Complicated Anastomoses: Turnbull-Cutait
Sherief Shawki
Perioperative Considerations
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
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