Left and Sigmoid Colectomy: Options for Colonic and Colorectal Reconstruction

Fig. 18.1

(a) Placement of a handsewn purse string in the colostomy. (b) Cinching down of the purse string with the stapling anvil in place

It is at the surgeon’s discretion whether to perform the anastomosis under pneumoperitoneum or open via the laparotomy incision. For the laparoscopic approach, the proximal colon and anvil are returned to the peritoneal cavity, and the fascia is definitively closed. Alternatively, with an extraction site in the suprapubic position, the creation of the anastomosis can be performed under direct visualization. The advantage of this open approach is the ease of management of any difficulties or complications associated with the anastomosis – these will be discussed in the Pitfalls and Troubleshooting section.

With either approach , the end to end anastomosis (EEA) stapling cartridge is passed transanally to the top of the rectal stump. The flat end of the stapler should be advanced so that the top of the rectal stump is splayed out flat across the device (Fig. 18.2a). This is to ensure that there are no rectal folds or redundant mucosa incorporated into the staple line. Once it is flush at the top of the rectal stump, the spike of the stapler should be deployed (Fig. 18.2b). The spike can pass through the rectal wall either just posterior or anterior to the staple line or even directly through the staple line. With the spike fully deployed, the anvil should be joined with the spike after confirming the proximal colon is properly oriented and not twisted. The anvil is then cinched down under direct visualization to ensure there is no extra tissue (e.g., vagina, bladder) incorporated into the staple line and make sure the proximal purse string remains intact (Fig. 18.2c). Once the stapler is fired and extracted, the anastomotic doughnuts should be inspected for completeness. A complete doughnut is intact circumferentially and includes all layers of the bowel wall – mucosa, muscularis, and serosa. The final step in creating a secure anastomosis involves assessing that the anastomosis is airtight and intact, which will be discussed below.

../images/465809_1_En_18_Chapter/465809_1_En_18_Fig2_HTML.png — Fig. 18.2

(a) Sagittal view of the pelvis and rectum . EEA stapler passed to the top of the rectal stump. (b) EEA stapler with the spike deployed. (c) The anvil is attached to the EEA staple cartridge

End to Side Anastomosis

An end to side anastomosis is variation of an end to end that does not require the placement of a purse string. It can be used for any level of rectal anastomosis. For this technique, the colon is divided sharply, and the colotomy is opened. The anvil is passed into the lumen via the end colotomy (Fig. 18.3a). The spike is then brought out through the antimesenteric wall roughly 3–4 cm proximal to the colotomy and secured in position with a clamp (Fig. 18.3b). The colotomy is then re-approximated with Allis clamps and closed with a firing of linear stapler (Fig. 18.3c). It is critical to ensure that the anvil is brought out through the colonic wall proximal enough to ensure that the linear staple line is not incorporated into the circular staple line and that there is enough tissue (>2 cm) between the circular and linear staples lines to maintain perfusion to this bridge of tissue. Once the placement of the anvil is complete, the anastomosis is created using the same technique as described above.

../images/465809_1_En_18_Chapter/465809_1_En_18_Fig3_HTML.jpg — Fig. 18.3

(a) The stapling anvil is passed through the open colotomy at the end of the colon. (b) The anvil is brought out the antimesenteric border of the colon 3–4 cm proximal to the end colostomy. (c) The end colotomy is closed by approximating it with Allis clamps and stapling with a linear stapler

Colonic J Pouch

Proctectomy with reconstruction has a very profound impact on a patient’s bowel function. Therefore, surgeons have developed several reservoir or neorectum procedures for anastomosis within 5 cm of the anal verge. Utilization of a reservoir above 5 cm often results in increased difficulties with evacuation. Options for reconstruction after proctectomy include a straight colorectal anastomosis (described under end to end anastomosis), colonic J pouch, transverse coloplasty, and the Baker anastomosis (described under end to side anastomosis). Functionally, the colonic J pouch has better immediate outcome, but after 2 years all of the types of reconstruction have similar functional outcomes [4]. Using a reservoir for an anastomosis above 5 cm may result in difficulties with evacuation. Anastomosis at the pelvic floor will require division of the inferior mesenteric artery at its origin, division of the inferior mesenteric vein at the inferior boarder of the pancreas, and complete mobilization of the splenic flexure to ensure adequate length for the proximal colon to reach the pelvic floor. For the best functional outcomes, it is recommended that soft, pliable descending colon be used for the anastomosis. Utilization of stiff, thickened sigmoid colon will result in decreased compliance of the neorectum and may increase the chances of developing low anterior resection syndrome.

