. B. Closure of the upper
portion of anterior pouch wall. Sutures incorporate the nipple valve.
When the tip of nipple valve is reached, the TA noncutting linear stapler is
inserted into the lumen of the valve and fired overlapping the
abovementioned suture line, providing additional fixation and stabilization
of the nipple valve (Fig. 46-10A and B).
FIGURE 46-10 A. Third firing of the noncutting linear stapler. B. Third row of stapled
deployed, including nipple valve and anterior pouch wall, overlapping anterior closure
suture line.
The rest of the anterior pouch wall is closed in the same manner (Fig. 46-
11).
FIGURE 46-11 Anterior pouch wall closure completed.
The fundus of the pouch is then anchored to the base of the exit conduit to
strengthen the valve using 3-4 interrupted seromuscular suture (Fig. 46-
12).
FIGURE 46-12 Anchoring stitches between the pouch fundus and exit conduit to
enforce the intussuscepted valve.
Intubation Simulation
During each step and prior to progress to the next step, intubation check is
performed using a Water tube to ensure no mechanical issue with the
valve that can accommodate and allow a smooth intubation (Fig. 46-13).
FIGURE 46-13 Water tube through the nipple valve.
Checking for Integrity and Continence

Water tube in passed through the valve. The pouch is filled with fluid and
evaluated for:
Integrity of the suture line (leak test) (Fig. 46-14A)
Suture line is inspected while the pouch is inflated under tension
(afferent limb should be occluded), and any enforcement of the
suture line can be implemented accordingly.
FIGURE 46-14 A. Leak test on the pouch. The intact suture line while pouch
is intubated and filled with fluid. B. The pouch is checked for integrity and
continence after the tube is removed.
Continence of the valve

After filling the pouch, the Water tube is removed, and the exit
conduit is evaluated for leakage.
A continent valve should not allow for leakage through the exit
conduit and allow for retention of all instilled fluid inside the pouch
(Fig. 46-14B).
The Water tube is placed again for drainage and decompressing the
pouch.
Stoma Creation
The stoma aperture is created at the marked site by a specialized wound
ostomy and continence nurse.
Preparing for the pouch to be anchored to the fascia at the base of the
stoma trephine
3-4 seromuscular bites are taken, distributed around the pouch, and
placed in the desired respective points on the fascia and are taken using
2-0 nonabsorbable polyester suture (Fig. 46-15A and B).
FIGURE 46-15 A. Tacking the pouch to the anterior abdominal wall. B. Pouch
parachuted in its place after ileostomy was delivered through stoma aperture. Note the
previously placed anchoring stitches.
The exit conduit is then delivered through the stoma aperture in an

oriented manner, while the pouch is parachuted in position. The anchoring
sutures are then tied securely (Fig. 46-16).
FIGURE 46-16 Stoma delivered. Anchoring sutures tied.
Another intubation and continence check is undertaken before final

placement of the Water tube inside the pouch for decompression.
The stoma is matured to the skin flush.
Water tube is anchored to the skin in a tripod manner using 0-silk suture
(Fig. 46-17A and B).
FIGURE 46-17 A. Final closure and Water tube placed. B. Stoma matures and Water
tube fixed in place. Note: In this case, the upper lesion was an old ileostomy site that was
closed. We usually located more inferiorly on the abdomen.
We place a JP drain adjacent to the pouch for a few days.
Postoperative Care
care plan.
instances, with proximal fistula and extensive dissection and dilated
bowel, a nasogastric tube may be kept in.
IV fluids are minimized.
The diet is slowly advanced to a soft diet.
acetaminophen.
The Water tube is kept in for 3 weeks and re-evaluated for intubation at
follow-up in clinic.
Suggested Readings
Aytac E, Dietz DW, Ashburn J, Remzi FH. Is conversion of a failed IPAA to a continent ileostomy a
risk factor for long-term failure? Dis Colon Rectum. 2019;62(2):217-222.
Nessar G, Fazio VW, Tekkis P, et al. Long-term outcome and quality of life after continent ileostomy.
Dis Colon Rectum. 2006;49:336-344.
PART VI
Pelvic Floor Disorders
Chapter 47
Rectal Prolapse
TRACY HULL
GIOVANNA DA SILVA SOUTHWICK
Rectal prolapse is a clinical diagnosis, as most patients present with a
protruding “mass” that may spontaneously reduce or stay continuously
prolapsed (Fig. 47-1).
FIGURE 47-1 Prolapsed rectum and initial exposure.
In severe (and rare) cases, patients may present with incarcerated or

strangulated prolapse that requires emergent treatment.
Prolapse is more than an anatomical problem, as most patients have
associated functional abnormalities, such as incontinence, constipation,
and outlet obstruction.
Rectal prolapse repairs are plagued, in part, by high recurrence rates
despite technical success.
Perineal rectosigmoidectomy (ie, Altemeier) involves the full-thickness
excision of the rectum and potentially a portion of the sigmoid colon,
followed by a coloanal anastomosis just proximal to the levators.
The procedure is associated with relatively high rates of postoperative
morbidity (up to 32%) and recurrence (up to 26% with prolonged
follow-up).
Functional outcomes may persist, including incontinence, soilage, and
urgency—largely due to the loss of the compliant rectum along with a
reduction in resting anal sphincter pressure.
The Delorme procedure involves stripping the mucosa of the prolapsing
rectum from the sphincters and muscularis propria, followed by plication
of the muscularis propria and reanastomosis of the mucosal ring.
Recurrence rates range from 4% to 38%.
Fecal incontinence can be seen up to 75% of patients, while 15%-65%
of patients have concomitant constipation or evacuation disorders.
Abdominal approaches involve mobilization of the rectum and fixating it
to the sacrum.
Abdominal mobilization classically involves a predominately posterior
mobilization with limited anterior and lateral dissection.
Mesh may be used to aid in fixation to the sacrum.
The addition of a sigmoidectomy is classically reserved for patients
with severe constipation and a large redundant sigmoid colon.
Complications in the operating room typically occur in <5%.
Most common is bleeding and hematoma.
Bleeding is often self-limiting, although it may require takeback and
oversewing. Pelvic sepsis, although rare, can occur.
Other postoperative complications include hemorrhage, fecal
impaction, deep space infections, anastomotic leak, urinary tract
infections, surgical site infections, and respiratory infections.
Late postoperative complications include bowel obstruction, ureteral
fibrosis, rectovaginal fistula formation and worsening, or new fecal
incontinence or constipation and recurrence.
TIPS
Patients should be aware that although the prolapse will resolve with
proper operative therapy, functional results often continue to be
problematic.
Patient Positioning
The patient is placed in modified lithotomy. Legs are held in Yellowfins
lithotomy position, giving the option to the surgeon to stand/sit between
the legs for perineal procedures as well as for perineal access for
abdominal procedures.
Alternatively, for the perineal procedures, a prone position may be
preferred.
Patient should be well secured to the operative table, and body parts are
well padded, and joints properly positioned as patient will be in steep
Trendelenburg for the majority of the operative procedure when
abdominal procedures are performed.
An orogastric tube is inserted as well as a Foley catheter, which comes out
The primary working monitor is on the patient’s left side or at the leg for
abdominal minimally invasive procedures.
Patients are given a full bowel preparation, including oral antibiotics and
perioperative intravenous (IV) antibiotics.
Equipment
Abdominal
Laparoscope with 0- and 30-degree camera
10-mm conventional laparoscopic port
5-mm ports ×3
10- to 12-mm conventional laparoscopic port for suturing (or stapler for
cases with a sigmoidectomy)
Standard minimally invasive instrument tray
Large-pore, soft, lightweight mesh (optional)
Laparoscopic mechanical tacker (optional)
Bipolar energy device (optional)
Sutures
Synthetic monofilament absorbable 3-0 suture
0-braided nylon nonabsorbable suture (for pexy)
2-0 polyglycolic acid, waxed suture
End-to-end sizers
Wound protector (if resection is performed)
Balfour retractor (optional, used if open approach)
Perineal
Anal eversion sutures or Lone Star retractor
Electrocautery
Bipolar energy device (optional)
2-0 and 3-0 Vicryl sutures
Anesthesia
General anesthesia is typically utilized.
multimodal analgesia with transversus abdominis plane perianal block,
and oral and IV analgesia.
DELORME PROCEDURE
Technique
Anal eversion sutures or a Lone Star retractor is placed to provide
exposure (Video 47-1).
The prolapse is grasped with a Babcock clamp(s) and exteriorized.
The mucosa is scored ∼1-3 cm proximal to the dentate line, and the initial
incision is performed.
Infiltration of the submucosa with epinephrine-based local anesthesia
(1:200 000) to separate it with the underlying muscle may facilitate
dissection and reduce bleeding.
The mucosectomy/submucosectomy is continued circumferentially and
proximally in an avascular plane, leaving a circular muscular tube (Fig.
47-2).
FIGURE 47-2 Continued proximal dissection in the submucosal plane.
Evert the mucosal/submucosal sleeve and continue the dissection

proximally until unable to do so.
Plication sutures (∼8) are placed longitudinally in a circumferential
manner with 2-0/3-0 Vicryl sutures or 2/0 polydioxanone (PDS) and tied
down to bring the muscle together in an accordion manner (Fig. 47-3).
FIGURE 47-3 Circumferential plication sutures.
The excess mucosa/submucosa is resected and passed off to pathology.

The mucosa is reapproximated over the plication to create the handsewn
anastomosis with 3-0 Vicryl sutures (Fig. 47-4).
FIGURE 47-4 Mucosal closure over the plication sutures.
Alternatively, 2/0 PDS sutures are placed at the edge of the anoderm and
proceeding distally toward the apex and finishing with a suture through
the colonic mucosa. As the sutures are tied, the muscle cuff is easily
reduced and the edges of the mucosa approximated.
ALTEMEIER PROCEDURE (PERINEAL

PROCTOSIGMOIDECTOMY)
Patients are given a full bowel preparation (including oral antibiotics).
If the prolapse is incarcerated and not reducible or the bowel is dead, no
bowel preparation is given.
A Foley catheter is placed, and IV antibiotics are given preoperatively.
The patient is urgently operated on in the lithotomy position. This is also
the primary procedure used for incarcerated or dead rectal prolapse (Fig.
47-5).
FIGURE 47-5 Necrotic prolapse: If the prolapse has become incarcerated and
necrotic, an Altemeier procedure (i.e., perineal rectosigmoidectomy) is urgently performed.
Anesthesia can be general, spinal, epidural, or monitored local.

This operation is typically used for the very infirmed patients, so
monitored local anesthesia in the lithotomy position would be our
approach for that specific type of patient.
The patient can be positioned prone or lithotomy if general, spinal, or
epidural anesthesia is used.
Technique
The prolapse is grasped with a clamp and exteriorized.
If a handsewn anastomosis is performed, a line is made with the
electrocautery, 1 cm proximal to the dentate line (Fig. 47-6).
Note: With the bowel exteriorized, proximal can be confused with
distal.
FIGURE 47-6 For a handsewn anastomosis, the prolapse is everted. An

electrocautery is used to mark the incision line one centimeter proximal to the dentate
line.
The using the electrocautery or the knife the incision is made (Fig. 47-7A
and B).
FIGURE 47-7 A. A full thickness incision is made 1 cm proximal to the dentate line. B.
Intraoperative photo of the incision.
The incision is deepened full thickness through the bowel, and the edges
marked with a suture (Fig. 47-8A and B).
FIGURE 47-8 A. A full thickness incision is made until the fat around the bowel is
detected. B. Intraoperative photo of the full thickness incision.
Dissection is continued proximally until the peritoneal cavity is entered,
allowing more proximal redundant bowel to be exteriorized.
The proximal bowel edge will be free at this point and extended out the
anus (Fig. 47-9).
FIGURE 47-9 The mesentery is divided either with ties or an energy device. This
allows for the colon to protrude out the anus.
The mesenteric vessels are divided and tied or divided and sealed with an
energy device. It is imperative to ensure the vessel of the proximal bowel
is securely ligated as it will immediately retract back into the pelvis when
released (Fig. 47-10).
FIGURE 47-10 Illustration of division of the mesentery between clamps.
With the peritoneal reflection opened (typically, it will be encountered

anteriorly), the operator will then be able to insert their finger into the
abdominal cavity. Usually after dividing this structure, more proximal
bowel will easily come down (Fig. 47-11A and B).
FIGURE 47-11 A. Anteriorly the peritoneal reflection is encountered and must be
opened for maximal mobilization of the colon and rectum. B. Intraoperative photo
demonstrating division of the peritoneal reflection.
A levatorplasty can be added at this stage, if desired. We would consider

this for a patient with significant fecal incontinence.
The levators are grasped with an Allis clamp and approximated with 1-0
polyglactin suture in a simple or figure-of-eight manner.
For the coloanal anastomosis, an opening is made with the electrocautery
on the anterior aspect of the proximal bowel.
Care is taken to ensure this is viable bowel and the planned proximal
resection margin will not be under excessive tension when the
anastomosis is completed.
A suture of 2-0 polyglactin is placed from the distal cut edge through the
newly made proximal cut edge and pinned out.
Similarly, the proximal bowel is divided in quarters, and a 2-0 Vicryl
suture is placed on the right, left, and posteriorly and the sutures pinned
out. This ensures that the proximal bowel does not retract as it is being
divided.
The sutures are tied down and augmented with additional sutures (Fig. 47-
12).
FIGURE 47-12 The proximal bowel is resected so there will be minimal tension on
the anastomosis. A handsewn coloanal anastomosis can be completed.
If a stapled anastomosis is performed, the initial incision is made 2 cm

proximal to the dentate line in order to accommodate the stapler.
The mobilization and mesentery division proceeds as described earlier.
A purse-string suture is placed in the proximal bowel. Another is placed at
the cut edge of the distal bowel.
The stapler with the head on is opened.
The stapler is carefully inserted, and the head placed in the proximal
bowel and tied down.
The distal purse string is tied down (Fig. 47-13).
Care is made in female patients to ensure the vaginal wall is not in the
staple line.
FIGURE 47-13 A stapled anastomosis for the Altemeier procedure.
The stapler is fired, and the result is a circular staple line just above the
sphincters.
TIPS
It is important with this procedure to ensure you enter the peritoneal

cavity.
TIPS
Deciding the extent of resection can be difficult. When the bowel does
not easily pull down out of the anus and a finger beside it detects mild
tension as far as the operator can feel, should signal adequate
mobilization.
ABDOMINAL PROCEDURES
Posterior Rectopexy +/– Sigmoid Resection

Patients are given a full bowel preparation (utilizing oral antibiotics also)
and one dose of IV antibiotics prior to skin incision (Video 47-2).
A Foley catheter is placed.
This procedure can be done open, laparoscopically, or robotically, though
the steps remain the same.
For the open approach, if feasible, a Pfannenstiel incision is used.
A wound protector and Balfour retractor aid in exposure.
The small bowel is packed in the upper abdomen, and the patient is placed
in steep head down.
The main part of the procedure then mirrors the laparoscopic approach
explained later.
The patient is secured on the table to prevent movement during steep head
down. Both arms are tucked. They are placed on split-leg attachments or
low lithotomy stirrups.
Access is gained via the umbilical area with 10- to 12-mm trocar.
Two 5-mm trocars are placed on the right (used for placing sutures), and a
10- to 12-mm trocar is placed in the suprapubic area or in the right lower
quadrant (used to insert sutures into the abdomen).
All under direct vision. In the video, the patient’s head is up and right is
on the left side of the screen. The camera is put in via the umbilical
port.
After gaining access to the abdomen, the patient is placed in steep head
down. The lateral attachments to the sigmoid are only taken down if they
are in the pelvis or obstruct the view into the pelvis.
Dissection is started at the right pelvic brim. The total mesorectal excision
plane (posterior to the superior rectal artery and anterior to the hypogastric
nerves) is entered with scissors or other laparoscopic dissection devices.
At the right pelvic brim, the overlying tissue is cleaning off to allow for
eventual sutures to be placed for the rectopexy.
Dissection is carried down to the pelvic floor posteriorly. On the right, we
dissect to the pelvic floor.
On the left side, dissection is only performed to the left “lateral” ligament,
which is not divided if the patient does not have recurrent rectal prolapse.
In the video, this patient has recurrent rectal prolapse, and dissection is
carried down on the left to the pelvic floor.
If the uterus is still present, a suture on a straight needle can be passed
from the suprapubic skin level into the abdomen under direct vision,
placed through the uterus and then advanced out back onto the skin and
tied outside the abdominal cavity.
This can aid in pulling the uterus toward the abdominal wall and out of
the field.
On the left, a 5-mm trocar can be placed, which can be used to retract
the uterus out of the field and also provide countertraction on the
vagina.
Neither of these techniques was required for the patient in the video.
Anteriorly in women, we dissect half or one-third of the rectovaginal
septum.
Also, if there is difficulty dividing the peritoneum to enter the pouch of
Douglas, a hook cautery can be helpful (not used in the video).
In men, we dissect to the prostate anteriorly.
The rectum is pulled up to the sacrum, and the redundancy of the sigmoid
is assessed.
The rectum is identified, and the mesentery divided where the rectum will
be divided. The linear laparoscopic stapler is introduced into the
suprapubic port. Ideally, rectal division accomplished with only one firing
of the stapler. As shown in the video, it often requires two firings to divide
the rectum.
Two permanent sutures of 0 or #1 nonabsorbable braided sutures are
placed in the right anterior sacral ligament at the pelvic brim.
The sutures are introduced via the suprapubic port. Care is taken to avoid
tangling them.
For the sigmoid resection, the inferior mesenteric artery and vein are
divided after identification of the left ureter typically using a laparoscopic
energy device. Since this is not for a cancer, the division can be performed
several centimeters distal to the aorta (not shown in the video).
The suprapubic port is lengthened, and a wound protector placed. The
colon is brought out, and the sigmoid is divided where it easily will reach
the pelvic brim and we will also leave about 1-2 cm of redundancy. The
mesentery and bowel are divided, and a purse string applied, and the head
of the stapler placed in the end of the sigmoid and tied down (not shown in
the video).
The colon is returned to the abdominal cavity, and pneumoperitoneum is
reestablished.
The colorectal anastomosis is performed in the standard manner, ensuring
that the proximal bowel does not twist as the stapler is closed (anastomosis
shown in the video).
The “donuts” are checked.
Tip: A flexible sigmoidoscopy is not done until after the sutures are
placed and tied to avoid air in the bowel, which can obstruct the view
when placing the rectopexy sutures.
The rectopexy sutures are placed through the right lateral rectal ligament
(shown in the video).
Prior to tying, each suture is traced out. Tying can be done with the knot
pusher (our preferred practice) or intracorporeally (neither method shown
in the video).
A flexible sigmoidoscopy is performed to verify an airtight anastomosis
and that there is no luminal kinking from the sutures (not shown in the
video).
We do not typically place a pelvic drain.
TIPS
A lot of the dissection, as seen in the video, can be done bluntly in the
embryologic plane.
TIPS
Placing sizers in the vagina and rectum and positioning them to open
the rectovaginal septum can aid in anterior dissection (not done for
the patient in the video).
TIPS
If the sigmoid will kink over significantly when the rectum is fixed to
the sacrum or if the patient has preoperative constipation, a sigmoid
resection is performed (sigmoid resection demonstrated in the video).
TIPS
It is crucial to be at the pelvic brim or flat portion of S1. Avoid distal

