The first step in understanding any surgery is achieving a clear overall picture of the patient. If the patient is healthy enough medically, nutritionally, and mentally to undergo debulking surgery, then the surgeon must have a concrete understanding of the anatomy involved.1 Without a thorough understanding of the anatomy, many pitfalls and complications may occur. The anatomy of the entire abdomen needs to be under the purview of the gynecologic oncologist. Because gynecologic cancers do not remain confined to the pelvis, our anatomic knowledge cannot remain confined to the pelvis.
Morrow and Curtin2 have previously elegantly illustrated that certain conditions must be met prior to creating any bowel anastomosis. First, healthy tissue with good blood supply needs to be used in both the afferent and efferent bowel limbs. If blood supply is questionable, then fluorescein dye with a wood’s lamp can be used to visualize the blood supply.3 Second, an adequate, nonstrictured, water-tight, hemostatic lumen must be created. Third, the anastomosis should be free of tension. Fourth, an anastomosis should not be created in the presence of established peritonitis. Applying these guidelinesto any bowel anastomosis is crucial.
INDICATIONS AND APPLICATIONS
The stomach at the proximal end of the small bowel is a site frequently involved with disease extending over from the lesser or greater omentum. Infrequently, disease is large enough to require wedge resection for complete cytoreduction or gastrojejunostomy for palliation secondary to a large node or mass obstructing the pylorus or proximal duodenum.4,5 Hoffman et al6 described cases in which en bloc resection of the left upper quadrant intra-abdominal contents (including 2 cases of partial gastrectomy), was able to leave the patient with minimal residual disease. In a larger series, Walter et al4 have shown that partial gastrectomy (or wedge resection) can be safely performed in radical debulking of ovarian cancer.
The most common surgery performed on the small bowel (jejunum and ileum) in gynecologic oncology is small bowel resection with primary reanastomosis. This can be performed for a variety of reasons by gynecologic oncologists. The resection may be for obstruction by cancer, debulking of cancer, radiation damage causing fistula or stricture, or for dead or damaged bowel as a complication of therapy.
Bristow et al7 demonstrated the safety and utility of colorectal resection and reanastomosis in women with ovarian cancer. Three years later, Hoffman8 built upon their study and echoed the safety of similar procedures. Both of these papers showed that large resections of the colon could be safely performed to aid in cytoreduction. Silver and Walter separately have shown that subtotal colectomies can be safely performed in achieving complete cytoreduction.9,10 These extensive resections with pouches (Figure 14-1) are associated with complications but are tolerated well by patients.11 Once the protective ostomy is reversed, patients will have continence but increased fecal frequency.9 This topic will be covered more extensively in Chapter 15.
Example of a ascending colonic J-pouch with low colorectal anastomosis.
Pertinent anatomic figures are provided in Chapter 2. The stomach is the most proximal abdominal organ of the digestive tract. It lies asymmetrically in the abdomen to the left of midline and is comprised of 4 parts: cardia, fundus, body, and pyloric antrum. The cardia surrounds the cardiac orifice where the stomach attaches to the esophagus just inferior to the lower esophageal sphincter. The cardiac notch or angle of His lies between the esophagus and fundus, and approximates the location of the gastroesophageal (GE) junction. The horizontal plane of the GE junction marks the inferior border of the distensible fundus, which is bounded superiorly by the left dome of the diaphragm and laterally by the spleen. The fundus is the most superior aspect of the stomach. The largest portion of the stomach is the body, which is located between the fundus and the pyloric antrum. It is bound on the right by the lesser curvature and on the left by the greater curvature. The sharp angle of the lesser curvature, the angular incisure, identifies the junction of the body and the pyloric antrum. Distally, the pylorus connects the antrum to the proximal duodenum.
The stomach is anteriorly related to diaphragm, left lobe of the liver, and anterior abdominal wall. The posterior surface of the stomach forms the anterior wall of the omental bursa. The gastrosplenic ligament attaches the proximal greater curvature to the spleen. Inferiorly, the stomach is attached to the transverse colon by the gastrocolic omentum as it courses along the greater curvature to the left colic flexure (splenic flexure). The lesser curvature is attached to the liver by the hepatogastric ligament (part of the lesser omentum).