A colonic J pouch is constructed to be 5 cm in length. A larger reservoir is associated with evacuation difficulties. The colon is divided with a linear stapler, and staple line may be oversewn to prevent a leak at the tip of the J. A colotomy is made on the antimesenteric border 5 cm proximal to the transecting staple line (Fig. 18.4a). One fork of the stapler is passed up the proximal limb, and the other fork is passed up the distal limb. The stapler is then reassembled, and the bowel wall is rotated so that the stapler will fire down the antimesenteric boarder of the colon (Fig. 18.4b). It is important to ensure that all epiploic appendages are excluded from the staple line. Once the stapler is removed, a handsewn purse string in a Connell fashion is placed at the colotomy. The EEA stapling anvil is placed into the colotomy, and purse string is cinched down (Fig. 18.4c). The anastomosis is then created by passing the stapling device transanally and deploying the spike through the rectal stump. The anvil is then connected to the stapling cartridge ensuring proper orientation of the left colon. As the stapler is cinched down, the anterior tissues (prostate and bladder in a male and the vagina in a female) must be elevated and confirmed to be free of the EEA staple line before firing. Given the complexity of J pouch and the low anastomosis, most surgeons would recommend proximal diversion.

../images/465809_1_En_18_Chapter/465809_1_En_18_Fig4_HTML.png — Fig. 18.4

(a) Creation of colonic j pouch . A 5 cm limb is measured, and a colotomy is made at the apex of the pouch on the antimesenteric border. (b) A GIA stapler is used to create the pouch. The finger is used to get the mesentery out of the staple line so the staple line is antimesenteric to antimesenteric. (c) A purse string is placed using a handsewn technique

Transverse Coloplasty

A transverse coloplasty is an acceptable alternative to a colonic J pouch when the pouch will not fit into the pelvis. Reasons that a J pouch will not fit into the pelvis include a bulky mesentery and or a narrow pelvis. Construction of the coloplasty begins with sharp division of the proximal colon, placement of a purse string, and securing of an EEA stapling anvil. On the antimesenteric border of the colon and 4 cm proximal to the anvil, an 8 cm colotomy is created and extended proximally (Fig. 18.5a) The longitudinal colotomy is then closed in a transverse direction in a handsewn fashion (Fig. 18.5b). A 3-0 monofilament suture is for the first layer. Beginning at one of the corners, a running Connell stitch is used to close the colotomy, and the second layer of imbricating Lembert stitches are placed to reinforce the suture line (Fig. 18.5c). With the coloplasty completed, an end to end anastomosis is completed as previously described.

../images/465809_1_En_18_Chapter/465809_1_En_18_Fig5_HTML.png — Fig. 18.5

(a) The anvil is in place in the distal colotomy and secured with a handsewn purse string. The measurement for the placement and extent of the colotomy are shown. (b) The colotomy is open with electrocautery. The first layer is closed in a transverse fashion with a running suture. (c) The colotomy closure is reinforced with a second layer of Lembert sutures

Baker’s Anastomosis

This is the same anastomosis as that described in the end to side technique. When constructed as an anastomosis at 5 cm or less from the anal verge, functional outcome falls in between that for a colonic J pouch and a transverse coloplasty.

Anastomotic Assessment

Once the anastomosis is created, it must be appropriately assessed to ensure that it is intact. Proper assessment has three components: (1) inspection of the anastomotic doughnuts, (2) air leak testing, and (3) direct intraluminal visualization of the anastomosis. The proximal and distal anastomotic doughnuts should be intact circumferentially with all three layers of the bowel. The management of incomplete doughnuts is addressed below. Inspection of the anastomosis itself can occur with either rigid proctoscopy or flexible endoscopy. With either technique, the pelvis is filled with normal saline, and the bowel is manually occluded proximal to the anastomosis. The endoscope is then introduced transanally into the rectum, air is insufflated to distend the anastomosis, and the pelvis is examined for the presences of air bubbles. The management of an anastomosis that is leaking air bubbles is described below. During or after the air leak test, the endoscope is used to directly evaluate the anastomosis. The anastomosis is examined for completeness, bleeding, and perfusion. For more details on techniques to assess the integrity and perfusion of left-sided anastomoses, please refer to Chap. 29 on minimizing colorectal anastomotic leaks.

Pitfalls and Troubleshooting

Unable to Pass Stapler to the Top of the Rectal Stump

The longer the rectal stump , the more difficult it can be to get the EEA stapler to navigate past all of the rectal folds and get the stapler head flush against the transverse staple line. Adhesions or scarring of rectum may make it difficult in which case further mobilization of the rectum will be beneficial. This may require mobilization below the peritoneal reflection. The upper rectal folds or a narrowed upper rectum may also prevent passage of the stapler. The use of EEA sizers may help flatten out the folds or dilate a narrowed rectum because of their oval shape, and this will help to facilitate the passage of the flat or square face of the stapler head. If this is unsuccessful, then the rectum needs to be divided again at the level to where the stapler can easily be passed.