or lateral placement of sutures. The needle must go through the
anterior sacral ligament, and the surgeon should be able to pull with
some force and the suture does not come out.
Postoperative Care
care plan.
Orogastric tubes are removed prior to extubation, IV fluids are minimized,
diet is given day 0, and urinary catheters are removed day 1.
acetaminophen.
Diet is varied per individual surgeon, though in general, constipation and
straining are to be avoided.
Suggested Readings
Bordeianou L, Paquette I, Johnson E, et al. Clinical practice guidelines for the treatment of rectal
prolapse. Dis Colon Rectum. 2017;60(11):1121-1131.
Carvalho E, Carvalho ME, Hull T, Zutshi M, Gurland BH. Resection rectopexy is still an acceptable
operation for rectal prolapse. Am Surg. 2018;84(9):1470-1475.
Hatch Q, Steele SR. Rectal prolapse and intussusception. Gastroenterol Clin North Am.
2013;42(4):837-861.
Riansuwan W, Hull TL, Bast J, Hammel JP, Church JM. Comparison of perineal operations with
abdominal operations for full-thickness rectal prolapse. World J Surg. 2010;34(5):1116-1122.
Steele SR, Varma MG, Prichard D, et al. The evolution of evaluation and management of urinary or
fecal incontinence and pelvic organ prolapse. Curr Probl Surg. 2015;52(2):17-75.
Steele SR, Varma MG, Prichard D, et al. The evolution of evaluation and management of urinary or
fecal incontinence and pelvic organ prolapse. Curr Probl Surg. 2015;52(3):92-136.
Chapter 48
Ventral Rectopexy
SHERIEF SHAWKI
Full-thickness rectal prolapse is a true intussusception of the rectum
through the sphincters versus the anorectal mucosa only.
Typically, patients present with symptoms to include fecal incontinence,
bulging “mass,” pain, mucous discharge, bleeding, and reduced quality of
life.
Perineal approaches may be best suited for high-risk patients, given the
less invasive nature of the procedure compared to traditional open
approaches, and the ability to be performed under regional or local
anesthesia.
With minimally invasive technology, data have shown reduced
postoperative pain, decreased length of hospital stay, earlier recovery,
lower surgical site infections, and similar functional results and recurrence
rates with an abdominal approach.
All patients (unless contraindicated) should receive preoperative oral
antibiotics (eg, metronidazole and neomycin), along with a full
mechanical bowel preparation, and provided a chlorhexidine body wash
for the night prior to surgery.
Patient Positioning
The patient is placed in modified lithotomy position. Legs are held in
Yellowfins. Lithotomy position gives the option to the surgeon to stand
between the legs when distal transverse colon mobilization is necessary.
Patient should be well secured to the operative table, body parts are well
padded, and joints properly positioned as patient will be in steep
Trendelenburg for the majority of the operative procedure, while the robot
is docked.
An orogastric tube is inserted as well as a Foley catheter that comes out
The surgeon is at the robot, and the bedside assistant stands at either side.
The primary working monitor is on the patient’s right side.
Equipment
Robotic platform with 0- and 30-degree camera
10-mm conventional laparoscopic port
8-mm ports × 3 (robotic)
8- to 12-mm conventional laparoscopic port
Robotic instruments
Cadiere forceps
Fenestrated bipolar grasper
Robotic scissors
13 cm × 15 cm biologic graft
Sutures
Synthetic monofilament absorbable 3-0 suture
0-Prolene
2-0 polyglycolic acid (PGA), waxed suture
End-to-end anastomosis (EEA) sizers
Anesthesia
General anesthesia is typically utilized.
multimodal analgesia with transversus abdominis plane block, oral, and
intravenous analgesia.
Technique
Port Placement
For Si Platform
A 10-mm conventional laparoscopic port at the umbilicus for the robotic
camera.
Two robotic trocars (8 mm) placed 9 cm lateral and 15 degrees caudal to
the umbilicus bilaterally.
A third robotic trocar corresponding to the fourth robotic arm is placed 9
cm lateral and 45 degrees cephalad on the left side.
An 8- to 10-mm conventional laparoscopic port is placed on the patient’s
right lateral side for assistant. This creates a flattened “W” configuration
(Fig. 48-1A).
FIGURE 48-1 da Vinci Si port placement. A. Si Port Placement. B. Xi Port Placement.
For Xi Platform
The four robotic arms are placed horizontally across the level of the
umbilicus (Fig. 48-1B). The robotic camera is placed through robotic arm
3. The assistant port remains the same (Fig. 48-2).
FIGURE 48-2 Xi robot and differences in arms.
The patient is subsequently placed in steep Trendelenburg for exposure of

the pelvis and in preparation for docking.
During this time, and prior to docking the robot, the surgeon may perform
any needed steps, in a conventional laparoscopic manner, to assure proper
pelvic exposure.
This may include moving the redundant sigmoid colon, and or cecum
out from the pelvic cavity, perform adhesiolysis, and/or tucking the
uterus to the anterior abdominal wall (Fig. 48-3A-D).
FIGURE 48-3 A. Bowel in pelvic cavity that will need to be removed. B. Bowel
being removed from pelvic cavity. C. Takedown of adhesions to remove the bowel
from the pelvis. Inset. Lysis of adhesions is done prior to docking for optimal pelvic
exposure and safe conduction of the procedure. This could also be done while the
robot is docked. D. Uterus anchored to anterior abdominal wall.
Docking
For both Si and Xi platforms, the robot is docked from the patient’s left
side, at a 45-degree angle on the operative table.
This allows access to the perineum for feeling level of distal dissection
and using sizers through the vagina and the rectum, at surgeon
discretion.
Appropriate positioning of the robotic arms is crucial.
Proper triangulation and spacing between robotic arms ensure full
range of movement and avoid external collision.
Arms should be checked and should be resting on patient’s extremities.
Robotic Instruments Placement

Scissors are placed through arm 1 and connected to monopolar
electrocautery (Xi arm 4).
Fenestrated bipolar grasper is placed through Si arm 2 (Xi arm 2) and
connected to bipolar electrocautery.
Cadiere grasper is placed through Si arm 3 (Xi arm 1).
Tip: All instruments need to be placed into the abdominal/pelvic cavity
under direct vision to avoid iatrogenic injury.
Rectopexy
Step 1: Identify the anterior sacral longitudinal ligament (ASLL) (Fig. 48-4A
and B)
FIGURE 48-4 A. Identification of surrounding anatomical structures. Peritoneum incised
to identify anterior sacral longitudinal ligament (ASLL). B. ASLL identified and cleared from
any overlying tissues.
Identification of surrounding anatomical structures to determine the target

area of dissection: right iliac vessels, right ureter, and sacral promontory.
The grasper in arm 3 holds a distal sigmoidal appendiceal epiploica and
retracts it cephalad toward the left shoulder. Occasionally, the bedside
assistant will retract the relatively redundant sigmoid colon to facilitate
exposure.
Dissection is started on the right lateral peritoneum at level of sacral
promontory in order to identify the ASLL. Care must be exercised here
not to drift to the left to avoid injuring the left hypogastric nerve, nor the
left iliac vein.
The ASLL should be well identified and cleared without overlying tissues
to ensure proper pexy suture placement of the mesh at the end of the
procedure.
Step 2: Dissecting and creating the right pararectal peritoneal flap (Fig. 48-
5A-D)
FIGURE 48-5 A and B. Outline for the peritoneal flap. C and D. Peritoneal flap
completed.
Here the dissection is performed at the level of the peritoneal covering only
and not deeper.
With the right ureter and uterosacral ligament identified laterally and
rectum identified medially, the right lateral peritoneum is incised along the
length of the pelvis. Dissection should remain just medial to the
uterosacral ligament.
The underlying fatty tissues are gently and bluntly pushed down to create
the peritoneal flap for future closure around the mesh.
Step 3: Entering and dissection of the rectovaginal septum (Fig. 48-6)
FIGURE 48-6 A. Entering and dissection of the rectovaginal septum (RVS). B. Continued
dissection in the septum. A-C. Entering the RVS. D. Dissection in the RVS is deepened. E.
Distal dissection reached.
The peritoneum overlying the cul-de-sac is incised to enter the

rectovaginal septum. The laxity associated with prolapse necessitates
proper traction and countertraction to enter that plane precisely and avoid
bleeding or organ injuries.
An EEA stapler sizer may be placed in the vagina and rectum to facilitate
entry in the rectovaginal septum and help with retraction.
Tip: Any bleeding suggests dissection is outside the proper plane and
reorientation is needed.
It is important to identify the anterior rectal wall for proper placement of
anchoring sutures between the mesh and the rectal wall.
Once confirmed you are in the correct plane, dissection is carried out
caudally, exposing the anterior wall of the rectum until the perineal body
is reached.
The pelvic floor on each side is exposed during dissection.
Step 4: Mesh preparation
A 13 cm × 15 cm biologic graft is prepared on the back table. The graft is
soaked in normal saline.
The graft is tailored and fashioned accordingly to avoid redundancy and
wrinkling in order to minimize fluid accumulation.
The graft is then wrapped from left to right and placed through the 8-10
mm assistant port and placed on the right side of the pelvis distally.
This way the surgeon can have it ready in position by unfolding it from
right to left and avoid struggling with intracorporeal positioning.
Step 5: Anchoring the mesh (Fig. 48-7A-D)
FIGURE 48-7 A. Preparing the mesh. A and B. Mesh tailored and placed in position. C.
First stitch to anchor the mesh. D. Anchoring mesh to the anterior wall of the rectum
completed.
The mesh is secured to the perineal body in the midline.

Next, it is secured to the anterior rectal wall with three or four rows.
The stitches in the rectum should be seromuscular bites precisely.
To use synthetic monofilament absorbable 3-0 suture for anchoring the
mesh.
Step 6: Securing the graft to the sacral promontory (Fig. 48-8A-F)
FIGURE 48-8 A. Tensing the mesh. B and C. First stitch taken to secure the mesh to the
anterior sacral longitudinal ligament (ASLL). D. Second stitch is now taken. E and F. The
mesh is secured to the ASLL with two stitches of 0-Prolene suture.
The mesh is tensed properly.

In this step, the graft should not be lax, but more importantly, should
not be under any tension to avoid overcorrection of the prolapse.
The point of anchoring stitch on the graft is chosen.
Two stitches of 0-Prolene are used to anchor the tail of the mesh to the
sacral promontory at the initially identified and cleared ASLL.
Step 7: Reperitonealization of the pelvis (Fig. 48-9)
FIGURE 48-9 A and B. Pelvic peritonealization starting with closing cul-de-sac
circumferentially. C and D. The pelvic cavity is now reperitonealized, and mesh is covered.
The cul-de-sac is closed circumferentially.

We prefer a 2-0 PGA, waxed suture, is placed circumferentially, and
then closed tightly.
The right lateral peritoneal flap is closed over the mash using running 2-0
PGA suture.
The robotic arms are all placed in visual field. If the uterus was anchored
to the anterior abdominal wall, this should be undone prior to de-
insufflation.
The robot is undocked, ports are removed, and port sites are closed in the
usual manner.
Postoperative Care
care plan.
acetaminophen.
Diet is varied per individual surgeon, though in general, constipation and
straining are to be avoided.
Suggested Readings
Emile SH, Elfeki HA, Youssef M, Farid M, Wexner SD. Abdominal rectopexy for the treatment of
internal rectal prolapse: a systematic review and meta-analysis. Colorectal Dis.
2017;19(1):O13-O24.
Gurland B, Carvalho E Carvalho ME, et al. Should we offer ventral rectopexy to patients with
recurrent external rectal prolapse? Int J Colorectal Dis. 2017;32(11):1561-1567.
Jallad K, Ridgeway B, Paraiso MFR, Gurland B, Unger CA. Long-term outcomes after ventral
rectopexy with sacrocolpoor hysteropexy for the treatment of concurrent rectal and pelvic
organ prolapse. Female Pelvic Med Reconstr Surg. 2018;24(5):336-340.
Chapter 49
Sacral Neuromodulation and
Sphincteroplasty for Fecal
Incontinence
LISA C. HICKMAN
CECILE A. FERRANDO
Fecal incontinence (FI) can be the result of a variety of factors, including
sphincter injury, irradiation, intestinal pathology, decreased rectal
compliance, central or peripheral neurologic dysfunction, diarrhea,
myopathy, and functional abnormalities.
It is essential that providers screen for FI, and the clinical evaluation
incorporates a comprehensive history, physical examination, and bowel
function evaluation to better define the underlying etiology.
The management of FI should follow a stepwise approach, starting with
conservative therapies, including diet modification, management of stool
consistency, and implementing a bowel-training program.
These interventions have been found to benefit ∼25% of individuals.
For those with FI refractory to conservative management, pelvic floor
physical therapy (PFPT) with biofeedback is recommended.
Interventions escalate in invasiveness thereafter and include perianal
bulking agents, sacral neuromodulation (SNM), barrier devices, the Secca
procedure, anal sphincter repairs, artificial sphincters, colostomies, and
dynamic graciloplasties.
The two main surgical modalities utilized for FI include SNM and anal
sphincter repair.
SNM was first utilized abroad for the treatment of FI starting in 1995
and was subsequently the Food and Drug Administration approved for
this indication in 2011.
Patients are first asked to record a baseline diary of their FI episodes and
then undergo a two-part procedure.
The first stage of the procedure involves the insertion of a tined lead
into the S3 sacral foramen under fluoroscopic guidance in the operating
room (OR) using sedation and local analgesia.
Once the lead is placed, it is attached to an external, temporary
stimulation device.
Alternatively, patients can undergo a percutaneous nerve evaluation
(PNE), which is an office placement of wire into S3 foramen without
fluoroscopic guidance using local analgesia only.
Patients are then again asked to collect a diary over a 2- to 4-week
period. If patients have at least a 50% improvement in FI episodes, they
can go on to the second stage of the procedure, in which a permanent
pulse generator is implanted in the upper buttock region and connected
to the internalized lead.
If patients do not meet the threshold of improvement to proceed with
the second stage, the lead is removed.
Due to the risk of a false-negative result from lead shifting after a PNE, it
is highly recommended to proceed with a formal stage 1 procedure for
those not meeting the improvement criteria.
Studies investigating the efficacy of SNM have shown encouraging results
with up to 5-year data, demonstrating that 85% of implanted individuals
maintain at least 50% improvement from their baseline FI episodes, with
up to 40% of patients reporting complete continence.
Anal sphincter repairs are more invasive and are reserved for individuals
with FI who have the following indications:
FI is refractory to conservative measures and PFPT with biofeedback.
There is a known sphincter defect on examination and imaging.
Perianal bulking and SNM are either not available or unsuccessful.
Individuals who meet these criteria often include postpartum women
with new-onset FI and those with known sphincter injuries from
nonobstetric etiologies.
SACRAL NEUROMODULATION
The goal of SNM is to improve the patient’s FI by at least 50%.
Preoperatively, patients should be counseled on the planned technique, the
need for an incontinence diary after PNE or stage 1, expected outcomes, and
postoperative recovery.
Patients should be provided with chlorhexidine gluconate scrubs to utilize
at home the day before and morning of surgery for cleansing of the lower
back and buttock area.
Perioperative antibiotics to cover gram-positive bacteria should be
administered prior to starting the stage 1 procedures. For stage 2 or a
combined stage 1 and 2 procedure, during which the permanent pulse
generator is implanted, coverage should be broadened to include
methicillin-resistant Staphylococcus aureus, with or without gram-
negative coverage. We suggest:
For a stage 1 procedure: second-generation cephalosporin
For a stage 2 or combined stages 1 and 2: vancomycin and gentamycin
Monitored anesthesia care with local anesthetic should be utilized. This
type of anesthesia is beneficial as it permits the patient to provide
feedback during the procedure and expedites postoperative recovery.
Patient Positioning
Patients should be placed in the prone position on an operating table that
can accommodate fluoroscopy with a C-arm.
Hips should be placed at the midportion of the table where the C-arm will
be located so that the sacrum can be visualized on anteroposterior (AP)
films.
The patient’s feet should be just off the edge of the operating table so that
motor response to sacral nerve stimulation can be appreciated.
Padding of the patient’s chest with rolled blankets or foam can help with
comfort and respiration. Similarly, padding beneath the patient’s hips and
shins can also provide comfort in the prone position.
The patient’s feet and low back/buttock area should remain exposed, while
the shoulders, upper back, and legs can be covered.
The patient’s buttock area should first be cleansed with soap and water if
any fecal soiling is present.
The back and buttock region is prepared with a 2% chlorhexidine
gluconate solution, such as ChloraPrep, starting at the low back, working
more cephalad and lateral, and saving the buttocks and gluteal cleft until
last. We prefer the inferior margin of the prep to reach just inferior to the
tip of the coccyx. Prior to draping the patient, sufficient time should be
given to permit the prep to dry.
For stage 1 procedures:
In addition to a standard drape, a sterile horizontal drape is placed over
the anus that can be lifted to view the perianal (bellow’s) response
without contaminating the surgical field.
A ground pad is placed on the patient’s heel and connected to the end
of the test stimulation cable. The test stimulation cable adapter is also
connected to the external neurostimulator (ENS). The ENS is then
paired with the hand-held programmer.
We begin using fluoroscopy and an instrument to identify the medial
edges of the S2 to S4 foramina. This area is marked bilaterally using a
marking pen. Lateral fluoroscopy is then used to identify the planned
needle entry site, which is cephalad and parallel to the bone fusion
seam of S3 (Fig. 49-1). Again, this location is marked with a marking
pen.
FIGURE 49-1 Lateral view of sacral bone seams on fluoroscopy.
Alternatively, if fluoroscopy is not present at the start of the procedure,