The duodenum is the most proximal segment of the small intestine, lying partially in the retroperitoneum. It is also the shortest segment of small intestine, only 25 cm in length. It has a C-shaped course around the head of the pancreas, beginning just distal to the pylorus and ending at the ligament of Treitz (duodenojejunal junction). It is divided into 4 parts: superior, descending, inferior, and ascending. Proximally, the superior part is attached to the hepatoduodenal ligament (lesser omentum) containing the portal triad. The descending portion curves around the head of the pancreas and is entirely retroperitoneal. The inferior part courses horizontally and is crossed by the superior mesenteric artery and the root of the mesentery of the jejunum and ileum. Posteriorly, the inferior part is related to the inferior vena cava, aorta, and right ovarian vessels. The ascending part of the duodenum curves anteriorly to join the jejunum at the duodenojejunal flexure.
The main blood supply to the stomach comes from the celiac axis and its branches. The lesser curvature is supplied by anastomoses formed between the right and left gastric arteries, arising from the hepatic artery and celiac trunk, respectively. An anomalous hepatic artery can arise from the left gastric artery 15% to 20% of the time, which occasionally is the only arterial flow to the left hepatic lobe. The gastroduodenal artery arises from the hepatic artery and supplies the right portion of the greater curvature along with part of the omentum (through the right gastroepiploic). The splenic comes either off a named branch or directly off the celiac trunk giving blood supply to the proximal greater curvature and fundus via short gastrics, and blood to the omentum and greater curvature through the left gastroepiploic before supplying the named organ. The duodenum is supplied by the superior and inferior pancreaticoduodenal arteries, via the celiac trunk (branch of gastroduodenal artery) and superior mesenteric artery, respectively. The veins of the stomach and duodenum parallel the arteries and drain into the hepatic portal vein either directly or indirectly via the superior mesenteric vein and splenic vein.
Because of its length (15–30 feet, with the female average of 21 feet), the small bowel is a frequently involved area with tumor or complications from therapy. The jejunum and ileum comprise the intraperitoneal portion of the small intestine, beginning at the duodenojejunal junction and extending to the ileocecal junction. It can be difficult to grossly distinguish between the ileum and jejunum as there is no distinct anatomic marking identifying them. Most of the jejunum lies in the left upper quadrant of the infracolic compartment of the abdomen, comprising about two-fifths of the small bowel. The ileum primarily resides in the right lower quadrant and makes up the remaining three-fifths of the small bowel. The jejunal mucosa is thicker with more prominent plicae circulares. The mesenteric vessels form one or two arcades with long, straight vasa recta. The ileum has a thinner wall with slightly smaller caliber, more prevalent mesenteric arcades and short vasa recta. There is also increased mesenteric fat in the ileum.
The superior mesenteric artery with its numerous branches is the main blood supply to the small bowel (embryologic midgut). It can be found arising from the aorta just posterior to the pancreas. The pancreaticoduodenal is the first branch followed by a variable number of jejunal and ileal branches (12–15). Next come the ileocolic, right colic, and middle colic vessels. The ileocolic and right colic may branch of together from the aorta before dividing, and so this is an anatomic variation.
The colon has 4 parts: ascending, transverse, descending, and sigmoid. The ascending colon is approximately 15 cm in length and is a secondarily retroperitoneal continuation of the cecum, extending between the level of the ileocecal valve and the right colic flexure. The transverse colon, the longest (45 cm) and most mobile part of the large intestine, is suspended between the hepatic and splenic flexures and attached to the greater omentum along its superior aspect. Like the ascending colon, the descending colon is also secondarily retroperitoneal, beginning at the splenic flexure and extending approximately 25 cm to the left iliac fossa. It is fixed against the retroperitoneum posteriorly with the lateral and anterior surfaces as true intraperitoneal structures. The white line of Toldt is the lateral peritoneal reflection that can be used as a guide to mobilize the colon. It should be noted that this lies in close proximity to the left ureter and ovarian vessels. At the level of the pelvic brim, the descending colon transitions to the S-shaped sigmoid colon with a mesentery (pelvic mesocolon) that is fixed to the posterior pelvic wall. It is highly variable in length (15–50 cm) and smaller in caliber than the descending colon. The sigmoid colon terminates at the rectosigmoid junction at the level of the sacral promontory, as do the characteristic markings of the colon—teniae, haustra, and omental appendices.