Rectal Stump Blowout

A disruption of the transverse staple line on the rectum can be one of the most frustrating situations because it often happens at the end of a long case. Poor tissue quality, thickened rectum, and traumatic rupture from passing the stapler are all causes of the rectal staple line falling apart. If this occurs in the upper rectum, it is easily rectified by dividing the rectum a few centimeters below the previous staple line. If this is due to a thicken rectum, it may be helpful to use a longer staple height when stapling across the rectum or dividing the rectum a level where it is the softest. When the disruption of the staple line occurs in the rectum below the peritoneal reflection, salvaging the rectum becomes much more complicated. The first step is to mobilize the rectum to the pelvic floor circumferentially. This will maximize the chances that another stapler can be fired across the rectum. If you are unable to re-staple the rectum laparoscopically, conversion with a suprapubic incision is warranted. This will allow the rectal stump to be grasped with clamps and re-stapled with an open linear stapler. If it is not possible to staple across the rectal stump , there are two remaining options. The first option is a handsewn purse string on the rectal stump. All of the staples must first be removed. The purse string can be placed intraabdominally from an open or laparoscopic approach. With the use of a 2-0 monofilament suture, a purse string is sewn in a full-thickness Connell fashion. This can be particularly challenging because of limitations of the laparoscopic instrumentation, and because visualization from an open approach is poor at best. A second option is to place the purse string transanally. With the patient in the lithotomy position, the legs are frog-legged in the stirrups to expose the anus. The anus in then everted with Lone Star retractor. An operating anoscopy is passed into the anal canal, and the purse string is then placed in the same fashion as above. In either the transabdominal or transanal technique, the stapler is inserted into the rectum, and the spike is deployed before the purse string is cinched down. The purse string is then tied around the spike of the stapler, ensuring that the rectal wall is securely and circumferentially drawn into the stapler. The ultimate fallback for when the rectal stump cannot be salvaged is a mucosectomy with a handsewn coloanal anastomosis. This will work for all the described types of reconstruction. Once again, the patient is placed in high lithotomy position to expose the anal canal. The anal canal is everted with a Lone Star retractor. If the top of rectal stump is visible and easily accessed, the staple line is excised, and the anastomosis is created. Otherwise, a mucosal incision is made circumferentially 1–2 cm above the dentate line. The submucosal plane is developed and dissected in a cephalad fashion, and eventually the dissection becomes full thickness resecting the rest of the rectal stump . The idea is to preserve as much of the internal sphincter as possible. With the dissection completed, the first sutures are placed in the rectum at the 12, 3, 6, and 9 o’clock positions. The sutures are placed from inside the lumen to the outside, and the needles are left on the suture. Next the proximal colon is grasped transanally and delivered into the anal canal. The sutures are then sutured to the proximal colon in an outside to inside fashion, so the knots for each suture are inside the lumen. Each quadrant is then completed with full-thickness, interrupted sutures.

Positive Air Leak Test of the Anastomosis

The assessment of the anastomosis entails inspection of the anastomotic doughnuts and air leak testing of the anastomosis as described above. As a result, there are four different scenarios that can arise (Fig. 18.6): (1) complete doughnuts with an airtight anastomosis, (2) complete doughnuts with air leaking from the anastomosis, (3) incomplete doughnuts with an airtight anastomosis, and (4) incomplete doughnuts with air leaking from the anastomosis. Each component of the scenarios impacts the management of the anastomosis. The ideal is intact doughnuts with an airtight anastomosis. However, if the doughnuts are incomplete or there is an air leak at the anastomosis, this will require further management. The presence of complete doughnuts with an air leaking from the anastomosis is managed based on the size of the air bubbles leaking and the source can be clearly visualized. Small “champagne” bubbles for the anterior half of the anastomosis that can be visualized can be managed by placing Lembert stitches across the anastomosis. The placement of multiple stitches along the anastomosis is recommended as a single suture is not adequate. If the small “champagne”-type bubbles cannot be seen, consider proximal diversion or revision of the anastomosis by taking it down and recreating it. If the bubbles are large with an obvious defect in the staple line, this needs to be managed with revision of the anastomosis. However, if the anastomosis is low and can be accessed transanally, the anastomosis can be repaired transanally with proximal diversion. When the doughnuts are incomplete with an airtight anastomosis, this anastomosis should be protected with proximal diversion, or it should be revised because it cannot be guaranteed that the anastomosis is full thickness. For an anastomosis with incomplete doughnuts and leaking air, it should be taken down and re-created as proximal diversion alone is unlikely to be sufficient. For more details on techniques to manage intraoperative air leak and other anastomotic complications, please refer to Chap. 30 on how to salvage the failed anastomosis.