the planned sites can be marked using the patient’s bony anatomy. A
ruler is used to mark the point 9 cm cephalad from the tip of coccyx
and 2 cm lateral on each side. An additional marking should be made 2
cm more cephalad from the previous two marks. This is also the
technique utilized for a PNE in the office.
A local anesthetic, such as 0.25% bupivacaine, is then injected to create
a wheal subdermally at the planned entry site.
The foramen needle is inserted in a cephalocaudal direction to a depth
at or below the posterior sacral surface near the hillock. Fluoroscopy is
used to confirm proper placement.
The sterile end of the test stimulation cable is then connected to the
noninsulated area on the foramen needle, and the programing device is
activated to confirm appropriate S3 motor and sensory responses at
low-amplitude levels:
The motor responses include plantar flexion of the great toe and a
bellow’s response, which is a tightening or pulling in motion best
seen in the perianal region.
The sensory response in women is stimulation in the vaginal and
perineal region and in men is stimulation at the base of the penis,
scrotum, and rectum.
The stylet from the foramen needle is removed, and the directional
guide is inserted through the foramen needle, after which the foramen
needle is removed. Care must be taken to ensure that the directional
guide is stabilized so that it is not accidentally removed or displaced.
An #11 blade scalpel is used to make a small incision at the base of the
directional guide.
The lead introducer sheath and dilator is placed over the directional
guide. Fluoroscopy in the lateral view should be used to ensure that the
radiopaque marker is located at approximately half the depth of the
sacrum.
The guidewire and dilator are removed, leaving the introducer sheath in
place. The tinned lead is then inserted, and fluoroscopy is utilized to
achieve lead placement just inferior to the posterior surface of the
sacrum on the lateral view (Fig. 49-2). On the AP view, the lead tip
should point laterally and slightly caudally (Fig. 49-3).
FIGURE 49-2 Lateral view of tined lead placement in relation to sacrum.
FIGURE 49-3 Anteroposterior view of tined lead placement in relation to sacral
foramen.
Each of the four electrodes are again tested for appropriate motor and
sensory responses with the test stimulation cable.
Under fluoroscopy, the introducer sheath is carefully removed while
concurrently stabilizing the lead in place, which deploys the lead tines.
The stylet is removed from the lead and again tested for appropriate
motor and sensory responses.
Next, the connection site, which is generally located below the iliac
crest and lateral to the sacrum, is identified and marked.
The area is injected with local anesthetic, and a horizontal incision ∼4-5
cm in length is made.
Blunt dissection is then used to create a pocket that will be the site for
the future permanent pulse generator. This pocket can be irrigated with
a dilute antibiotic solution, such as bacitracin, in sterile water.
The tunneling tool with passing straw is inserted at the lead exit site
and passed underneath the skin in the subcutaneous tissue to exit the
newly created pocket. The tunneling tool is then removed, leaving the
straw in place, through which the lead is passed to exit the pocket. The
straw is then removed.
The site for the percutaneous extension is then marked on the
contralateral side superior to the iliac crest. The tunneling tool with the
passing straw is reassembled and then passed from the pocket to the
newly marked exit site. The passing straw is again left in place after
removal of the tunneling tool, and the percutaneous extension is passed
from the exit site to the pocket. The straw is then removed.
The lead and percutaneous extension connector are connected, and the
set screws are tightened with a torque wrench. The protective boot is
then secured over the connection using two permanent sutures.
After irrigating, the connection is placed in the pocket.
After hemostasis is achieved, the pocket is then closed in two layers, a
deeper layer of 2-0 polyglactin suture, followed by a subcuticular
closure with a 4-0 polyglactin suture.
The test stimulation cable and ENS are disconnected from the
grounding pad on the patient’s heel.
The percutaneous exit site is dressed and connected to the twist lock
cable associated with the ENS. The area is padded and dressed for
patient comfort.
Postoperatively, the patient is observed in the postanesthesia care unit.
The patient is instructed on utilizing the programmer, completing a
diary, and caring for the surgical sites.
We discharge all patients home with an oral antibiotic regimen, such as
trimethoprim-sulfamethoxazole or doxycycline. These antibiotics
should be taken for the duration of the trial period, which is generally 2
weeks.
At the end of the trial period, if the patient has at least 50%
improvement in incontinence symptoms, she can proceed with the stage
2 procedure.
For stage 2 procedures:
Local anesthesia is administered over the previously created upper
buttock incisional site.
The test stimulation cable is disconnected from the twist lock cable.
This incision is opened, and the percutaneous extension wire is
identified, disconnected, and discarded.
The pocket is further developed to allow implantation of the permanent
pulse generator. The pulse generator is connected to the lead, and the
set screw is tightened.
After copious irrigation of the pocket with the dilute antibiotic solution,
the generator is placed into the pocket with the noninsulated side facing
up, and electrical programming analysis is performed to evaluate pulse
width, frequency, amplitudes, and impedances (Fig. 49-4).
FIGURE 49-4 Permanent pulse generator placement.
After hemostasis is achieved, the incision is then closed in two layers, a

deeper layer of 2-0 polyglactin suture, followed by a subcuticular
closure with a 4-0 polyglactin suture.
The skin can be covered with steri-strips, and a sterile dressing should
be applied. Patients should be instructed to remove the dressing on
postoperative day 1 or 2 and the steri-strips on postoperative day 7.
For patients who do not reach the improvement threshold:
The programmer is turned off, and the patient is taken to the OR for
lead removal.
The patient is prepared and draped as previously described, and local
anesthetic is injected.
The previously created pocket is opened, and the percutaneous
extension wire is identified, disconnected from the tinned lead, and
discarded.
The previous lead introducer site is opened, and the lead is gently
pulled through the subcutaneous tissue from the pocket and out the
previous entry site.
Gentle traction is then used to remove the lead from its sacrum.
After hemostasis is achieved, the lead introducer site and pocket are
closed as previously described.
PEARLS AND PITFALLS
Pearls
If vancomycin is used for antibiotic prophylaxis, it takes 1 hour to

infuse. Antibiotic administration should be started in the preoperative
area to ensure complete infusion before initiation of the procedure.
Although the S3 foramen is the preferred location for lead placement,
occasionally, this cannot be successfully accessed. In these situations,
S4 can be utilized. S2 is generally not appropriate for chronic
neuromodulation.
Only sterile water should be utilized for irrigation, and saline should be
avoided.
Care should be taken during tunneling to avoid the lead being too
superficial.
SNM may be an excellent option for individuals with both urinary and
FI; however, the magnitude of effect may not be equal. SNM can also
be utilized for women with obstetric anal sphincter defects up to 120
degrees.
Data on efficacy of SNM for FI are encouraging. Approximately 90%
of patients who undergo a stage 1 procedure will go on to stage 2
placement of the permanent pulse generator. At up to 5 years after
SNM, ∼85% of patients report maintaining the original >50%
improvement in FI episodes, and ∼40% experienced no further
incontinence episodes.
Pitfalls
If a wound infection occurs, all implanted components should be

removed. The pulse generator pocket should be allowed to close by
secondary intention. The patient should be treated with antibiotics. A
combined stage 1 and 2 procedure should be delayed for ∼3 months and
until complete healing has occurred.
Pain at the permanent pulse generator site that is refractory to oral
analgesics can be managed with a topical anesthetic or a trigger point
injection.
There is concern over the use of a magnetic resonance imaging (MRI)
in individuals with a permanent pulse generator implant; however,
evidence supports the safety of an MRI for the head or upper spine
when a smaller magnet (1.5 T) is used.
If there is declining efficacy overtime, one should first troubleshoot the
programming and impedance of the neuromodulator. Fluoroscopy can
be used to evaluate the integrity and placement of the lead. Providers
may consider a trial with the device turned off, to obtain a full
understanding of the patient’s symptoms. If the patient is still
symptomatic, one can consider a placing a new tined lead in the
contralateral S3 foramen in a stepwise manner or removing and
replacing the poorly functioning lead in a combined stage 1 and 2
procedure.
ANAL SPHINCTEROPLASTY
The goal of an anal sphincter repair is to correct the sphincter defect using
either an end-to-end or overlapping approach. Preoperatively, patients should
be counseled on the planned technique, outcomes, and postoperative
recovery, in addition to the standard informed consent process.
Some surgeons recommend a mechanical bowel preparation prior to
surgery, but we elect to utilize a Malecot catheter with betadine or a baby
shampoo solution to lavage the rectum of any stool.
Perioperative antibiotics with a third-generation cephalosporin and
metronidazole should be administered prior to starting the surgery. These
antibiotics can be continued postoperatively. We elect to continue
intravenous antibiotics for the first 24 hours.
The approach to anesthesia can be either regional or general and should be
selected based on clinical factors and the extent of the planned surgery.
Prophylaxis for venous thromboembolism (VTE) should be administered.
We utilize sequential compression devices on the lower extremities, and if
patients are at increased risk for VTE, perioperative heparin is
administered.
Patient Positioning
Patients can be placed in either lithotomy or the prone jackknife position.
We generally choose to position patients in lithotomy with their legs in
Allen-type stirrups. This permits the surgeon and one or two assistants to
access the surgical field. This position also provides excellent access to the
perianal region and vagina for female patients. Care must be taken during
positioning to not hyperextend or hyperflex the hips or knees, as this can
result in a postoperative neuropathy if there is nerve entrapment. The
technique we describe in this chapter is for patients placed in the lithotomy
position.
The benefit of utilizing the prone jackknife position is that the buttocks
either can be taped or will naturally fall out of the way of the surgical
field. This is the preferred procedure for more extensive repairs, such as an
artificial anal sphincter or a muscle graft procedure.

An examination under anesthesia should be performed to evaluate the
distance between the posterior vaginal wall and the rectum, determine the
presence and extent of any rectocele or perineocele, and to assess the
sphincter defect.
After the patient is prepared and draped, we start by inserting a Foley
catheter to continuously drain the bladder.
An inverted U-shaped arc should be marked on the perineum, ∼1-1.5 cm
ventral and lateral to the anal verge (Fig. 49-5). The arc should not extend
beyond 200 degrees, as pudendal nerve branches innervating the external
anal sphincter approach from a posterolateral manner.
FIGURE 49-5 Planned incision location for sphincteroplasty.
For females, we also place two Allis clamps along the hymenal remnant
and a third Allis clamp on the vaginal epithelium at the proximal edge of
any posterior vaginal wall defect.
We inject dilute lidocaine and epinephrine solution into the subepithelial
space along the planned incision site, as well as along the posterior wall of
the vagina for women (Fig. 49-6).
FIGURE 49-6 Allis clamp placement and lidocaine with epinephrine injection.
Using the scalpel, an incision is made along the previously marked

inverted U.
Allis clamps are placed along the epithelial edges, and sharp dissection
using Mayo scissors is performed to separate the epithelium from the
subepithelial tissue. This dissection should be performed down to the
rectovaginal septum.
For women undergoing a concurrent posterior colporrhaphy or levator
myorrhaphy, we elect to make a vertical incision along the midline of the
posterior vaginal wall and perineal body. Allis clamps are placed along the
edges of posterior vaginal wall, and dissection with Mayo scissors is
performed to separate the epithelium from the underlying fibromuscular
layer bilaterally. This is continued until the lateral edge of the rectocele is
identified or the levator ani muscles are encountered (Fig. 49-7). A finger
can be placed rectally during the dissection to help reduce the risk of an
unintentional proctotomy.
FIGURE 49-7 Posterior vaginal dissection.
Attention is then turned back to the perianal region. Electrosurgical

cautery and sharp dissection are utilized to further delineate the
rectovaginal septum. Care must be taken here to avoid injury to the
remaining internal anal sphincter, if intact, as well as to prevent buttonhole
defects into the anal canal or rectum.
The dissection is then carried laterally to the ischiorectal fat.
Next, the scar tissue in the midline of the defect is identified (Fig. 49-8)
and divided (Fig. 49-9). It is important to leave the scar attached to each
end of the sphincter, as it will help provide strength to the completed
repair and will contribute to the sphincter flaps needed for an overlapping
repair.
FIGURE 49-8 Identification of anal sphincter scar.
FIGURE 49-9 Division of anal sphincter scar.
Using sharp dissection, anal sphincter flaps of ∼1.5-2 cm in length should

be created (Fig. 49-10).
FIGURE 49-10 Creation of external anal sphincter flaps.
Prior to initiating the sphincter repair, the area should be copiously

irrigated with a dilute antibiotic solution, such as bacitracin, and judicious
electrosurgical technique should be used to obtain hemostasis.
If the internal anal sphincter is intact, it can be plicated using a several
interrupted delayed-absorbable sutures, such as 3-0 polyglactin. If the
internal anal sphincter is disrupted, it can be repaired en mass with the
external anal sphincter.
Next, the external anal sphincter is repaired in an either overlapping or
end-to-end manner. For overlapping repairs, we prefer to use either a 0 or
2-0 polyglactin or a polydioxanone suture. The ends of the sphincter flaps
are grasped with Allis clamps and overlapped with one half placed deep
and the other half placed more superficially. A total of two to three
vertical mattress sutures are placed through the overlapping sphincter on
each side, starting at the attached lateral portion of the more superficial
flap. Next, an additional two to three vertical mattress sutures are placed in
a similar manner at the scarred end of the more superficial sphincter flap
(Fig. 49-11).
FIGURE 49-11 Overlapping repair of external anal sphincter.
For an end-to-end repair, the same sutures can be utilized to bring the ends
of the sphincter together. Allis clamps are placed along the edges of the
sphincter. Interrupted sutures are sequentially placed on the posterior,
inferior, superior, and anterior portions of the sphincter. Although it is our
preference to perform an overlapping repair, in situations where flaps
cannot be sufficiently mobilized, this is an acceptable alternative.
If a posterior colporrhaphy or levator myorrhaphy are planned, they
should be performed at this point. The rectovaginal fascia or levator ani
muscles should be plicated using interrupted sutures of 2-0 polyglactin or
polydioxanone suture. Care should be taken to ensure that the vaginal
caliber is not significantly narrowed, so as to permit penetrative
intercourse for sexually active women.
Distal sutures to rebuild the perineal body are placed. For this portion of
the procedure, we prefer to use a larger gauge absorbable suture such as 0
polyglactin.
If there is excess vaginal tissue, the vaginal epithelial edges can be
trimmed.
A rectal examination should be performed to ensure that no remaining
posterior vaginal wall defect is present or that no unrecognized injury or
suture is present in rectal mucosa. Additionally, the anal canal should
permit one fingerbreadth on digital rectal examination.
The tissue should be irrigated an additional time with the antibiotic
solution, and hemostasis should be achieved.
If there is a vaginal incision, it is closed using a running 2-0 polyglactin
suture to the level of the hymen.
The distal vaginal incision and perineal skin edges are closed using 3-0
polyglactin sutures in an interrupted manner after excess skin edges on the
perineal body are trimmed, if needed.
If possible, a V-Y closure is performed for the perineal body incision (Fig.
49-12). This technique leaves the central portion of the incision open for
drainage. Sometimes, a vertical closure may afford better cosmesis and a
greater perineal body length.
FIGURE 49-12 Skin closure using V-Y technique.
All patients are admitted for overnight observation, primarily for

continuation of antibiotics and to ensure adequate analgesia. In our
experience, the large majority of patients meet the postoperative
milestones necessary for discharge on postoperative day 1.
PEARLS AND PITFALLS
Intraoperative Pearls
Intraoperatively, a needle-tipped Bovie at a low setting can be utilized

to help identify the sphincter muscle by causing muscular twitching
when applied to its fibers.
If dead space exists on the perineal body, a Penrose drain can be placed
and removed postoperatively to avoid seroma or hematoma formation.
For those who have failed previous repairs, require a complex
procedure, or have concomitant bowel disease, one can consider
concurrently creating a stoma to divert stool.
If there is difficulty with hemostasis during the vaginal portion of the
procedure, vaginal packing can be placed to provide pressure on the
posterior vaginal wall. We elect to leave these in place until
postoperative day 1. If vaginal packing is used, an indwelling Foley
catheter should remain in place until the packing is removed.
If a levator myorrhaphy is performed, we recommend utilizing a
retrograde-fill voiding trial to ensure that patients are able to effectively
empty their bladder postoperatively.
Postoperative Pearls
An aggressive bowel regimen is essential postoperatively. We routinely

send all patients home on twice-daily docusate sodium, daily
polyethylene glycol, and a teaspoon of daily mineral oil. Fiber
supplements can also be utilized. We recommend that patients utilize
the mineral oil until they have a bowel movement. After that, the bowel
regimen can be titrated to keep stool at a soft, but tolerable, consistency.
Providing the patient with a foam ring, such as the head pillows used by
anesthesia, is helpful, as it permits sitting without direct pressure on the
perineum and perianal region.
Patients often experience significant postoperative pain after these
procedures, so an effective analgesic regimen is key. For individuals
without contraindications, we recommend scheduled nonsteroidal anti-
inflammatory medication and acetaminophen, for the first 72 hours after
discharge, in addition to as-needed opioid analgesics.
Pitfalls
Sometimes, there is very little tissue between the rectum and the
posterior vagina. A finger placed rectally can help decrease the risk of
an unintentional proctotomy. If a proctotomy does occur, the area
should be copiously irrigated with an antibiotic containing solution,
such as bacitracin, and then repaired with a 4-0 chromic or
poliglecaprone suture.
Wound infection can occur in up to 25% of patients and can be
managed with oral antibiotics.
Suture disruption is common and will often heal by secondary intention
when good perineal hygiene is implemented.
Although initial outcomes after anal sphincter repair are encouraging,
with 80%-90% demonstrating functional improvement, studies suggest
this effect decreases over time, with <40% of patients having
satisfactory continence 5-10 years after surgery.
Suggested Readings
El-Gazzaz G, Zutshi M, Hannaway C, Gurland B, Hull T. Overlapping sphincter repair: does age
matter? Dis Colon Rectum. 2012;55(3):256-261.
Halverson AL, Hull TL. Long-term outcome of overlapping anal sphincter repair. Dis Colon Rectum.
2002;45(3):345-348.
Rodrigues FG, Chadi SA, Cracco AJ, et al. Faecal incontinence in patients with a sphincter defect:
comparison of sphincteroplasty and sacral nerve stimulation. Colorectal Dis. 2017;19(5):456-
461.
Chapter 50
Vertical Rectus Abdominis
Myocutaneous Flaps, Gluteal Flaps,
and Plastic Surgery Reconstruction in
Colorectal Surgery
EMRE GORGUN
RAY ISAKOV
Several flaps are available to bring healthy, well-vascularized tissue into
complex, often irradiated, and large wounds that would otherwise take
months to heal or not heal at all.
Prior or planned surgeries (eg, ostomies) need to be accounted for when
choosing the type of flap utilized.
Vertical rectus abdominis myocutaneous flaps (VRAMs) fill the pelvis
with muscle bulk and can also be used for vaginal wall reconstruction.
VRAMs result in relatively lower complication rates compared with other
flap types.
VRAMs use an oblique or vertical skin flap and an inferior pedicle.
VRAMs are the most commonly used abdominal flap in the perineal
region and consists of skin, subcutaneous tissue, and muscle.
Gluteal and gracilis flaps also provide healthy bulking tissue and can be
used to heal in defects following abdominoperineal resection and fistula
(eg, rectourethral and rectovaginal).
Multidisciplinary approach with plastic surgery is advised.
Positioning
Positioning should be in the lithotomy position for harvesting of a VRAM
and gracilis graft.
Prone positioning is typically utilized for gluteal flaps.
Change of positioning for various segments of the operation may be
necessary.
Proper perineal and lower extremity skin preparation is required for all
grafts.
Special Equipment
#15 or #10 blade and scalpel
Marking pen
Electrocautery
Forceps
Suture or staples
Standard soft-tissue operating set
Drain
Mesh may be required to close the resultant abdominal defect after the
graft is harvested.
Abdominal binder
VERTICAL RECTUS ABDOMINIS MYOCUTANEOUS FLAPS
Technique
After standard sterile preparation and draping, palpate and outline the
rectus abdominis muscle and then mark the midline and lateral borders of
the flap.
Start the incision from the midline down to the linea alba and down to the
mons pubis.
Designate the skin island to fill the perineal defect, and when cutting the
skin island, pay attention to preserve the blood supply.
Extend the incision laterally to dissect the flap from the rectus sheath.
Ligate the perforators coming off of posterior rectus sheath.
After separating the rectus muscle, open the posterior sheath to enter the
abdomen (Fig. 50-1).
FIGURE 50-1 Borders of the ventral rectus flap are marked based on the dimensions
of the defect.
Incise the lateral and superior margins of the flap deep into the fascia.
Identify and preserve the deep inferior epigastric artery pedicles.
After complete dissection and mobilization of the flap, rotate the flap 180
degrees on the long axis, and using the abdominal incision, pass the flap
deep into the pelvis and position it in the perineum (Figs. 50-2 to 50-4).
FIGURE 50-2 Flap is incised and raised then rotated 180 degrees and passed
through pelvis to close the defect.
FIGURE 50-3 Intraoperative photo of muscle passed to the perineum.
FIGURE 50-4 Intraoperative photo of rotated flap with skin paddle facing outward.
Following locating the flap in the perineum, suture the proximal edge of
the flap to the vagina/perineum.
Align the flap with the skin island staying outward and fixate the position
using staples.
Subsequently use dermal sutures and close the skin (Fig. 50-5).
FIGURE 50-5 Intraoperative photo of completed vertical rectus abdominis