The rectum extends approximately 12 to 15 cm into the true pelvis and is mostly extraperitoneal. The posterior rectal wall is covered in a thin fascia propria (visceral layer) opposed by a thicker, presacral fascia (parietal layer) that covers presacral veins. A fine areolar fascia is present between the anterior surface of the parietal layer and the posterior surface of the visceral layer of the rectum. The Waldeyer’s fascia is formed by fusion of these 2 layers just superior to the coccyx. Anteriorly, Denonvilliers fascia, a bilaminar fascial layer, separates the anterior rectum from the vagina. It is also known as the rectovaginal septum and is continuous with the uterosacral folds.
The ascending and transverse colon is supplied by branches of the superior mesenteric artery, including ileocolic, right colic, and middle colic arteries. Beginning at the splenic flexure, the remainder of the colon and rectum is supplied by branches of the inferior mesenteric artery, including the superior and inferior left colic arteries, multiple sigmoid arteries, and the middle rectal artery. The posterior wall of the rectum is also supplied by branches of the median sacral artery. One area of confusion that continues until today regarding the blood supply of the colon is caused by the different names used for vessels. The central anastomotic artery of the mesocolon is sometimes referred to as the arc of Riolan and sometimes as the marginal artery of Drummond. The key point to understand is that this vessel extends from the ileocolic artery to the lowest sigmoid vessel (Figure 14-2).
Diagram of colorectal blood supply with special attention to arc of Riolan (marginal artery of Drummond).
Box 14-1 KEY SURGICAL INSTRUMENTATION
60- to 80-mm linear stapler/cutter with 3.5- to 4.8-mm staple
45- to 60-mm endoscopic linear stapler/cutter
2.0-mm staple for vascular pedicles
3.0- to 3.5-mm staple for bowel
21- to 33-mm circular stapler/cutter with 3.5–4.8 mm staple-size
30- to 60-mm linear stapler with 3.5–4.8 mm load
3-0 monofilament, delayed-absorbable suture on taper needle
Argon beam coagulation device
At our institution, before performing any surgical procedure on a woman with a pelvic mass albumin and prealbumin are checked.12 If the prealbumin level is below 10 mg/dL, then patients are started on parenteral nutrition even if tolerating supplemental enteral feeds. If the prealbumin does not increase to at least 10 mg/dL after 7 to 10 days, the patient will undergo paracentesis or percutaneous biopsy to attempt to get a cancer diagnosis. Once the diagnosis is made, they will be offered neoadjuvant chemotherapy because of the increased risk of morbidity and mortality when operating on women with a low prealbumin level.1 All patients with a starting prealbumin from at least 10 to 18 mg/dL are placed on postoperative supplementation with oral supplements being preferred.
Although the redundant blood supply of the stomach makes the stomach a forgiving organ on which to operate, several points exist about which to be aware when operating on the stomach. Surgical adventures to the patient’s right of the angular notch can turn into misadventures if the biliary tree is damaged. If performing gastrostomy, then it is best to sew the stomach to the anterior wall to decrease the chances of spilling gastric contents into the abdomen.
