Constipation
Tracy Hull
SLOW TRANSIT CONSTIPATION
Perioperative Considerations
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.
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.
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.
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.
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.
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).
FIGURE 52-3 ▪ Lateral mobilization of the cecum.
FIGURE 52-4 ▪ Lateral mobilization of the hepatic flexure.
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 52-5 ▪ 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.Related posts:
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