myocutaneous flaps.
GLUTEAL FLAPS
Technique
After the oncologic resection is completed, following standard preparation
and draping, palpate the gluteal muscles and delineate and mark the
gluteal fasciocutaneous flap.
Mark the flap site unilaterally or bilaterally depending on the defect
dimensions.
Flaps can be performed via a rotational method or in a V-Y manner.
After marking is completed, make the curvilinear skin incision and
continue down to the subcutaneous tissue and fascia using electrocautery
(Fig. 50-6).
FIGURE 50-6 Curvilinear skin incision is made to fit the gluteal defect. Left or right
gluteus maximus can be selected to harvest the flap.
Carry out the dissection cautiously, as to not harm the perforator vessels.
Continue the dissection until the fascia is released and flap can be raised
(Fig. 50-7).
FIGURE 50-7 Dissection is carried out until the fascia is released to allow raising of
the flap.
Form the flap into an island and advance it medially to fit in the perineal
defect.
Adjust the flap to close the defect and de-epithelialize the sides of the flap
(Fig. 50-8).
FIGURE 50-8 Gluteal flap is raised and turned to fit the perineal defect. It can be
stabilized by stapling or placing corner sutures.
Stabilize the flap on the new location by stapling or placing corner sutures.
We usually prefer interrupted 1# Vicryl for fascia and 0 Vicryl for
approximation (Fig. 50-9).
FIGURE 50-9 Raised flap is stabilized, and layers are sutured.
Place the drain through a separate incision after fashioning the gluteal flap.
Close the fascial layer of the defect with 2-0 Vicryl suture and the
subcutaneous layer with 3-0 Monocryl sutures.
Close the skin with 3-0 Prolene mattress sutures (Fig. 50-10).
FIGURE 50-10 Closed defect after gluteal flap reconstruction.
GRACILIS FLAP
Technique
After standard sterile draping and preparation, in lithotomy position,
extend the knee and abduct the hip at 30 degrees.
Mark the muscle axis after determining dimensions of the graft needed
based on the size of the defect. Draw a line on the skin down to the
middle/distal end of the outlined gracilis muscle (Fig. 50-11).
FIGURE 50-11 Borders of the gracilis muscle is delineated and marked according to
the size of the defect.
First incision of the gracilis muscle should be 4 fingerbreadths distal to the

anterior superior iliac spine, and the distal incision should be over the
tendon. Adjust the incision size based on the defect size.
Make a full-thickness skin incision down to the muscle and muscular
bundles.
Elevate the fascia off the muscle, and after identifying the junction of
gracilis and adductor longus, enter this space.
Free and isolate the gracilis muscle except for the pedicle and transect the
muscle. Pay close attention to the neurovascular bundle during this step.
Rotate the muscle flap and locate it over the defect (Fig. 50-12).
FIGURE 50-12 Adequate size of gracilis flap is rotated and placed over the defect,
layers are closed with suturing.
Fixate and inset the flap into the defect site and suture with 3-0 interrupted
chromic sutures.
Close the subcutaneous and deep dermal layers with 3-0 Vicryl in an
interrupted manner and close the skin with 4-0 absorbable subcuticular
sutures.
Place a 15-Fr Blake drain and extract through distal thigh skin with 2-0
silk sutures.
Postoperative Care
Patients should be kept on their sides and off of the flap, with rotation.
Specialized air or other nonpressure beds are preferred.
We utilize early ambulation and venous thromboembolic
chemoprophylaxis in nearly all patients.
Drains are kept until serous, and, in general, <50 mL/24 hours (though
individualized).
Sutures are generally left in for a few weeks and then removed in the
outpatient clinic.
Suggested Readings
Althumairi AA, Canner JK, Gearhart SL, et al. Risk factors for wound complications after
abdominoperineal excision: analysis of the ACS NSQIP database. Colorectal Dis.
2016;18(7):O260-O266.
Bell SW, Dehni N, Chaouat M, Lifante JC, Parc R, Tiret E. Primary rectus abdominis myocutaneous
flap for repair of perineal and vaginal defects after extended abdominoperineal resection. Br J
Surg. 2005;92(4):482-486.
Chan S, Miller M, Ng R, et al. Use of myocutaneous flaps for perineal closure following
abdominoperineal excision of the rectum for adenocarcinoma. Colorectal Dis. 2010;12(6):555-
560.
Choudry U, Harris D. Perineal wound complications, risk factors, and outcome after abdominoperineal
resections. Ann Plast Surg. 2013;71(2):209-213.
Chapter 51
Complex Abdominal Wall
Reconstruction Following Colorectal
Surgery
CLAYTON C. PETRO
MICHAEL J. ROSEN
For the most part, complex abdominal wall reconstruction implies the
utilization of a component separation technique, which, in our hands, is
typically a transverses abdominis muscle release (TAR).
The technique is relevant as hernia rates follow colorectal surgery can be
as high as 18% and often occur in the context of permanent, temporary, or
prior ostomy sites.
Although the TAR technique has been described elsewhere in great detail,
in this chapter, we focus on subtle caveats to consider following a
previous colorectal operation.
Specifically, we focus on the impact of a prior colectomy, proctectomy,
and/or ostomy site on the retromuscular dissection as these planes may
have been violated during a previous colorectal procedure.
Parastomal repairs will be addressed separately in Chapter 45.
Sterile Instruments
Sterile blue or green surgical towel, moistened
10 Kocher clamps
Bonney or Ferris-Smith forceps
Right-angle clamp
Two large Richardson retractors
Kittner (blunt) dissector on a medium or long Kelley clamp
Two large Crile retractors
Carter-Thomason suture passer
Large malleable
Positioning
Patients are approached in a supine position, and both arms can be left out.
We widely prep and drape the patient in a diamond configuration so that
the xyphoid, pubis, and lateral abdominal wall (including both anterior
superior iliac spines) are sterile and palpable within the surgical field. This
allows for wide placement of transfascial fixation sutures once the
retromuscular mesh is in place (Fig. 51-1).
FIGURE 51-1 Sterile preparatory and draping landmarks. The bold black line
indicates the boundaries of draping—xyphoid, pubis, and bilateral anterior superior iliac
spines (black star) should be palpable within the sterile field. Red stars indicate the typical
placement of transfascial sutures fixating mesh reinforcement. The thin gray line highlights
the prior ostomy site in the right lower quadrant. Note the previous right lower quadrant
paramedian incision from a remote appendectomy. This patient had laparoscopic ports
from a more recent sigmoid colectomy for diverticular disease. An anastomotic leak
required a laparotomy and diverting loop ileostomy that has subsequently been reversed.
He now has a 12-cm wide midline ventral hernia.
We routinely place a Foley catheter.

INTRA-ABDOMINAL ACCESS, ADHESIOLYSIS, AND SETUP
Technique
We begin with a midline laparotomy extending cephalad to the previous
incision, when possible, in order to divide a native portion of the linea
alba. A complete adhesiolysis is done to free the anterior abdominal wall
—see Pearls and Pitfalls.
Laterally, the intra-abdominal adhesiolysis should extend to the white
lines of Toldt so as not to dissect the colon away from the lateral
abdominal wall and inadvertently enter the retroperitoneum. To address
adhesiolysis at a prior colectomy site, see Pearls and Pitfalls.
When possible, all interloop adhesions should be taken down unless the
risk of an enterotomy is prohibitory and the patient did not have
obstructive symptoms.
The bowel should be examined thoroughly to confirm the absence of any
full-thickness enterotomies, and serosal tears should be oversewn.
Once the viscera are freed from the abdominal wall, they are covered with
a moistened blue or green surgical towel. This step signifies that the intra-
abdominal portion of the procedure is complete—the surgeon should be
satisfied with the viscera (ie, anastomoses, serosal injuries, hemostasis).
After placement of the towel, with no tension on the abdominal wall, the
dimensions of the defect should be measured from its widest point by the
length of the laparotomy incision.
Tip: If the patient is in a split-leg or lithotomy position for the
colorectal portion of the procedure (ie, Hartmann reversal), this should
not disrupt the operation if the thighs are placed leveled with the torso.
We do place a fresh set of sterile drapes in these concomitant scenarios
when the contaminated portion of the procedure is complete.
Tip: Avoiding inadvertent enterotomies during multiply reoperative
surgery is critical. We advocate for taking down adhesions from the
midline first to optimize exposure of the lateral abdominal walls, which
are approached separately.
PEARLS AND PITFALLS

When taking down adhesions from the lateral abdominal wall, be
cautious not to enter the preperitoneal plane. When possible, place your
hand behind—lateral to—the small bowel and omentum being removed
from the abdominal wall so that you have a defined lateral endpoint and
do not inadvertently dissect into the abdominal wall.
The dictum “better to leave abdominal wall on the bowel than bowel on
the abdominal wall” can ultimately leave you with holes in your
visceral sac of peritoneum and make the TAR dissection much more
difficult. Visceral adhesions should be taken directly off the peritoneum
in order to preserve it when possible.
The lateral extent of the adhesiolysis should be the peritoneal reflection
over the colon. However, if the patient has had a previous colectomy,
this plane was likely entered in the past. Dissect the viscera away from
the anterior abdominal wall just enough so that it can be covered with a
towel during the TAR dissection. Attempting to dissect the viscera
away from the abdominal wall too far lateral at a prior colectomy site
will lead to the retroperitoneum and detach the peritoneum from its
lateral/retroperitoneal fixation point. Lateral detachment of the
peritoneum is an almost unfixable problem for even the most
experienced abdominal wall surgeon.
The placement of a towel protects the underlying viscera from an
inadvertent injury during the TAR dissection.
Conversely, if the viscera are left adhered to the retroperitoneum at a
prior colectomy site and not covered by the towel, the surgeon must be
cautious not to injure the underlying intestine during the TAR
dissection.
Regaining proper intraperitoneal exposure after the TAR dissection can
be challenging, potentially ruin the dissection by tearing the
peritoneum, and should not be relied upon. Do not routinely plan on
returning to the peritoneal cavity once the towel is placed over the
viscera.
RETRORECTUS DISSECTION
Technique
Place four to five Kocher clamps on the medial aspect of the anterior
rectus fascia. Be sure to palpate the tubular rectus muscle so as not to
inadvertently clamp the hernia sac (Fig. 51-2).
FIGURE 51-2 Kocher placement on medial edge of rectus. Bold black line indicates
medial edge of rectus.
Identify the defect in the posterior rectus sheath at a prior ostomy site (Fig.
51-3). The lateral dissection will occur superior and inferior to the Kocher
clamps, marking the defect in the posterior sheath.
FIGURE 51-3 Prior ostomy site. Black circle highlights the defect in the posterior
rectus sheath indicative of a previous ostomy.
The retromuscular dissection is begun by incising the posterior rectus

sheath medially to expose the medial edge of the underlying rectus muscle
(Fig. 51-4). Bonnie forceps are helpful for retraction.
FIGURE 51-4 Initiation of retrorectus dissection. Incision of the posterior rectus
sheath (purple arrow) exposes the medial edge of the underlying rectus muscle (black
arrow) to confirm entry into the retrorectus space.
Once the rectus muscle is exposed, the entire length of the posterior sheath
can be incised following the medial edge of the rectus muscle (Fig. 51-5).
FIGURE 51-5 Complete division of medial posterior rectus sheath. Black arrows
pointed at medial cut edge of the posterior rectus sheath that exposes the entire rectus
abdominis.
The remaining five Kocher clamps can then be placed on the exposed edge
of the posterior rectus sheath for countertraction while developing the
retrorectus plane using a combination of blunt dissection and
electrocautery for hemostasis (Fig. 51-6). Take care to preserve laterally
perforating neurovascular bundles, and note that the prior ostomy site is
avoided at this point.
FIGURE 51-6 Retrorectus space developed. Green arrows highlight neurovascular

bundles demarcating the lateral extent of the retrorectus dissection. The blue arrow points
out the subtle loss of the posterior rectus sheath indicative of the arcuate line.
Inferiorly, take care to protect the epigastric vessels as they are not yet
enveloped by the rectus muscle below the arcuate line. Dissect them
anteriorly with the rectus muscle.
Tip: Begin incising the posterior rectus sheath at a point where the
rectus is clearly identified and do not proceed until muscle is
visualized. We find the rectus muscle is most consistently found
cephalad near the costal margin, though a large epigastric hernia,
previous subcostal incision, or diastasis can distort this finding.
Tip: If part of the rectus is exposed elsewhere by virtue of you initial
laparotomy, use this as a landmark to divide the rest of the posterior
sheath, taking care to stay as medial as possible.
PEARLS AND PITFALLS
When developing the retrorectus plane, most lateral perforating

neurovascular bundles should be preserved. That said, there are
consistently several perforators that will encroach on the medial
retrorectus space. Although an attempt should be made to mobilize
these laterally if possible, it is not unusual to have to sacrifice some of
these in order to completely mature the retrorectus pocket. This should
only be done once it is clear that the retrorectus space extends far lateral
to these perforators.
Note that the linea semilunaris is immediately lateral to the majority of
neurovascular perforators.
Inferiorly, the epigastric vessels need to be identified and should be
preserved. There is typically a large medial branch off of the epigastric
artery just below the arcuate line that will need to be divided.
Again, the linea semilunaris is often found ∼1 cm lateral to the
epigastric vessels. When developing the retrorectus space, be sure to
keep the vessels anterior with the rectus muscle.
INFERIOR TAR DISSECTION
Technique
The inferior TAR dissection is begun by incising the posterior lamina of
the internal oblique just medial to the perforating neurovascular bundles.
This is typically ∼1 cm lateral to the epigastric vessels. The surgeon
should attempt to identify the linea semilunaris so as not to dissect too far
lateral.
Dividing the posterior lamina of the internal oblique will expose the
aponeurotic portion of the transversus abdominis muscle above the arcuate
line—this layer must also be divided carefully to preserve the underlying
peritoneum (Fig. 51-7). Often, it is difficult and unnecessary to distinguish
between these two aponeurotic layers. Rather, the remaining
thin/translucent peritoneum is the landmark that indicates the correct depth
of dissection.
FIGURE 51-7 Inferior transverses abdominis muscle release dissection. Above the
arcuate line, division of the lateral posterior rectus sheath—consisting of fibers from the
posterior lamina of the internal oblique and aponeurosis of the transversus abdominis—
just medial to the semilunar line isolates the underlying peritoneum.
Below the arcuate line, there is a thin layer of transversalis fascia that must
also be divided to isolate the peritoneal layer that was exposed above the
arcuate line, making the two planes contiguous.
Using medial retraction on the peritoneum, the transversus abdominis
muscle can be bluntly dissected away from the peritoneum using a Kittner
dissector. This will lead to the retroperitoneum.
Staying on the peritoneum, continue this preperitoneal dissection laterally
until the psoas muscle is exposed (Fig. 51-8).
FIGURE 51-8 Exposure of the psoas muscle. The lateral extent of the preperitoneal
transverses abdominis muscle release dissection ends with exposure of the psoas
muscle, highlighted by visualizing the white stripe of the psoas tendon (black arrow). This
is reached by entering a subtle cleavage plane in the retroperitoneal fat, leaving some fat
(blue lines) adherent to the lateral abdominal wall (yellow arrow).
Blunt dissection of the transversus abdominis away from the peritoneum

can continue cephalad along the psoas muscle, behind (lateral to) the prior
ostomy site that has been left intact.
A dry sponge can be placed in the superior aspect of this retroperitoneal
dissection pocket to mark the end of the inferior TAR dissection.
Inferiorly, the gonadal structures will often be encountered as they are
adherent to the peritoneum as they exit the internal inguinal ring.
For women, the round ligament can be divided slowly with cautery
with no consequence.
For men, the gonadal vessels should be carefully de-peritonealized and
left tucked in the retroperitoneum, allowing for medial peritoneal
advancement.
Of note, adequate exposure for this portion of the procedure may only
be possible once the suprapubic portion of the dissection is complete
—to follow.
Tip: Obtain the appropriate depth of the TAR dissection by maintaining
tight medial traction on the posterior rectus sheath, keeping it flat, and
briskly cauterizing the line of dissection until a thin layer of peritoneum
remains beneath the incised fascia.
Tip: Once the appropriate depth of the TAR dissection is reached at a
single location—dividing the posterior aponeurosis of the internal
oblique and aponeurosis of the transversus abdominis while leaving the
underlying peritoneum intact—use a right angle to mature the
dissection plane.
Tip: Keeping tension on the posterior sheath will aid this dissection.
Tip: If you are experiencing difficulty identifying the psoas muscle
during the retroperitoneal dissection—that can be challenging in large
patients with excess retroperitoneal fat—gentle palpation of the iliac
vessels can be a helpful landmark. The psoas is just lateral and deep to
the iliac vessels.
PEARLS AND PITFALLS
While bluntly dissecting away the transversus abdominis muscle from

the peritoneum, retroperitoneal fat is encountered. There are typically
two layers of fat separated by a cleavage plane. Entering this plane
leaves some fat adhered to the lateral retroperitoneum and will lead to
the psoas muscle. Alternatively, dissecting all retroperitoneal fat off of
the abdominal wall will lead to bleeding from retroperitoneal lumbar
vessels.
SUPERIOR TAR DISSECTION
Technique
Next, the superior portion of the TAR dissection begins with division of
the posterior lamina of the internal oblique just medial to the laterally
perforating neurovascular bundles and linea semilunaris. This exposes the
underlying transversus abdominis muscle belly, whose medial aspect is
more prominent in the upper one-third of the abdomen (Fig. 51-9).
FIGURE 51-9 Superior transverses abdominis muscle release dissection. Dividing the
superior one-third of the posterior lamina of the internal oblique (IO) (black arrow) just
medial to the perforating neurovascular bundles (green arrow) exposes the underlying
belly of the transversus abdominis muscle.
Using a right angle, the transversus abdominis muscle belly is isolated and
divided (Fig. 51-10). Again, medial traction on the posterior rectus sheath
aids this dissection.
FIGURE 51-10 Division of transversus abdominis muscle. Division of the transversus
abdominis muscle (“transverses abdominis muscle release” [TAR]) isolates the underlying
peritoneum (blue arrow), which is contiguous with the medial posterior rectus sheath.
Once the transversus abdominis muscle is divided, the peritoneum can be

bluntly dissected away from the transversus abdominis muscle. Again, a
Kittner dissector is used to push the muscle away with medial traction on
the posterior rectus sheath and contiguous peritoneum.
The result is a wide lateral retromuscular/preperitoneal dissection
superiorly and inferiorly (Fig. 51-11).
FIGURE 51-11 Lateral preperitoneal dissections. Superior and inferior preperitoneal
planes developed after division of the transversus abdominis muscle can be matured and
connected laterally.
Tip: When bluntly dissecting away the transversus abdominis muscle from
the underlying peritoneum, begin under the costal margin where the
peritoneum is more durable. Mature the plane superior and lateral first,
then lateral and inferior.
PEARLS AND PITFALLS
Development of the TAR dissection plane must lead under the costal
margin.
A common pitfall is to dissect too far lateral due to fear of making a
hole in the peritoneum. Misidentification of the semilunar line can
result in division of the internal oblique muscle instead of the
transversus abdominis. The intramuscular plane between the internal
oblique and the transversus abdominis is subsequently entered instead
of the preperitoneal plane. The intramuscular plane will not mature
below the costal margin and indicates that the dissection is incorrect.
DISSECTION AROUND THE PRIOR OSTOMY SITE
Technique
Develop the superior and inferior retromuscular dissection planes as
lateral as possible under direct visualization using the Kittner dissector and
medial traction on the peritoneum.
Eventually, the superior and inferior planes will meet lateral to the prior
stoma site that is left intact—identifying the sponge placed at the superior
apex of the inferior dissection signifies the two planes have merged.
Once the planes are merged, placing your hand behind the stoma site will
allow for lateral to medial dissection of the preperitoneal plane until only
the stoma site remains (Fig. 51-12).
FIGURE 51-12 Prior stoma site isolated. Maturing the lateral preperitoneal plane and
connecting the superior and inferior dissections allows lateral to medial dissection to
isolate the prior stoma site.
Now, in a controlled manner, the stoma site can be dissected from the
anterior abdominal wall with minimal damage to the posterior rectus
sheath and contiguous peritoneum (Figs. 51-13 and 51-14).
FIGURE 51-13 Retromuscular dissection at prior stoma site. Dissection toward the
posterior sheath will preserve the anterior muscle, leaving a limited defect in the posterior
sheath.
FIGURE 51-14 Unilateral transverses abdominis muscle release dissection complete.