Preservation of the blood supply of the small bowel is paramount. Careful surgical manipulation of the mesentery and bowel wall is of utmost importance. Although the small bowel can be stripped of its mesentery in creating an ileostomy for up to 6 cm, this is often not necessary and potentially harmful if done incorrectly.13,14
While operating on the colon, several key points must be considered. First, while the small intestine’s arcades allow up to 6 cm of bowel to be devascularized, the colon’s vascular redundancy is more proximal; therefore, only 2 cm can be devascularized without necrosis. Next, operating on the left colon near the splenic flexure and sigmoid near Sudeck point, can be precarious if the surgeon is not aware of the vascular watershed areas. It is best to create anastomoses proximal or very distal to these points.
A further point of caution has recently been illustrated.15 It is critical for good outcomes when performing ovarian cancer cytoreduction, especially bowel resections and anastomoses, to not allow hypothermia to occur. Patients in whom core temperatures dropped below 96.8°F (36°C) had increased complications compared to those in whom hypothermia did not occur.15
Bowel resections are performed in gynecologic oncology most commonly for either debulking or obstruction. Each of these is fraught with potential pitfalls for the unwary. Also, each is more quickly performed if the surgeon is knowledgeable of the surgical anatomy, surgical techniques, and surgical tools. Over the past few decades, the paradigm has shifted away from preoperative oral antibiotic bowel preparation and mechanical bowel preparation to using just parenteral antibiotics one hour before incision. The paradigm may be shifting again. Recent data demonstrate that the best combination to achieve the lowest surgical site infection rate in patients undergoing elective colon surgery is the combination of preoperative oral antibiotic bowel preparation, mechanical bowel preparation, and parenteral antibiotics within 1 hour of incision.16
If an ostomy is being considered preoperatively, then enterostomal therapy is consulted to talk with the patient and mark optimal sites. In any patient that receives an ostomy, enterostomal therapy is consulted immediately postoperatively to begin patient education.
Currently, most intestinal anastomoses are performed using mechanical surgical devices and endomechanical surgical devices.17 These are supplied by a variety of companies. The specific devices associated with each procedure are discussed in the related section along with device sizes and staple diameters.
Box 14-2 MASTER SURGEON'S PRINCIPLES
Healthy tissue with good blood supply needs to be used in both the afferent and efferent bowel limbs (test with fluorescein dye if unsure)
An adequate, nonstrictured, water-tight, hemostatic lumen must be created
Anastomosis should be free of tension
Anastomosis should not be created in the presence of established peritonitis without a proximal diversion
Even after an infragastric omentectomy, the redundancy of the gastric blood supply allows wedge resection to be safely performed. To avoid a key area of complication when working with the lesser omentum or lesser curvature, the surgeon must stay to the patient’s left of the hepatoduodenal ligament in the hepatogastric area of the lesser omentum. The key anatomic point to recognize is the stomach’s angular notch. Damage to the biliary tree can be safely avoided if the surgeon stays to the patient’s left of this anatomic point on the lesser curvature. Using a laparoscopic gastrointestinal linear stapler/cutter (Figure 14-3), a full thickness resection can be safely and easily accomplished using a 45- to 60-mm long stapler with a 3- to 3.5-mm thick staple. A second load is used to create a wedge around the tumor and crossing the original line to seal the stomach (Figure 14-4). This type of resection can be undertaken on either the greater or lesser curvature. The staple line from an endoscopic linear stapler/cutter has 3 rows of staples so oversewing is not usually necessary (see Figure 14-3).
Laparoscopic gastrointestinal linear stapler/cutter with a 45-mm long stapler and 3.5-mm thick staple.
Diagram of wedge resection with overlapping staple lines from a Laparoscopic gastrointestinal linear stapler/cutter.
Alternatively, a smaller lesion can be resected with a football or elliptical-shaped resection of the gastric serosa (with or without muscularis and mucosa as indicated). This may result in the stomach mucosa (and the gastric contents momentarily being open. The site should be closed with a delayed absorbable 3-0 monofilament suture (polyglyconate or polydioxanone) on a taper needle. A running or Connell stitch can be used. Recent studies have even demonstrated that a running stitch using a barbed suture is equivalent to a running stitch using a delayed absorbable suture.18 Whether or not a second imbricating layer is used depends on the patient’s history and status, as well as surgeon preference. A small resection can also be accomplished by pulling the tumor up to be resected, then placing an endoscopic 45- to 60-mm long stapler with a 3- to 3.5-mm staple, and firing it. This results in a closed resection without any exposure of the abdomen to gastric contents.