Note that isolating the retromuscular dissection at the prior stoma site allowed for a
minimal defect in the posterior sheath.
Wide retroperitoneal dissection in the preperitoneal plane allows for
significant advancement of the posterior rectus sheath and contiguous
peritoneum (Fig. 51-15).
Tip: Maintain stiff lateral traction on the peritoneum while maturing the
lateral preperitoneal pockets superiorly and inferiorly. This traction is
most easily set up using your left hand on a dry sponge so that your
finger does not inadvertently pierce the peritoneum.
FIGURE 51-15 Wide retroperitoneal dissection. Note the significant advancement

of the posterior rectus sheath gained by wide retroperitoneal dissection in the
preperitoneal plane.
Tip: Remembering to put the patient in the Trendelenburg position

during the inferior dissection and reverse Trendelenburg during the
superior dissection can often aid in visualization.
PEARLS AND PITFALLS
Once the prior ostomy site is isolated (Figs. 51-11 and 51-12), the
anterior and posterior layers can be separated. Erring toward the
anterior abdominal wall will prevent a larger hole in the posterior layer,
but will reciprocally cause a defect in the anterior muscle. Rather, since
the posterior layer is typically redundant, err away from the anterior
muscle. The remaining hole in the posterior sheath can be repaired
easily since it was isolated to this small reoperative site (Fig. 51-13).
CONTRALATERAL TAR AND ADDITIONAL DISSECTION
Technique
Completion of the contralateral TAR dissection—in the absence of a prior
lateral operative site—will likely be less difficult.
When maturing the inferior preperitoneal plane toward the
retroperitoneum—after the TAR dissection—on the side of a previous
colectomy, the dissection may be more challenging. Remember that after a
previous colectomy, this area is reoperative and the dissection planes are
less obvious. Only dissect laterally enough to create a pocket for the mesh
with sufficient overlap of the midline. Lateral dissection to the psoas does
not necessarily need to be achieved, particularly in the inferior TAR
dissection, and trying to do this can create a lateral detachment of the
peritoneum that is difficult to repair.
Once both retromuscular dissections are complete, they must be merged in
the suprapubic and subxyphoid regions.
The suprapubic dissection occurs in the preperitoneal plane medial to
the epigastric vessels inferiorly until Cooper ligament is exposed under
direct visualization. Retraction of the rectus muscle with a large
Richardson retractor, superior traction on the posterior rectus sheaths
with Kocher clamps, and Trendelenburg position can aid this
visualization. Once Cooper ligaments are exposed bilaterally, the
surgeon should be able to gently dissect the space of Retzius bluntly
between the Cooper ligaments. What preperitoneal attachments remain
adherent to the linea alba can be divided while keeping the linea alba
intact until the space of Retzius is encountered inferiorly (Fig. 51-16).
FIGURE 51-16 Suprapubic dissection. Preperitoneal dissection medial to the
epigastric vessels will expose Cooper ligaments bilaterally and the space of Retzius
can be matured. The posterior rectus sheaths and preperitoneal attachments can be
detached from the linea alba until the space of Retzius and pubis are visualized. A.
Anatomy B. Intraoperative dissection. (Rosen MJ. Posterior component separation
with transversus abdominis release. In: Rosen MJ, ed. Atlas of Abdominal Wall
Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:90-102; with permission.)
The subxyphoid dissection is aided by similar exposure—superior

retraction of the rectus muscles with Crile retractors, inferior traction
on the posterior sheaths, and reverse Trendelenburg position. The
dissection requires detachment of the posterior rectus sheaths from their
insertion into the linea alba while keeping the linea alba intact (Fig. 51-
17). This can continue superiorly on each side for 5-7 cm above the
defect. Under the xyphoid, the preperitoneal fat plane just beneath the
linea alba can be merged with the preperitoneal TAR plane by dividing
the most superior transversus abdominis muscle fibers. This plane can
be matured cephalad to the central tendon of the diaphragm (Fig. 51-
18).
FIGURE 51-17 Subxyphoid dissection. The medial aspect of the posterior rectus
sheaths are detached from the intact linea alba to merge the preperitoneal plane
beneath the linea alba with the lateral retrorectus spaces. (Rosen MJ. Posterior
component separation with transversus abdominis release. In: Rosen MJ, ed. Atlas of
Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:90-102; with
permission.)
FIGURE 51-18 Large visceral sac closed. Closure of the posterior rectus sheaths
isolates the underlying viscera from the retromuscular pocket created by the
transverses abdominis muscle release dissection.
Tip: When you make a hole in the peritoneum, it is wise to begin

dissecting elsewhere if possible (ie, if you make a hole during your
inferior TAR dissection, begin the superior dissection, or vice versa).
Tip: Alternatively, a hole in the peritoneum can be addressed by
quickly moving the dissection more lateral to the hole, with traction on
the peritoneum lateral to the iatrogenic defect. Placing traction on the
peritoneum medial to a hole will no double tear the peritoneum
adjacent to the hole.
Mesh is then placed in the large retromuscular pocket, typically in a
diamond configuration (Fig. 51-19).
FIGURE 51-19 Retromuscular mesh placement. In this case, a piece of 30 × 30 cm
heavyweight polypropylene mesh was placed in the retromuscular space in a diamond
configuration.
Transfascial fixation sutures are then place with a Carter-Thomason suture

passer under direct visualization. Typically, we fixate the mesh with eight
#1 slowly absorbable monofilament sutures at the locations outlined in
Figure 51-1.
Next, we typically place two 19 Fr round Blake drains above the mesh.
These stay in postoperatively until their output is approximately <30
mL/day.
During the subxyphoid dissection, the lateral TAR plane can be merged
with the medial preperitoneal fat plane by dividing the superior most
fibers of the transversus abdominis. The most cephalad portion of the
transversus abdominis is actually contiguous with the diaphragm, and care
should be taken not to dissect anterior to the diaphragm fibers into the
chest.
PEARLS AND PITFALLS
During the suprapubic dissection, the space of Retzius typically matures

easily with gentle blunt dissection, releasing the bladder inferiorly. Any
difficulty—particularly in the context of a reoperative pelvis due to a
prior proctectomy—could indicate that the bladder is anteriorly
adherent to the midline. If this occurs, extend the midline laparotomy
for better visualization and slowly divide the underlying attachments
from the midline so that if a bladder injury occurs, it is visualized.
If there is any concern or uncertainty of a bladder injury, the Foley
catheter can be filled with 400-500 mL of saline tinted with
methylene blue.
ABDOMINAL WALL RECONSTRUCTION
Technique
Once the TAR, suprapubic, and subxyphoid dissections are complete, the
posterior rectus sheaths and contiguous peritoneal layer can be closed to
begin the reconstructive phase of the operation.
Small holes in the peritoneum can be closed with 3-0 absorbable figure-of-
eight stitches, while larger holes can be closed with a running 3-0
absorbable stitch.
The midline posterior rectus sheaths are closed with a running 2-0
absorbable stitch to create a large visceral sac (Fig. 51-18).
The anterior fascia is closed with #1 slowly absorbable monofilament
suture.
After excising any excess soft tissue and prior scars, we close any dead
space in the subcutaneous tissue with a deep running layer of 3-0 chromic
suture.
The skin is closed with a running 4-0 monofilament suture using a
subcuticular stitch.
Figure 51-20 demonstrates the final retromuscular location of the mesh
and orientation of transfascial fixation stitches.
Tip: When placing transfascial mesh fixation sutures, there are
innumerable subtleties. Keep in mind that the aim is for the mesh to lay
flat after the anterior fascia is closed. The following are a few pointers:
Always use the Carter-Thomason suture passer under direct
visualization and protect its destination with a large malleable.
FIGURE 51-20 Final retromuscular mesh placement. (Rosen MJ. Posterior

component separation with transversus abdominis release. In: Rosen MJ, ed. Atlas
of Abdominal Wall Reconstruction. 2nd ed. Philadelphia, PA: Elsevier; 2017:90-
102; with permission.)
Place the suprapubic and subxyphoid stitches first.

Place three lateral fixation sutures on one side of the abdominal
wall.
Each time a stitch is placed, those stitches adjacent to it should be
tightened.
When approximating the appropriate place for anterior fixation, the
anterior fascia should be pulled toward the midline to simulate the
final location of the anterior abdominal wall.
Tie the three lateral fixation sutures on one side before placing the
contralateral stitches and tying those.
The mesh should made as taut as possible, as closing the anterior
fascial layer will always allow for laxity.
PEARLS AND PITFALLS
Regarding closure of the anterior fascia with slowly absorbable #1

monofilament suture:
If there is little tension on the closure, the anterior fascia is closed in
a running manner with 0.5-1 cm bites of clearly defined fascia,
taking care to minimize the incorporation of excess fat and muscle.
If there is any tension on the anterior fascial closure, it is done with
interrupted figure-of-eight stitches, with the majority of traveling
occurring within the stitch and minimal traveling between stitches.
Postoperative Care
Resumption of diet is often up to the presence of any concomitant
colorectal surgery. In general, patients can resume a diet immediately
following surgery.
Drains are commonly placed, and we monitor the drain content for
decreasing output and consistency. In general, wide variation exists in
practice of removal.
We are proponents of abdominal binders for patient comfort and support.
Venous thromboembolism mechanical and chemoprophylaxis and
ambulation following surgery are critical to avoid venothromboembolic
disease.
SUMMARY
Prior ostomy sites and colorectal resections can increase the difficulty of a
TAR dissection.
Perform a TAR dissection inferior and superior to a lateral reoperative site
such as a former ostomy or paramedian incision to minimize the injury to
the posterior rectus sheath and peritoneum.
Minimize the adhesiolysis and lateral/retroperitoneal dissection at a prior
colectomy site so as not to compromise the lateral fixation of the
peritoneum.
Beware of a difficult suprapubic dissection if the patient had a previous
pelvic surgery such as a proctectomy—have a low threshold to investigate
for a bladder injury.
Suggested Readings
Novitsky YW, Elliott HL, Orenstein SB, Rosen MJ. Transversus abdominis muscle release: a novel
approach to posterior component separation during complex abdominal wall reconstruction. Am
J Surg. 2012;204(5):709-716.
Pauli EM, Wang J, Petro CC, Juza RM, Novitsky YW, Rosen MJ. Posterior component separation with
transversus abdominis release successfully addresses recurrent ventral hernias following
anterior component separation. Hernia. 2015;19(2):285-291.
Singh R, Omiccioli A, Hegge S, Mckinley C. Does the extraction-site location in laparoscopic
colorectal surgery have an im-pact on incisional hernia rates? Surg Endosc. 2008;22(12):2596-
2600.
Chapter 52
Constipation
TRACY HULL
SLOW TRANSIT CONSTIPATION
Patients who fail conservative therapy and have slow transit constipation
are documented by a colonic transit study (Fig. 52-1). They also are able
to empty their rectum demonstrated on defecography. When meeting these
conditions, they are considered relative surgical candidates.
FIGURE 52-1 Colonic transit study showing markers scattered throughout the colon
on day 5— consistent with slow transit constipation.
Sometimes, especially if there remains uncertainty about the diagnosis or

when a patient has comorbidities such as malnourishment, a laparoscopic
ileostomy (Fig. 52-2) is constructed to allow the patient to regain their
health and determine whether symptomatic improvement occurs.
In essence, the ileostomy removes the colon from the circuit and should
relieve the bloating and cramping if the source is the colon and not the
upper gastrointestinal or small bowel.
FIGURE 52-2 Sometimes, patients have drastically reduced eating due to the
uncomfortable abdominal symptoms from their constipation. A laparoscopic stoma is a
quick procedure that allows the colon to be taken out of the picture and the patient to
regain their health. In the future, a much more involved resectional operation can be
planned.
If the colon is massively dilated, a laparoscopic loop ileostomy can also

provide a conduit for the colon to be irrigated and reduce in size before
a definitive resection.
If there is concern for ischemic changes due to a dilated colon, a total
abdominal colectomy with end ileostomy is performed.
When a planned colectomy is scheduled, the patient should attempt to
preoperatively perform a mechanical bowel preparation. This is variably
successful.
Equipment
General laparotomy/laparoscopic operating set
Balloon (Hasson) trocar, 12-mm trocar, 5-mm trocars × 3
Endoscopic linear stapler with reloads (as needed)
End-to-end anastomotic stapler
10-/5-mm 30-degree camera
Wound protector
Energy device/vessel sealer
Positioning/Preoperative (See Chapter 3)
In the operating room, a Foley catheter is placed, and preoperative
antibiotics are given.
Venous thromboembolic prophylaxis (chemical and mechanical) is given.
The patient is positioned either in stirrups or on a split-leg table.
The patient is secured to the table as steep head down may be required.
Technique
We typically utilize a laparoscopic approach for a total colectomy;
however, if the colon is massively dilated, it can be performed via a
traditional open laparotomy.
A midline incision is performed for the open approach.
For the laparoscopic approach, access is gained in the umbilical or
supraumbilical area with a 10- to 12-mm balloon or Hasson trocar.
Under direct vision, a 5-mm trocar is placed on the right and left mid-
abdomen and a 10- to 12-mm trocar in the suprapubic midline or right
lower quadrant region. The trocar site in the suprapubic or umbilical
region can be extended for the extraction site.
The entire colon is mobilized in a lateral-to-medial or medial-to-lateral
manner according to the preference of the surgeon. We typically use an
advanced bipolar energy device to resect the mesentery.
The right colon is mobilized from lateral to medial and the mesentery
divided (Figs. 52-3 and 52-4).
The ileocolic vessels are divided (Fig. 52-5). Of note, they do not need
to be divided high near the origin, but the mesentery should be freed
from the duodenal attachments to aid delivery of the colon to the
extraction site when the time comes.
FIGURE 52-3 Lateral mobilization of the cecum.
FIGURE 52-4 Lateral mobilization of the hepatic flexure.

FIGURE 52-5 Division of the ileocolic pedicle. Black arrow depicts the pedicle.
The red arrow is the area of the second portion of the duodenum.
The patient’s position is then changed to head up, and the cut edge of the
mesentery is identified.
The plane is entered that allows simultaneous division of the omentum and
the mesentery of the transverse colon. Alternatively, the omentum can be
removed, followed by division of the mesentery (Fig. 52-6). This is not for
cancer, so the vessels to the colon can be divided relatively near the colon.
Again, we use the bipolar energy device to seal and cut.
The transverse colon is always elongated, and care is taken to avoid
straying from this plane.
FIGURE 52-6 Division of the omental attachments to the transverse colon.
When the splenic flexure is close, the patient is tipped to the extreme right
with head up. The descending colon is mobilized from lateral to medial as
the operator takes down the attachments around the splenic flexure (Fig.
52-7).
This is typically very redundant and folded on itself. Again, it is easy to
lose proper orientation.
FIGURE 52-7 Splenic flexure mobilization. Black arrow depicts the spleen. Blue
arrow is the splenic flexure of the colon mobilizes medially. The green arrow
demonstrates the omental attachments. The orange arrow shows the retroperitoneal
attachments.
Frequently alternating between the transverse and descending colon

areas will aid dissection.
The cut edge from the transverse colon is carried onto the descending
colon as the splenic flexure is totally freed.
The patient is placed in steep head down, and the sigmoid is next
addressed. The inferior mesenteric vessels are divided, after verifying the
position of the left ureter (Fig. 52-8). The redundant sigmoid colon may be
adherent in the pelvis and need to be freed up before the vessel is
dissected.
FIGURE 52-8 Identification of the left ureter and dissection of the inferior mesenteric
artery (IMA).
The entire remaining left colon is mobilized from lateral to medial, and the
cut edge of the sigmoid mesentery divided and joined to the cut edge of
the descending colon.
The presacral space is entered, and the upper rectum mobilized. This will
aid in the anastomosis.
The mesentery to the upper rectum is divided with the energy device.
Using the suprapubic port, the rectum is divided with the linear stapler.
The goal is always one firing of the stapler if possible (Fig. 52-9).
FIGURE 52-9 Transection of the rectosigmoid. Ensure division is at a right angle.
The suprapubic port is expanded to allow the colon to be extracted.

A small wound protector is placed.
The colon is carefully removed until the terminal ileum is encountered.
The bowel is divided at the ileocecal junction, and any remaining
mesentery is divided.
A purse string of 0 monofilament nonabsorbable polypropylene suture is
placed in the cut edge of the ileum.
The head of a circular stapling device is placed in the terminal ileum.
Depending on availability and the size of the terminal ileum, the size
varies from 29 to 31 mm.
Also, lack of an anal stricture is required for stapling.
The small bowel is replaced in the abdomen.
The trocar is placed inside the wound protector, and a Penrose is wrapped
around and secured. Piercing towel clamps (usually two) are placed on one
side to seal, and pneumoperitoneum is re-established.
The small bowel mesenteric orientation is verified to be straight.
The stapler is advanced to the top of the rectal staple line, and spike is
brought through (Fig. 52-10). We do not advocate end-to-side anastomosis
for constipation.
FIGURE 52-10 Spike through the distal staple line.

PEARLS AND PITFALLS
Even with a decompressed colon, it is almost always severely

elongated, making it easy to lose the orientation laparoscopically,
particularly around the distal transverse and splenic flexure.
The cecum is usually very mobile, and steep head down brings it out of
the pelvis. Also tipping the patient to the left will keep the other bowel
out of the field.
PEARLS AND PITFALLS
If there is difficulty reaching the rectal staple line, there are two choices.
The first is to resect more rectum.
When the rectum is enlarged and has redundancy of the mucosa, it
may be difficult to advance the body of the stapler. In that situation,
the head of the stapler with bowel is secured.
Pneumoperitoneum is stopped, and the suprapubic incision is
lengthened transversely.
The rectal staple line is identified and resected. A purse string is
applied.
The operator’s index finger is placed in the rectum through the purse
string, and the other hand reaches between the legs to guide the body
of the stapler. With the index finger placed deep in the rectum, the
body can be manipulated and the redundant mucosa swept away.
The stapler can be brought to the top of the rectum, and the spike
extended. The purse string can be tied down, and the anastomosis
completed (Figs. 52-11 and 52-12).
FIGURE 52-11 The outline of a colectomy and ileorectal anastomosis for slow
transit constipation.
FIGURE 52-12 Schematic of ileorectal anastomosis.
A proximal loop ileostomy is considered in certain circumstances when

the patient’s tissues are of suboptimal quality or they are taking
medication that significantly alters their immune system.
PELVIC CONSTIPATION
Perioperative Considerations: Hirschsprung Disease
Short-segment Hirschsprung disease may be detected in an adult. An
absent rectoanal inhibitory reflex is noted on anal physiology testing.
If we are looking for the absence of ganglion cells, a posterior strip biopsy
may be done.
Alerting the pathologist that you will be sending this tissue and
orienting the specimen are important.
Typically, the width of the strip is about 1.5 cm and starts from dentate
to ~2-3 cm cephalad.
If there is dilated rectum, the length goes onto the distal aspect of the
dilated rectum.
When the diagnosis is confirmed, conservative therapy is not considered,
and surgery is planned.
Pearl: Some patients have megarectum, and a temporary loop ileostomy
(usually laparoscopic) and bowel cleanout are necessary to allow the colon
and rectum to return to a manageable diameter.
Equipment
General laparotomy/laparoscopic operating set
Balloon (Hasson) trocar, 12-mm trocar, 5-mm trocars × 3
Endoscopic linear stapler with reloads (as needed)
End-to-end anastomotic stapler
10-/5-mm 30-degree camera
Wound protector
Energy device/vessel sealer
Positioning/Preoperative (See Chapter 3)

In the operating room, a Foley catheter is placed, and preoperative
antibiotics are given.
Venous thromboembolic prophylaxis (chemical and mechanical) is given.
The patient is positioned either in stirrups or on a split-leg table.
The patient is secured to the table as steep head down may be required.
With the definitive surgery, the approach can be laparoscopic. If the
patient had previous congenital pelvic surgery, an open approach may be
needed.
Sometimes, a combination of cephalad laparoscopic mobilization of the
left colon can be combined with open lower transverse suprapubic
abdominal incision.
Technique
The inferior mesenteric vessels are divided after the position of the left
ureter is verified (Fig. 52-8).
Mobilization is carried to the pelvic floor by entering the presacral space
in the total mesorectal excision plane (Figs. 52-13 and 52-14).
FIGURE 52-13 Entering the avascular presacral space.

FIGURE 52-14 Mobilization/dissection is carried to the pelvic floor.
When the rectum is circumferentially mobilized to the pelvic floor, the

approach is changed to the anal region.
Anal everting sutures are placed. Using the electrocautery, a mucosectomy
starting at the dentate line is performed and carried cephalad.
When cephalad to the anal sphincters, a plane is entered around the rectum
(similar to the plane of a perineal rectosigmoidectomy) until the
abdominal mobilization is reached.
The bowel is advanced out the anus (Figs. 52-15 and 52-16) and
amputated.
FIGURE 52-15 For Hirschsprung disease, a mucosectomy is performed. The large
bowel is mobilized, and ganglion cells are verified at the edge planned for the
anastomosis. A handsewn anastomosis is performed at the dentate line.
FIGURE 52-16 Schematic of the colon brought down for a handsewn anastomosis at
the dentate line.
The proximal edge is sent for frozen.

Pearl: The pathologist should have been alerted that you would be
sending this specimen.
Ganglion cells are verified.
The bowel is amputated, verifying bleeding at the cut edge of the proximal
colon.
2-0 or 3-0 polyglactin sutures are used to perform the anastomosis (Fig.
52-17).
FIGURE 52-17 The final appearance of a handsewn anastomosis at the dentate line.
If the patient does not have a loop ileostomy, one is performed.

A pelvic drain is placed.
All abdominal incisions (and trocar sites) are closed.
Postoperative Care
Routine enhanced recovery is utilized following colectomy for almost all
patients.
There is no indication for ongoing antibiotics.
Stoma teaching for those patients with a new ostomy is critical.
Suggested Readings
Bordeianou LG, Carmichael JC, Paquette IM, et al. Consensus statement of definitions for anorectal
physiology testing and pelvic floor terminology (revised). Dis Colon Rectum. 2018;61(4):421-
427.
Paquette IM, Varma M, Ternent C, et al. The American Society of Colon and Rectal Surgeons’ clinical
practice guideline for the evaluation and management of constipation. Dis Colon Rectum.
2016;59(6):479-492.
Reshef A, Alves-Ferreira P, Zutshi M, Hull T, Gurland B. Colectomy for slow transit constipation:
effective for patients with coexistent obstructed defecation. Int J Colorectal Dis.
2013;28(6):841-847.
Chapter 53
Botox of the Pelvic Floor and
Acupuncture
MASSARAT ZUTSHI
The levator ani complex is composed of the pubococcygeus, puborectalis,
and iliococcygeus muscles.
The levator ani muscles are innervated by the pudendal nerve branches
(perineal nerve and inferior rectal nerve) as well as sacral nerves S3 and/or
S4.
In general, the levator ani complex is in a state of contraction, to support
the abdominal and pelvic organs.
Gross continence is aided by a forward pull on the anorectal angle
between the rectum and the anal canal. Relaxation allows straightening of
the angle and facilitates defecation.
Levator ani syndrome results in symptoms of a chronic idiopathic deep
aching pelvic pain, versus proctalgia fugax, which is described as a sharp
“electrical shock” type pain.
This is characteristically worse with sitting or lying and improves with
standing and is chronic or recurring.
Pain typically worsens throughout the day.
Pain lasts at least 20 minutes.
Digital rectal examination can palpate the puborectalis sling that often
feels firm or in spasm. Palpation in the area of the coccygeal attachment
can reproduce the pain.
Botulinum toxin is one management option (along with biofeedback,
electrogalvanic stimulation, physical therapy, and sacral nerve
stimulation), which involves injection of the toxin with normal saline into
the muscle.
Symptomatic relief rates are widely variable in the literature.
Six tuberculin syringes with a 22-gauge 1-1/2 inch needles
One 10-mL syringe with a 22-gauge 1-1/2 inch needle
Botox 100 units, two vials
Exparel 20 mL, one vial
Saline 10 mL, one vial
Betadine solution for skin prep
Lighted Hill-Ferguson anal retractor
Surgical Approach
Perianal Approach
Preoperative: one fleets enema or a laxative to clear the anal canal of stool
Anesthesia: general with a laryngeal mask airway
Position: lithotomy
Technique
Dilute the Botox injection vials with 3-1/2 mL of normal saline in each
vial and loaded in six tuberculin syringes (Fig. 53-1). Load the long-acting
bupivacaine in a 10-mL syringe.
FIGURE 53-1 Setup: 200 units of Botox with saline and six tuberculin syringes.
With the patient in the lithotomy position, clean the inside of the anal
canal first with a gauze soaked in betadine solution and then clean the skin
over the perineum up to the scrotum or the vagina anteriorly and the
tailbone posteriorly. On the lateral side, the preparation should go beyond
the ischial tuberosity.
Carry out an anal examination by placing a finger in the anal canal and
sweep the anal canal for any abnormalities (Fig. 53-2A). Insert a Hill-
Ferguson anal retractor and perform a visual examination, recording any
findings or abnormalities (Fig. 53-2B).
FIGURE 53-2 A. Digital anal examination. B. Visual anal examination.
Place a finger of the nondominant hand in the anal canal and identify the
internal anal sphincter and levator muscle in the right and left lateral
quadrants and posteriorly.
Place a finger in the posterior quadrant in the anal canal and push down on
the levator muscle. Feel the levator muscle with the thumb of the
nondominant hand (Fig. 53-3A and B).
FIGURE 53-3 A. Palpation of the levator muscle in the posterior midline using the
finger in the anus to push the muscle toward the thumb. B. Posterior midline injection.
Push the levator muscle down using the finger in the anus to guide the tip of the needle
into the muscle.
Take the first syringe filled with Botox and insert through the perianal skin
in the midline posterior region advancing gently until the needle is felt
against the fingertip (Fig. 53-4).
FIGURE 53-4 Right posterolateral injection. Feel the levator muscle using the finger in
the anus to guide the tip of the needle into the muscle.
Pull the needle back until it is felt to be in the muscle. Aspirate and inject
one-third of the solution in the syringe, redirecting the needle at an ∼30-
degree angle and inject one-third, followed by the final one-third in the
opposite direction at an ∼30 degrees (Fig. 53-5).
FIGURE 53-5 Left posterolateral injection. Feel the levator muscle using the finger in
the anus to guide the tip of the needle into the muscle.
Take the next syringe and follow the same procedure, this time going
posterolaterally on the right (Fig. 53-6) and left and then laterally to the
right and left (Fig. 53-7), making sure that the needle remains in the
muscle. Based on the patient’s symptoms, the last syringe can be injected
where the pain is maximally located.
FIGURE 53-6 Changing the angle of the needle to reach a larger area.
FIGURE 53-7 Left lateral injection.
Repeat the above steps with 10 mL of Exparel (liposomal bupivacaine).

Inject the remaining 10 mL of Exparel as a pudendal block using 5 mL on
each side.
This is performed by placing the left index finger in the anal canal and
palpating the ischial spine of one side.
The needle is then directed on the skin from below the ischial
tuberosity toward the finger, and the solution is injected after aspirating
and gently withdrawn.
The direction is changed multiple times in a fanlike manner so that all
the 5 mL is injected in one side.
This procedure is then repeated on the opposite side.
Finish the procedure by doing a gentle levator massage.
Place the index finger in the anal canal, starting in the midline
posteriorly, feeling the levator muscle and gently massaging in an
anterior-to-posterior direction.
Next go from the midline to one side and then the other, performing
gentle right-to-left movements.
The massage should not be over vigorous, and only the levator ani
muscle needs to be massaged.
Check the anal canal for any bleeding.
Clean the skin area.
Return the patient to a supine position.
Anal Approach
The first steps are similar to the perianal approach.
To inject the Botox, place the finger of the nondominant hand in the anal
canal and feel the levator muscle—push it up with the thumb.
Remove the index finger and place the Hill-Ferguson anal retractor in the
anal canal and direct the needle about 1 cm above the dentate line toward
the thumb, pushing the levator ani muscle up.
Aspirate and inject one-third of the solution.
Withdraw the needle and change direction ∼30 degrees and repeat the
injection.
Withdraw the needle again and direct the needle in the opposite direction
at the 30-degree angle and inject the remaining solution.
The process is repeated at different levels just like as described in the
perineal route, but this time the injection is given through the anus.
Again, carry out anal massage going along the levator muscle from lateral
to midline on each side and from anterior to posterior.
The long-acting liposomal bupivacaine is injected as described for the
Botox injections using 10 mL into the levator ani muscle and 10 mL as a
pudendal block.
Postoperative Care
Sitz bath or use of an ice pack daily as needed.
Pain medications as per the surgeons and patient’s preference, though
narcotic sparing when able.
Reevaluation in the office in ∼10-12 weeks.
The patient is counseled to contact the office if there is any evidence of
redness, swelling increase in pain, temperature above 101°F, or unable to
void urine.
Suggested Reading
Bastawrous AL, Lee JK. Proctalgia fugax, levator spasm, and pelvic pain: evaluation and differential
diagnosis. In: Beck D, Steele SR, Wexner SD, eds. Fundamentals of Ano-rectal Surgery. 3rd
ed. New York, NY: Springer Publishing; 2019:318-321.
Chapter 54
Perineal Proctectomy
AMY LIGHTNER
Perineal Proctectomy
General and Perioperative Consideration

In unobstructed patients, an oral polyethylene-based bowel preparation
and three doses of 1-g neomycin and 500-mg metronidazole orally were
given the day before surgery.
Digital rectal examination, imaging, and endoscopy are utilized to
determine the relation of pathology (eg, tumor, fistulizing Crohn disease)
to the vagina/prostate anteriorly, involvement of the internal/external
sphincter, and relation to the pelvic side wall in the situation of bulky local
tumors.
Prior to beginning the procedure, a digital rectal examination may be
performed in the case of rectal tumors to ensure the need for an
abdominoperineal resection.
Prior to reaching the final portion of the proctectomy, the colon has been
mobilized for sufficient length for an end colostomy, and the rectal
dissection has been largely performed from an abdominal approach. The
presacral space entered for the posterior dissection down to the level of the
levators, lateral ligaments divided, and anterior approach one layer
posterior to Denonvilliers fascia to dissect the plane between the anterior
rectal wall and seminal vesicles and prostate/vaginal wall.
Equipment
Bean bag (if desired)
Iodine
Bottom table setup with stool and headlight
Fine-tip cautery
Regular cautery
Lone Star retractor
Kocher clamp
St. Mark self-containing retractor × 1
Vaginal retractor × 2
Harrington retractor × 2
Gelpi retractor
Heavy straight scissor
Long scissor
Long needle driver
DeBakey
Russians
Adson delicate with teeth
1/0 Vicryl
2/0 Vicryl
4/0 absorbable monofilament suture
2/0 nylon
19Fr Jackson-Pratt drain
Kidney basin for irrigation
Suction
Specimen bucket
Anesthesia
General anesthesia is utilized.
A spinal block and/or a transversus abdominis plane block are used for
pain control, in combination with oral and intravenous analgesia.
Patient Positioning
The patient should be placed in the Lloyd-Davies synchronous position or
modified lithotomy. Both arms are tucked, and the patient is secured on a
bean bag. Legs are held in Yellowfins stirrups such that the weight is on
the heals to prevents pressure on the peroneal nerve as it passes around the
fibular head. The hips should be abducted to accommodate the perineal
dissection and positioned at the end of the bed to allow ready access to the
tip of the coccyx.
Prone positioning may be considered in the case of a large anterior tumor,
when a posterior vaginectomy is planned, or when this is the patient
preference.
A rectal washout using dilute betadine solution to remove any residual
stool is performed using a red rubber catheter.
For this portion of the case, the operative technician is typically sitting on
a stool between the legs, with the legs moved upward.
The table is usually moved up and Trendelenburg position to allow better
access to the perineum.
An assistant may be useful to the right or left side, depending on the
surgeon’s preference for retraction.
Equipment
A bottom table is assembled for this portion of the case with
electrocautery, a Lone Star retractor, a variety of additional preferred
retractors and rakes for exposure during the dissection, and suture for
primary closure.
A headlight may be needed depending on the lighting available in the
operating room.
A separate suction tubing should be available, and kidney basin, normal
saline, and betadine solution for washing out the pelvis after the specimen
has been extracted.
Technique
A Lone Star retractor is placed around the anus just outside where the
incision is going to made outside the external sphincter.
The procedure begins by making an elliptical incision around the anus,
extending from the midpoint of the perineal body in the man, or posterior
vaginal introitus in a woman, posteriorly to a point midway between the
coccyx and the anus.
The incision should include all the external sphincter muscle, but does not
need to extend laterally to the ischial tuberosities.
Electrocautery is then used to carry the incision down to the ischiorectal
fat (Fig. 54-1).
FIGURE 54-1 Electrocautery is used to dissect the distal most dissection in the
ischiorectal fat circumferentially.
The anus is held shut with a series of Kocher clamps in order to allow
luminal access during the final stages of the anterior dissection if needed.
The Lone Star is then repositioned to the cut edge of the skin to provide
exposure to continue the dissection cephalad in the ischiorectal fat.
Posterior Dissection
The dissection proceeds posterior and laterally. The St. Mark self-
containing retractor may be useful here in addition to the Lone Star
depending on the patient’s body habitus.
The posterior dissection can be directed just anterior of the coccyx by
keeping a finger on the tip of the coccyx.
The posterior dissection is completed when the anococcygeal raphe is
divided. This is performed using the heavy straight scissors to make a stab
incision just anterior to the coccyx and spreading as the scissors are
withdrawn to widen the space enough to allow an index finger (Fig. 54-2).
FIGURE 54-2 The last step of the posterior dissection is diving the anococcygeal
raphe by the heavy straight scissors to make a stab incision just anterior to the coccyx and
spreading as the scissors are withdrawn to widen the space enough to allow an index
finger for subsequent lateral dissection.
Lateral Dissection
The lateral dissection can then take place from posterior toward anterior
by placing an index finger behind the levator muscle. The puborectalis is
then transected with electrocautery on the right and left sides, working
anteriorly.
As one moves further anteriorly, the vaginal retractors may be useful for
adequate visualization laterally.
Anterior Dissection
When all that remains is the anterior dissection, a hand is used to retrieve
the proximal end of the proctectomy specimen at the staple line that is
brought through the perineal defect posteriorly so that the rectum has an
apex at the anterior point of the dissection.
Under traction, the transverse perineal and rectourethralis muscles are
divided anteriorly (Fig. 54-3).
FIGURE 54-3 The anterior dissection is performed by dividing the transverse perineal
and rectourethralis muscles under traction.
The last portion of the dissection is separating the rectal wall from the
prostate or the vagina. Care should be taken not to enter the rectum
posteriorly and risk tumor spillage. Simultaneously, care needs to be taken
not to injure any urogenital structures by moving the dissection too
anteriorly.
Extracting the Specimen

The specimen is extracted without perforation or spillage.
The specimen is checked for adequate total mesorectal excision without
violation of the mesorectal fascia.
The specimen is put on the back table and may be opened for assessment
of the tumor prior to sending in a specimen bucket to pathology.
Hemostasis is then critical to achieve to prevent postoperative hematoma
and subsequent abscess formation.
Hemostasis is achieved with a combination of suture ligation and
electrocautery.
After hemostasis is achieved, the open wound is irrigated from above with
2 L of normal saline followed by 1 L of a betadine solution.
Closure of the Perineal Wound