In women with ovarian cancer, the infragastric omentum should already have been surgically resected at the initial debulking, so one difficulty with the gastrojejunostomy in other patients is absent. When performing the procedure, a decision has to be made whether the jejunum is going to be anastomosed to the anterior stomach, the greater curvature, or posterior stomach. If the plan is to perform an anastomosis to the anterior stomach or greater curvature, the jejunum is brought over the transverse colon. If a posterior attachment is planned, then the jejunum is passed through the transverse colon mesentery through a window of Dever.
Either way, the anastomosis is most easily performed using a 60- to 80-mm long linear stapler/cutter (Figure 14-5) with a 2.5- to 3.8-mm staple. For example, the jejunum is placed with its antimesenteric border against the greater curvature. Stabilizing sutures can be placed before small incisions are made in the stomach and the jejunum. Alternatively, the two bowel segments can just be carefully aligned or even held with Allis clamps. A small hole is made in the stomach and the jejunum on the antimesenteric side. The linear stapler/cutter is placed with one piece in each lumen and fired (Figure 14-6). The remaining opening can be then closed with a linear stapler (3.5- to 4.8-mm staple) or sewn closed with a 3-0 delayed absorbable suture.
linear stapler/cutter with 60-mm load with a 2.5-3 mm staple.
Diagram of gastrojejunostomy with linear stapler/cutter placed with one side in each lumen and fired.
Another surgery performed in women with ovarian cancer is a Stamm gastrostomy procedure.19 This procedure used to be performed more commonly than it is today because percutaneous endoscopic gastrostomy tubes (PEG) can be placed safely in many patients without the need for a laparotomy or laparoscopy.20,21 In ovarian cancer patients, gastrostomies are used palliatively because of obstruction or tumor ileus rather than for feeding. Because of the specific need, occasionally tumor or ascites prevent percutaneous placement. When still performed, a Stamm gastrostomy can be performed through a 7- to 8-cm upper midline or left subcostal incision. The tube itself can be a standard PEG tube, a Foley catheter or a Mallinckrodt catheter of large gauge. The stomach is grasped on the anterior mid surface near the greater curvature with a Babcock clamp. Two purse string sutures of 3-0 delayed absorbable monofilament are placed around the Babcock clamp with needles left attached. The tube is brought through the anterior wall away from the incision. It is placed through a small puncture wound in the stomach. The purse sutures are closed inner first and then outer, and then the sutures are sewn to the anterior abdominal wall. The tube can be connected to suction or can be left capped only to be opened when needed. Alternatively, a permanent tube can be made from the anterior gastric wall and brought as a gastrostomy through the anterior abdominal wall. The defects are closed with a 3-0 delayed absorbable suture. Complications from this approach include the possibility of gastric contents getting on the skin.
The actual resection of the bowel can be accomplished using bowel clamps or using a 60- to 80-mm open linear stapler/cutter. The mesentery can be resected by hand with clamps, scissors, and ties; by endoscopic linear stapler/cutter with a 2- to 2.5-mm staple load; or by a vessel-sealing device. A smaller diameter staple is used on mesenteric vascular tissue than on the adjacent bowel to seal the vessels. If this same diameter staple was used on bowel, then the staples could cause local necrosis and failure of the staple line.22 The linear staple/cutter is passed through the avascular window just below the bowel edge (Figure 14-7) in a healthy area of bowel proximal to the area to be resected. The linear staple/cutter is closed (Figure 14-8), and the bowel is divided giving 2 fresh staple lines (Figure 14-9) closing the bowel lumen on both sides. If a linear stapler alone was used, then one side of the bowel would be open. A similar procedure is performed in a healthy area of bowel distal to the site being resected. The mesentery can then be resected quickly with either an endoscopic linear staple/cutter with vascular loads (staple 2–2.5 mm) or a vessel-sealing device. After completion of the anastomosis, the mesentery should be closed with 3-0 delayed absorbable suture.
linear staple/cutter through the avascular window just below the bowel edge in a healthy area proximal (and distal) to area to be resected.