A 19Fr Jackson-Pratt drain is positioned through an abdominal trocar site,
preferably on the same side as the ostomy, in case of a future need for a
rectus flap in the case of recurrence, and placed into the pelvis.
In a primary closure, the perineal wound is closed in multiple layers using
absorbable sutures.
The remaining levator muscle is closed with interrupted 0 or 1 Vicryl in a
figure-of-eight manner.
The subcutaneous fat and ischiorectal space is then reapproximated with 1
Vicryl and the last layer 2/0 Vicryl in a figure-of-eight manner, ensuring
no dead space.
If no preoperative radiation of sepsis was present, the skin can be closed
with a running 4/0 monocryl.
If a patient was exposed to preoperative radiation, then the skin can be
closed with 2/0 nylon in a vertical mattress stitch (Fig. 54-4).
FIGURE 54-4 To close the defect, the subcutaneous fat and ischiorectal space are
reapproximated with a 1/0 Vicryl and 2/0 Vicryl for the most distal layer, ensuring no dead
space. The skin is then closed with a 2/0 nylon in a vertical mattress stitch.
Additional Options for Perineal Wound Closure

Negative-pressure wound therapy
Biologic or synthetic mesh placement to reconstruct the perineal defect
Omentoplasty
Vertical rectus abdominis muscle flap
Gracilis flap
Gluteus maximum flap
An Intersphincteric Dissection
May be used in the setting of benign disease such as a proctectomy for
Crohn disease or in the case of an ultralow rectal tumor with an intent of a
handsewn coloanal anastomosis. For the purposes of this discussion, the
intersphincteric dissection will be considered for benign disease in which
the anus is shut.
With the same patient positioning as above, the Lone Star retractor is
again placed; this time just outside the skin color change at the
demarcation of the internal and external sphincter.
The groove between the internal and external sphincter is appreciated at
the anodermal junction.
A fine-tip cautery is used on the cut mode to make the incision around the
anus in the intersphincteric groove. This plane is relatively avascular and
should be carried out until circumferential.
The Lone Star retractor can then be repositioned at the cut edge. The
electrocautery tip is then replaced to a regular tip.
The remaining dissection proceeds as described earlier.
In the case of an ultralow rectal cancer, the dissection should begin just
above the dentate line, where the intersphincteric plane is dissected
cephalad until the dissection from the pelvic cavity is reached.
PEARLS AND PITFALLS
The wound will often open up and drain—let patients know about this
ahead of time to manage expectations.
Perineal eversion sutures can be used in place of a Lone Star retractor.
The anterior dissection is often the most difficult. Gentle traction on the
Foley can help identify the urethra.
Postoperative Care
care plan.
Jackson-Pratt drains are removed prior to dismissal.
The perineal wound should be examined every day for signs of infection
as it has the highest rate of breakdown. Serous drainage may be normal,
but any sign of purulent drainage should result in opening the wound with
drainage of any collection.
Suggested Readings
Delacroix SE Jr, Winters JC. Urinary tract injuries: recognition and management. Clin Colon Rectal
Surg. 2010;23(3):221.
Peirce C, Martin S. Management of the perineal defect after abdominoperineal excision. Clin Colon
Rectal Surg. 2016;29(2):160-167.
Shirouzu K, Murakami N, Akagi Y. Intersphincteric resection for very low rectal cancer: a review of
the updated literature. Ann Gastroenterol Surg. 2017;1(1):24-32.
Index
A
Abdominal wall reconstruction, 586–588, 587f
contralateral tar and additional dissection, 584, 585–586f
dissection around the prior ostomy site, 582–584, 582–583f
inferior tar dissection, 579–581, 580f
intra-abdominal access, adhesiolysis, and setup, 576–577
patient positioning, 575, 576f
perioperative considerations, 575
postoperative care, 588
retrorectus dissection, 577–579, 577–579f
sterile instruments used in, 575
superior tar dissection, 581–582, 581–582f
Anal dysplasia
anal chromoendoscopy, 167
anal colposcopy/high-resolution anoscopy, 165–166, 165–166f
detection of, 165–167
Anal fissures
examination of, 72, 72–73f
history of, 72
perioperative considerations, 71f
Anal intraepithelial neoplasia
anal dysplasia, detection of, 165–167, 165–166f
chromoendoscopy with retroflexion and insufflation, 167–172, 167–171f
performing high-resolution anoscopy, 163–172
perioperative considerations, 163, 164f
preprocedural interview, 163, 164f
sterile instruments/equipments used in, 163, 165
Anal sphincteroplasty
approach and equipments used in, 561–564, 561–564f
patient positioning, 561
pearls and pitfalls, 564–565
perioperative considerations, 560–561
Anal stenosis
anoplasty for, 77–84
approach and equipments used in, 78
flap preparation and scar release, 78–80, 78–81f
operative preparation, 77–78
specific flap configurations, 81–84, 82–84f
Anal transitional zone (ATZ), 167–168, 168f
Anastomoses based on anatomy, types of
enteroenteric or ileocolonic anastomoses, 173–181, 174–180f
ileorectal and colorectal anastomoses, 181–185, 182f, 184–185f
Anastomotic construction techniques
anastomoses based on anatomy, types of
enteroenteric or ileocolonic anastomoses, 173–181, 174–180f
ileorectal and colorectal anastomoses, 181–185, 182f, 184–185f
general technical considerations, 173
Anoplasty
for anal stenosis, 77–84
flap preparation and scar release, 78–80, 78–81f
operative preparation, 77–78
specific flap configurations, 81–84, 82–84f
Anorectal abscess
antibiotics, role of, 87
deep anterior or posterior anal space and horseshoe abscess, 89–91, 89–91f
examination under anesthesia, 86
fistula at time of abscess drainage, identification of, 87
intersphincteric abscess, 88
pearls and pitfalls, 86
perianal and ischioanal abscess, 87–88, 87f
perianal sepsis, principles of dealing with, 85, 86f
specific considerations in management of, 87
sterile instruments/equipments used in, 85
submucosal abscess, 88
supralevator abscess, 88–89
Anorectal fistulas
cutting seton, 99, 99f
draining seton, 97–99, 97–98f
endorectal advancement flap, 102–104, 102–104f
fistulotomy, 100–101, 100–101f
ligation of intersphincteric fistula tract (LIFT), 104–106, 105–106f
other procedures, 106–107
patient positioning, 94f, 95f, 97
setons, 97
sterile instruments/equipments used in, 94–96, 94–96f
types of, 93, 93f
Anoscopy, 59, 59f
Anus, 7f, 8
Appendix, 5
Arm tucking
equipments used in, 26
technique, 26–28, 27–28f
Ascending colon, 6
ATZ. See Anal transitional zone (ATZ)
B
Blow hole/traverse colostomy
sterile surgical equipment used in, 459
surgical technique, 459–460, 460f
Botox
anal approach, 543
of pelvic floor and acupuncture, 599–603
perianal approach, 599
surgical approach, 599–603, 600–602f
C
Cecum, 5
CELS. See Combined endoscopic and laparoscopic surgery (CELS)
Chest strap
technique, 28–29, 28f
Chromoendoscopy with retroflexion and insufflation, 167–168, 167f
approach advantages, 168
examples of, 168–170, 169–171f
normal anal anatomic landmarks, 168–170, 168f
Colon
ascending, 6
descending, 7, 7f
sigmoid, 7, 7f
transverse, 7
Colonoscopy through colostomy, 62
Colorectal anastomoses
end-to-end anastomoses, stapled, 181, 182f, 183
end-to-end anastomoses, sutured, 180f, 183
side-to-end anastomoses, stapled, 183–184, 184f
side-to-end anastomoses, sutured, 184–185, 185f
Colorectal cancer
applicators
placement of, 274, 274f
use of, 272, 272f
approach and equipments used in, 271–272
Geiger meter, 276, 276f
indications for, 271
intraoperative radiation therapy for, 271–277
management of stage IV disease, 451–461
abdominal portion, 454–455
blow hole/traverse colostomy, 459–460, 460f
closure, 457
combined liver colon/colon or rectum approach, 452
endoscopic stenting, 460–461
laparoscopic sigmoid colostomy, 458–459
palliative approach to obstructing disease, 458
pelvic portion, 455, 455–456f, 457
perineal port, 457
positioning and preoperative considerations, 454
surgical approach to distant metastatic disease, 451–452
surgical approach to local metastatic disease, 452, 452–453f, 454
radiation safety sign, 275, 275f
technique, 272–277, 272–276f
Colovaginal and colovesicle fistula repair
bladder repair, 364
colovaginal fistula, 364
drains, 365
fecal diversion, 364
hand assist, 362–363
laparoscopic approach, 359
laparoscopic division of the fistula, 362, 363f
lateral-to-medial approach, 371
medial-to-lateral approach, 371
omental pedicle flaps, 364
open procedure, 363, 363–364f
port placement, 360–361, 360f
specific considerations, 364–365
sterile surgical equipments used in, 360
surgeon and monitor positioning, 359
vaginal repair, 364
Combined endoscopic and laparoscopic surgery (CELS)
combined wedge resection, 45, 46f
equipment used in, 44
perioperative considerations, 43, 43–44f
Combined wedge resection, 45, 46f
Computed tomography (CT)
of horseshoe abscess, 89f
presacral tumors, 290, 291f
Constipation
pelvic
equipment, 594
Hirschsprung disease, 594
patient positioning/preoperative antibiotics, 594–595
technique, 595–597, 595–596f
slow transit
equipment, 590
patient positioning/preoperative antibiotics, 590
pearls and pitfalls, 593, 593–594f
perioperative considerations, 589–590, 589–590f
technique, 590–593, 591–593f
Crohn anorectal disease
technique anal tags
anal fissure, 148, 148f
anal fistula, 149, 149f
anal stenosis, 148, 148f
“elephant ear” tags, 147, 147f
hemorrhoidal disease, 149–150
perianal abscess, 149, 149f
Crohn disease, 62
equipment laparoscopic or single-incision laparoscopic surgery diverting loop ileostomy
alternative method, 422
procedure, 422–428, 423–428f
traditional method, 422
laparoscopic and open ileocolic or small bowel resection
dealing with fistulae, 441
equipments used in, 429–430
handsewn end-to-end ileocolic anastomosis, 433–437, 433–436f
ileo-duodenal fistula, 441–442
ileocolic resection and ileocolic anastomosis, 430–432, 431–432f
procedure, 430–442, 430f
stapled end-to-side ileocolic anastomosis, 432, 433f
stapled side-to-side ileocolic anastomosis, 437–441, 437–441f
laparoscopic surgery for inflammatory bowel disease, 420
laparoscopic transversus abdominis preperitoneal plane block, 421–422
pearls and pitfalls, 448–449, 449f
postoperative care, 449–450
sterile instruments/equipments used in surgery, 420–421
stoma, maturing, 428–429, 428–429f
surgery for small intestinal strictures—small bowel resection and strictureplasty procedures
duodenal strictures, 446–448, 447–448f
Finney strictureplasty, 445, 445f
Heineke-Mikulicz strictureplasty, 442–444, 442–445f
isoperistaltic strictureplasty, 446, 446f
procedure, 442–448
surgical management of, 419–450
traditional method for mesentery ligation and sutured anastomosis, 421
CRS. See Cytoreductive surgery (CRS)
Cutting seton, 99, 99f
Cytoreductive surgery (CRS)
cytoreduction, 239, 242
cytoreduction score, completeness of, 241, 241t
hyperthermic intraperitoneal chemotherapy, 239–249
operating team for, 242f
D
Deep anterior or posterior anal space abscess
postoperative care, 91, 91f
Deep pelvic instruments, 16–17, 17f
Descending colon, 7, 7f
Desmoids
clinical presentation, 258, 258f
definitions of, 257, 257f
in familial adenomatous polyposis (FAP), 257–258
genetics, 257
incidence and risk with regard to surgical planning, 257–258
lysing adhesions in patients with desmoid disease, 261–262
staging system for abdominal desmoid disease, 258, 259t
technique of resection, 259–261, 260–261f
treatment for, 259
Difficult stoma
abdominal wall defects, 485
colostomy, 491, 491f
equipment and supplies, 484–485
ileostomy, 487–490, 487–490f
obese patients, tips for, 485–486, 486f
obesity, 485, 485f
operative variables encountered during surgery, 483
ostomy siting, 483–484, 484f
preoperative variables, 483
risk factors for, 483–484
shortened mesentery, 487
stomal complications
ischemia, 492, 492–493f
peristomal hernia, 493–495, 493–498f, 497–498
stoma prolapse, 498–502, 498–499
Draining seton, 97–99, 97–98f
Duodenum, 2–3, 2–3f
E
EBD. See Endoscopic balloon dilation (EBD)
ECF. See Enterocutaneous Fistula (ECF)
EMR. See Endoscopic mucosal resection (EMR)
Endorectal advancement flap (ERAF)
technique, 102–103, 102–104f
Endoscopic balloon dilation (EBD) of strictures
equipments used in, 47, 49f
technique, 49
Endoscopic closure of surgical leak
technique, 55
Endoscopic fistulotomy
technique, 53
Endoscopic mucosal resection (EMR)
Endoscopic sinusotomy
perioperative considerations, 55, 55–56f
technique, 56
Endoscopic stenting, 460–461
Endoscopic stricturotomy
technique, 50–51f, 51
Endoscopic submucosal dissection (ESD)
dissection, 39–41, 40–42f
injection, 39, 39f
technique, 38f
Enterocutaneous Fistula (ECF)
abdominal closure, 268, 268f
approach and equipment, 264
basic principles of, 263, 263f
diverting loop or end ileostomy/jejunostomy, use of, 268, 269f
hydrodissection, 265
loop jejunostomy, 268, 269f
operative preparation, 263
patient positioning, 263–264
technique, 264–268, 264–267f
total parental nutrition (TPN), 267
Enteroenteric anastomoses
end-to-end anastomosis, stapled, 176, 178–179, 178f
end-to-end anastomosis, sutured, 180, 180f
end-to-side anastomosis, sutured, 179, 179f
omental pedicle flap over anastomosis, 176, 176f
perioperative considerations/approach, 173
side-to-side (functional end-to-end), stapled, 174, 175f
side-to-side (functional end-to-end), sutured, 176, 177f
ERAF. See Endorectal advancement flap (ERAF)
ESD. See Endoscopic submucosal dissection (ESD)
Examination under anesthesia (EUA), anorectal abscess, 86
F
Familial adenomatous polyposis (FAP), 257
desmoid disease in, 257–258
desmoid tumors, 257, 258, 260
risk factor score for the development of desmoid disease, 258, 258t
FAP. See Familial adenomatous polyposis (FAP), 257
Fecal incontinence (FI)
anal sphincteroplasty
sacral neuromodulation
Ferguson (closed) hemorrhoidectomy, 65, 68f
FI. See Fecal incontinence (FI)
Fistulotomy, 100–101, 100–101f
Flap configurations
diamond flap, 82–83, 82f
Hill-Ferguson anoscope, 84, 84f
house flap, 81
pitfall and pearls, 84
rotational S flap, 83, 83f
U flap, 83, 83f
Y-V or V-Y flap, 81, 82f
Flap preparation and scar release, 78–79, 78–79f
flap creation, basic steps in, 79, 80f
flap, securing, 80, 80–81f
Flexible ileoscopy, 62
Flexible sigmoidoscopy, 60
G
Gluteal flaps
technique, 570–572, 570–572f
Goodsall rule, 85, 86f
Gracilis flap
Gynecologic oncology (GYN-Onc) considerations
anatomic considerations, 332–334, 332–333
for complex and multivisceral colorectal disease, 331–339
en bloc resection of uterus, cervix, and rectosigmoid, 334–336, 334–336f
gynecologic organ involvement by colon cancer, 331
hypogastric artery ligation, 338f
intraoperative considerations, 332–337
lymphadenectomy, 337, 337f
magnetic resonance imaging, 332f
preoperative considerations, 331
tumor extension below peritoneal reflection, 336–337, 336f
H
Hemorrhoidectomy
Ferguson (closed), 65, 68f
Milligan-Morgan (open), 66–68, 66–68f
postprocedural management of, 69–70
surgical approach, 65, 65f
using an energy device, 69, 69f
Hidradenitis suppurativa (HS)
dressings, options for, 114
excision and flaps, 114
I&D/lay-open technique, 111–114, 111–113f
meshing, 113–114
perioperative considerations, 109–110, 109f
risk factors of, 109
High-resolution anoscopy (HRA)
anal intraepithelial neoplasia
anal dysplasia, detection of, 165–167, 165–166f
chromoendoscopy with retroflexion and insufflation, 167–172, 167–171f
preprocedural interview, 163, 164f
sterile instruments/equipments used in, 163, 165
Hill-Ferguson anoscope, 84, 84f
HIPEC. See Hyperthermic intraperitoneal chemotherapy (HIPEC)
Horseshoe abscess, 89–91, 89–91f
computed tomography (CT), 89f
postoperative care, 91, 91f
HRA. See High-resolution anoscopy (HRA)
HS. See Hidradenitis suppurativa (HS)
Hyperthermic intraperitoneal chemotherapy (HIPEC)
abdominal wall and pelvic viscera, 244–245, 245f
during administration, 248–249
bowel resections, management of, 244
fewer complications, frustrations, and improving safety, commonsense guidelines for, 243
hemidiaphragm, disease on, 244
intraoperative and anesthesia concerns, 248–249
intraoperative assessment, 240–242, 240–242f
perfusion technique, 243–244, 243f
placement of HIPEC tubing (closed technique), 245–248, 245–248f
postoperative management, 249
preoperative considerations, 239–240, 239f
program requirements, 242–243, 242f
successful program, developing, 243
surgical considerations, 244
I
IBD. See Inflammatory bowel disease (IBD)
Ileal pouch-anal anastomosis (IPAA)
sterile instruments and equipments used in, 396
technique
double-staple “J” pouch, 396–400, 396–400f
J pouch construction, 400–402, 400–402f
mucosectomy and Handsewn anastomosis with J pouch, 402–404, 403–404f
redo ilealanal pouch, 406–410, 407–410f
S pouch construction, 404–406, 404–406f
surgical management of pouch complications, 410–417, 410–418f
Ileocolonic anastomoses
end-to-end anastomosis, stapled, 176, 178–179, 178f
end-to-end anastomosis, sutured, 180, 180f
end-to-side anastomosis, sutured, 179, 179f
omental pedicle flap over anastomosis, 176, 176f
perioperative considerations/approach, 173
side-to-side (functional end-to-end), stapled, 174, 175f
side-to-side (functional end-to-end), sutured, 176, 177f
Ileorectal anastomoses
end-to-end anastomoses, stapled, 181, 182f, 183
end-to-end anastomoses, sutured, 180f, 183
side-to-end anastomoses, stapled, 183–184, 184f
side-to-end anastomoses, sutured, 184–185, 185f
Ileum, 4, 5f
Inflammatory bowel disease (IBD)
endoscopic balloon dilation of strictures, 47–50
endoscopic closure of surgical leak, 53–55
endoscopic fistulotomy, 52–53
endoscopic management of, 47–56
endoscopic sinusotomy, 55–56
endoscopic stricturotomy, 50–52
Intersphincteric abscess, 88
Intestinal stomas
construction of, 463–481
instruments and equipment used in, 464–465
laparoscopic technique
ileostomy, 465–469, 465–469f
right transverse colostomy, 471–473, 471–473f
sigmoid colostomy, 473–476, 473–476f
open technique
colostomy, 479–481, 479–481f
ileostomy, 476–479, 476–478f
Intraoperative radiation therapy (IORT)
applicators
placement of, 274, 274f
use of, 272, 272f
approach and equipments used in, 271–272
for colorectal cancer, 271–277
Geiger meter, 276, 276f
indications for, 271
radiation safety sign, 275, 275f
technique, 272–277, 272–276f
Intraoperative urology consultation
bladder repair, 356
Boari flap +/– psoas hitch, 354–355, 355f
delayed presentation, 349–350, 349f
distal ureteral injury, 354
endourologic options, 352, 352f
intraoperative consultation for injury, 351
intraoperative cystoscopy, 350
intraoperative management of ureteral injury, 351
intraureteral indocyanine green, 350
lighted ureteral catheters, 350
mid-ureteral injury, 353
open options for repair, 352–353
postoperative care, 358f
postoperative identification of ureteral injury, 357, 357f
proximal ureteral injury, 352–353, 352f
safeguards, 350
special considerations, 356
transureteroureterostomy, 353, 353f
ureteral catheters, 350
ureteral injury, types of, 351
ureteral reimplant or ureteroneocystostomy with or without psoas hitch, 354, 354f
ureteral repairs, 351
ureteroureterostomy, 354
urethral repair, 356, 356f
IORT. See Intraoperative radiation therapy (IORT)
IPAA. See Ileal pouch-anal anastomosis (IPAA)
Ischioanal abscess, 87–88, 87f
Ischiorectal abscess, 87–88. See also Ischioanal abscess
J
Jejunum, 4, 4f
K
Kock pouch (K-pouch)
anterior wall of pouch, closure of, 528–529, 528–529f
integrity and continence, checking for, 530–531, 530f
intubation simulation, 530, 530f
pouch creation, 521–525, 522–525f
stoma creation, 531–532, 531–532f
technique, 521
valve creation, 526–527, 526f
valve fixation, 527, 527f
“Kraske” positioning. See Prone positioning
L
Laparoscopic diverting loop colostomy
indications, 371
procedure, 371–373, 371–373f
specific equipments used in, 371
Laparoscopic diverting loop ileostomy
indications, 367
specific equipment used in, 367–368
technique, 368–370, 368–370f
Laparoscopic sigmoid colostomy
surgical technique, 458–459
Large bowel obstruction (LBO)
endoscopic decompression of sigmoid volvulus and drain placement
equipment needed for, 376
indications, 376
procedure, 376, 377f
endoscopic placement of self-expanding metal stent for palliation
equipment needed for, 377
indications, 377
procedure, 377–378, 378f
laparoscopic diverting loop colostomy
indications, 371
procedure, 371–373, 371–373f
specific equipments used in, 371
laparoscopic diverting loop ileostomy
indications, 367
specific equipment used in, 367–368
technique, 368–370, 368–370f
laparotomy with sigmoid resection on-table colonic lavage, colorectal anastomosis, and diverting
loop ileostomy
indications, 373
procedure, 374–376
specific equipment used in, 374
Large intestine, 4, 5f
anus, 7f, 8
ascending colon, 6
cecum and appendix, 5
descending colon, 7, 7f
rectum, 6f, 7–8
sigmoid colon, 7, 7f
transverse colon, 7
Lateral internal sphincterotomy
perioperative considerations, 73, 73t
LBO. See Large bowel obstruction (LBO)
Left colectomy, 195, 195–196f
abdominal exploration, 198, 199f
colorectal or coloanal anastomosis, 204, 204f
high ligation of inferior mesenteric artery and vein, 198–201, 199–201f
left colon and splenic flexure mobilization, 201, 202f
operative approach, 197, 197f
patient positioning, 196–197, 197f
pearls and pitfalls, 205–206, 205–206f
perioperative consideration, 196
preparation of proximal colon and distal transection, 202–203, 202–203f
LIFT. See Ligation of intersphincteric fistula tract (LIFT)
Ligation of intersphincteric fistula tract (LIFT)
pearls and pitfalls, 105f
technique, 105–106, 105–106f
Lithotomy position
Lithotomy with boot-type stirrups
Lithotomy with candy cane stirrups
technique, 21, 22f
Lithotomy with split-leg table
M
Milligan-Morgan (open) hemorrhoidectomy, 66–68, 66–68f
Multivisceral colorectal cancer
spinal and orthopedic considerations for
closure, 347, 347f
indications/contraindications, 341
instrumentation/reconstruction, 347
navigation/localization for osteotomy, 344–346, 345f
nerve root dissection, 346, 346f
osteotomies, 346–347
posterior approach, 344, 344f
retroperitoneal (less frequently used), 343–344
sterile instruments/equipment used, 341–343, 341f
surgical approaches, 343–344
transperitoneal (workhorse approach), 343
Multivisceral colorectal disease
gynecologic oncology (GYN-Onc) considerations
anatomic considerations, 332–334, 332–333
en bloc resection of uterus, cervix, and rectosigmoid, 334–336, 334–336f
gynecologic organ involvement by colon cancer, 331
hypogastric artery ligation, 338f
intraoperative considerations, 332–337
lymphadenectomy, 337, 337f
magnetic resonance imaging, 332f
preoperative considerations, 331
tumor extension below peritoneal reflection, 336–337, 336f
N
Nerve root dissection, 346, 346f
O
Office endoscopy
anoscopy, 59, 59f
colonoscopy through a colostomy, 62
digital examination, 58–59
flexible ileoscopy, 62
flexible sigmoidoscopy, 60
inspection, 58
pouchoscopy, 60–62, 61f
rigid ileoscopy, 62
rigid proctoscopy, 60
scoping diverted bowel, 62–63
scoping stomas, 62
“Open Sesame” technique, 58–59, 60
Operating room equipment
anoscopy, proctoscopy, and transanal procedures, 13–14, 14–15f
deep pelvic instruments, 16–17, 17f
Dr. Lavery fistula set, 13, 13f
minor anorectal procedures, 13, 13f
retractors, 15–16, 15–16f
staplers, 17, 17f
transanal endoscopic microsurgery (TEM), 14, 15f
transanal minimally invasive surgery, 14, 14f
Operative positioning, principles of
arm tucking, 26–28, 27–28f
chest strap, 28–29, 28f
lithotomy position, 20–21, 20f
lithotomy with boot-type stirrups, 22–24, 23–24f
lithotomy with candy cane stirrups, 21–22, 21–22f
lithotomy with split-leg table, 24–26, 25–26f
prone (kraske) positioning, 29–30, 30–31f
rectal irrigation, 31–32, 31–33f
supine positioning, 19
Osteotomies, 346–347
navigation/localization for, 344–346, 345f
Outpatient office equipment
anorectal abscess and fistula set, 11f
anoscopy and proctoscopy, 10, 10f
flexible endoscopy, 11, 12f
general equipment, 9–10, 9–10f
hemorrhoid banding equipment, 11, 11f
pelvic floor evaluation, 12, 12f
P
Parastomal hernia repair
keyhole mesh preparation, 510–511, 510–511f
laparoscopic sugarbaker technique, 512, 512–513f
laparoscopic technique
adhesiolysis, 509
port placement, 509, 509f
positioning, 508–509
mesh choice, 508
open technique
operative approach, 514–517, 515–517f
preoperative evaluation, 513–514
operative approach, 506–507, 506t
with ostomy in situ, 517–518
patient assessment, 505–506
patient preparation, 507–508
robotic, 518
Park classification, of anorectal fistulas, 88, 88f
PCI. See Peritoneal carcinomatosis/cancer index (PCI)
Pelvic constipation
equipment, 594
Hirschsprung disease, 594
patient positioning/preoperative antibiotics, 594–595
technique, 595–597, 595–596f
Perianal abscess, 87–88
Perianal sepsis, principles of dealing with, 85, 86f
Perineal proctectomy
anesthesia, 606
general and perioperative consideration, 605
anterior dissection, 608, 608f
intersphincteric dissection, 609
lateral dissection, 608
perineal wound closure, additional options for, 609
perineal wound, closure of, 608–609, 609f
posterior dissection, 607, 607f
specimen, extracting, 608, 608f
Peritoneal carcinomatosis/cancer index (PCI), 240f
Peritoneum, 1, 2f
Pezzer catheter, 31, 31f
“Pezzer” catheter, 87
Pilonidal disease
bascom flap (cleft lift), 159–160, 159–160f
excise vs. flap, 151–161
general technique for all cases, 152, 153f
lay-open technique with marsupialized pilonidal pits and excision of pilonidal pits, 154, 154f
limberg flap (rhomboid flap), 155–158, 155–159f
wide local excision, 155
incision and drainage, 152
patient positioning, 151–152, 151f
positioning and preparation, 152
surgical treatment, indications for, 152
Pouchoscopy, 60–62, 61f
Presacral tumors
biopsy indications, 291
computed tomography, 290, 291f
multidisciplinary team approach, 291
operative considerations, 291–292
pathologic considerations, 291f
preoperative evaluation for, 289–291, 289–291f
technique
abdominal approach, 295–296, 295f
combined abdominal/posterior approach, 296
incision, types of, 292–294, 293f
posterior approach, 292–294
posterior technique of dissection into retrorectal space, 294, 294–295f
Proctectomy
instrument and personnel positioning, 300
laparoscopic low anterior resection, 299–310
port insertion, 300–301, 300–301f
sterile instruments and equipments used in, 299
technique
anastomosis, 308–310, 308–309f
left colon mobilization, 301–304, 302–304f
rectal mobilization, 305–310, 305–306f
transection, 307–308, 307f
Prone (kraske) positioning
Purse-string suture
distal, 325–329, 326–329f
placement, 313, 314f
points to consider when performing, 314–316, 314–316f
R
Rectal irrigation
Rectal neoplasia
final mobilization for closure, 287f
indications for surgical treatment, 279–280
limitations of, 280
local excision of, 279–287
muscular layer intact, 286, 286–287f
preoperative preparation, 280
standard transanal excision, 280–282, 281–283f
transanal minimally invasive surgery (TAMIS), 283–285, 283–285f
Rectal prolapse
abdominal procedures, 540–542
Altemeier procedure (perineal proctosigmoidectomy)
technique, 536–540, 537–540f
anesthesia, 535
Delorme procedure, 535–536, 535–536f
posterior rectopexy +/– sigmoid resection, 540–542
Rectourethral fistulas (RUF)
patient positioning and draping
high lithotomy position, 136–137, 136–137f
padding of pressure points, 137
prepping and draping, 137
sterile equipments used in, 136
technique
gracilis muscle interposition, 140, 140–141f, 142
initial dissection, 138, 138f
perineal approach with gracilis muscle interposition, 137, 138f
posterior urethroplasty, 140
rectal closure, 139
urethral closure, 139–140, 139f
wound closure, 142
Rectovaginal fistula (RVF)
algorithm for surgical repair, 118f
fistula closure, techniques of
advancement flaps, 119
episioproctotomy, 123–127, 123–127f
semicircular advancement flap, 119–120, 119–121f
sleeve advancement flap, 121, 122–123f
tissue interposition, 128–133, 128–133f
Rectum, 6f, 7–8
Retractors
lighted pelvic retractors, 16, 16f
self-retaining retractors, 15–16, 15–16f
Right colectomy
anesthesia, use of, 209
approach and equipment, 209
equipments used in, 207–208, 208f
isolation of ileocolic pedicle, 211–213, 212–213f
laparoscopic assessment of resectability, 210–211, 211f
mobilization of ascending colon and hepatic flexure, 214–215, 214–216f
mobilization of cecum and small bowel mesentery, 216, 216–217f
port insertion, 209–210, 210f
standard extracorporeal resection and anastomosis, 218–219, 218–220f
transversus abdominis plain block, 217
umbilical incision and exteriorization of right colon, 218, 218f
Rigid ileoscopy, 62
Rigid proctoscopy, 60
RUF. See Rectourethral fistulas (RUF)
RVF. See Rectovaginal fistula (RVF)
S
Sacral neuromodulation
Scoping diverted bowel, 62–63
Scoping stomas
colonoscopy through a colostomy, 62
flexible ileoscopy, 62
rigid ileoscopy, 62
Setons, 97
cutting seton, 99, 99f
draining seton, 97–99, 97–98f
Sigmoid colon, 7, 7f
Slow transit constipation
equipment, 590
patient positioning/preoperative antibiotics, 590
pearls and pitfalls, 593, 593–594f
technique, 590–593, 591–593f
Small intestine, 1, 2f
duodenum, 2–3, 2–3f
ileum, 4, 5f
jejunum, 4, 4f
Spinal and orthopedic considerations
for advanced multivisceral colorectal cancer, 341–348
closure, 347, 347f
indications/contraindications, 341
instrumentation/reconstruction, 347
navigation/localization for osteotomy, 344–346, 345f
nerve root dissection, 346, 346f
osteotomies, 346–347
sterile instruments/equipment used, 341–343, 341f
surgical approaches
posterior approach, 344, 344f
retroperitoneal (less frequently used), 343–344
transperitoneal (workhorse approach), 343
Splenic flexure
approaching, 304, 304f
instruments and equipments used in, 230
pearls and pitfalls, 235–236, 235–237f
technique, 230–234, 230–234f
Standard transanal excision, 280–282, 281–283f
Staplers, 17, 17f
Stoma prolapse, 498–499
parastomal varices, 502, 502f
retraction, 502, 502f
stricture, 502–503, 502–503f
technique, 499–501, 499–501f
Submucosal abscess, 88
Supine positioning
technique, 19
Supralevator abscess, 88–89
T
Taeniae coli, 4
TAMIS. See Transanal minimally invasive surgery (TAMIS)
Transanal minimally invasive surgery (TAMIS)
closure of defect, 285, 285f
excision, 284–285, 284–285f
final mobilization for closure, 287f
and laparoscopic equipment, 283–284, 283f
muscular layer intact, 286, 286–287f
preparation for, 284
procedure of, 284
Transanal total mesorectal excision
anastomosis, 325, 325f
anesthesia, 311
dissection, 320–321, 320–321f
extraction of specimen, 324–325, 324f
handsewn anastomosis, 325, 325f
instruments used in, 312–313, 312–313f
preoperative setting for rectal cancer patients, 311
proctotomy, 316–319, 317–319f
purse-string suture
distal, 325–329, 326–329f
placement, 313, 314f
points to consider when performing, 314–316, 314–316f
stapled anastomosis, 325–329, 326–329f
sterile field preparation
and operating room setup, 312, 312f
prior to, 312
transanal and abdominal dissections, connection of, 322–323, 322–323f
Transverse colon, 7
anesthesia and patient positioning, 221
dividing transverse mesocolon from right, 224–225, 224–225f
instruments and equipments used in, 221
left-sided medial-to-lateral dissection approach to, 226, 226f
mesenteric approach to, 226–227, 226f
port placement, 221, 222f
right-sided medial-to-lateral dissection approach, 223, 223f
superior approach to, 227
surgical approaches, 222, 222f
Trauma laparotomy, conduct of
damage control scenarios, 392–393
injuries of colon, 389–390, 390f
injuries of rectum, 391–392, 392f
proximal fecal diversion, 393
technique, 389
Trauma of colon, rectum, and anus
diagnosis/mechanism of injury, 387
blunt trauma, 387–388
pelvic trauma/potential rectal injury, 388
penetrating trauma, 387
patient positioning and preparation, 388–389
trauma laparotomy, conduct of
damage control scenarios, 392–393
injuries of colon, 389–390, 390f
injuries of rectum, 391–392, 392f
proximal fecal diversion, 393
technique, 389
Turnbull-Cutait technique, for complicated anastomoses
discussion with patient, 187
operative planning, 188
preoperative assessment and evaluation, 187
technique
abdominal phase, 188–189
delayed anastomosis, 191–192, 191–193f
exteriorization, 190–191f, 191
pre-exteriorization, 189, 189–190f
V
Ventral rectopexy
anesthesia, 544
docking, 546
equipment used in, 543–544
port placement, 544–545, 544–546f
rectopexy, 546–553, 547–553f
robotic instruments placement, 546
Vertical rectus abdominis myocutaneous flaps (VRAMs)
technique, 568–569, 568–570f

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Acquisitions Editor: Keith Donnellan

Development Editor: Sean McGuire

Copyright © 2021 Wolters Kluwer.

Library of Congress Cataloging-in-Publication Data

Names: Steele, Scott R. (Surgeon), editor. | Cleveland Clinic Foundation.

IN THE OPERATING ROOM AND ANATOMY

1• Anatomy of the Colon, Rectum, and Anus

19 • Anastomotic Construction Techniques

28 • Intraoperative Radiation Therapy for Colorectal Cancer

TECHNICAL TIPS FOR SPECIFIC SITUATIONS

36 • Complex Diverticular Disease: Colovaginal and

PELVIC FLOOR DISORDERS

Mohammad Ali Abbass, MD

Kenneth Angermeier, MD, FACS

Anuradha R. Bhama, MD, FACS, FASCRS

Vladimir Bolshinsky, MBBS, FRACS

Bradley J. Champagne, FACS, FASCRS

James Church, MBChB, FRACS

Conor P. Delaney, MD, MCh, PhD, FACS, FRCSI, FASCRS (Hon),

Richard L. Drake, PhD

Daniel R. Fish, MD, MS

Emre Gorgun, MD, FACS, FASCRS

Stefan D. Holubar, MD, MS

Michelle D. Inkster, PhD, MD

Eric K. Johnson, MD, FACS, FASCRS

Hermann Kessler, MD, PhD

Amy Lightner, MD, FACS, FASCRS

Jeremy M. Lipman, FACS, FASCRS

David Liska, MD, FACS, FASCRS

David Maron, MD, MBA

Jennifer M. McBride, PhD

Peter Mark Neary, MD

Ajita Prabhu, MD, FACS

Giovanna da Silva Southwick, MD

Scott R. Steele, MD, MBA

James P. Tiernan, PhD, MD

Joseph Trunzo, MD, FACS, FASCRS

Michael A. Valente, DO, FACS, FASCRS

Eric G. Weiss, MD, DIO

James S. Wu, PhD, MD

Scott R. Steele, MD, MBA

Editor: Scott R. Steele, MD, MBA

Associate Editors: James Church, MBChB, FRACS,

James Church, MBChB, FRACS

Surgical Anatomy, properly understood, implies not merely relation

Peritoneum. The peritoneum is a closed serous sac, having no external

The duodenum is divided into four parts (Fig. 1-4) as follows.

FIGURE 1-5 Details of the arterial supply to the duodenum.

Jejunum and Ileum

Cecum and Appendix

Outpatient Office Equipment

General Equipment (Fig. 2-1)

FIGURE 2-2 Colorectal tables.

Reusable anoscopes (eg, Hirschman) of different lengths and diameters

Instruments for simple incision and drainage procedures and assessment of

Local anesthetic (eg, lidocaine, bupivacaine)

FIGURE 2-7 Flexible endoscopy equipment and tower.

Flexible sigmoidoscopes (Fig. 2-8)

Ileoscopes for endoscopic assessment of ileostomy or continent ileal

FIGURE 2-9 Endorectal ultrasound.

Anorectal manometry system (Fig. 2-10)

Operating Room Equipment

Minor Anorectal Procedures

Two clamps, Hemostatic, straight, 6 in