A 60-mm linear stapler/cutter has been passed through an avascular window on the mesenteric side of the ileum and has been closed with the other part of the linear stapler/cutter. When looking closely at the bowel coming through the device, notice that the device had to be repositioned prior to firing. Although in this picture the entire bowel would have been appropriately stapled, the bowel extended past the “cut” line and so would be sealed but not cut.
The previously shown piece of ileum has been stapled and divided as intended. A hemostat is shown hold the apex.
The next decisions that need to be made are what type of anastomoses and whether to use staplers or sew by hand. Two main types of anastomoses performed in the small bowel currently are the more common side-to-side functional end-to-end anastomoses and the less common end-to-end anastomosis.
If a side-to-side anastomosis is being performed, then the 60- to 80-mm linear stapler/cutter is then used to recreate the lumen. The 2 bowl limbs that are to be joined are placed antimesenteric to antimesenteric side. The antimesenteric corners of the staple lines on both limbs are cut open with heavy- curved scissors. One side of the linear stapler/cutter is placed in each lumen (Figure 14-10A). If needed, stay sutures can be place to stabilize the bowel. The bowels are now connected in a side-to-side functional end-to-end anastomosis. The right side of the figure demonstrates the residual opening after creating the anastomosis (Figure 14-10B). The edges of the opening are grasped carefully with Allis or Babcock clamps and are brought above the future staple line of the linear stapler. The residual opening is closed with a linear stapler 30 to 60 mm in length with a 3.5 or 4.8 mm load (Figure 14-11A). Any tissue above the staple line is removed with a pair of heavy scissors. Figure 14-11B shows an already fired 45-mm linear stapler with 3.5-mm staples. As can be seen, there are two rows of alternating staplers and no knife or knife ridge to cut the tissue. This type of instrument only seals one side of bowel. Therefore, it should not be used in a procedure where you are dividing bowel and want both proximal and distal lumens closed unless another load is used immediately adjacent to the first.
(A) The 2 antimesenteric sides of the bowel to be anastomosed are lined up with a linear stapler/cutter in position to join the bowels in a side-to-side functional end-to-end anastomosis. (B) The residual opening is shown after the bowel has been anastomosed.
(A) Linear stapler is used to close opening from Figure 14-8B. Tissue protruding above device is trimmed away prior to loosening the device. (B) A close-up of an already used linear stapler. Note that there are only 2 rows of stable and no blade to cut.
An end-to-end anastomosis can be performed by hand- sewn closure or be an end-to-end anastomotic circular cutter/stapler (Figure 14-12). As can be seen in Figure 14-12, the end-to-end anastomotic circular stapler/cutter has 2 concentric rings of staples with an inner circular knife. An end-to-end anastomosis can be performed of varying inner diameter based on the size of the smallest piece of bowel being connected. An analogous procedure will be described in the section on colorectal procedures. An even less common procedure is an end-to-side anastomosis. This type is usually performed in the situation where a bowel bypass, rather than a bowel resection, is being performed. This is also quickly performed with an end-to-end anastomotic circular stapler/cutter.
A circular stapler/cutter for end-to-end anastomosis is demonstrated in this picture. In gynecologic oncology, these devices are most frequently used to anastomose colon to rectum or anus during a debulking with low anterior resection. Two rows of staples are seen with a circular blade closer to the center.
Ileostomies may be placed in patients to protect more distal anastomoses or as an end ostomy. The more distal the ostomy is in the small bowel, the less the chance of electrolyte and fluid problems. Often, vitamin K must be supplemented if the ostomy is prior to the terminal ileum. Diverting ostomies can either be an end or a loop ileostomy. Loop ostomies add the benefit that a closure of the ostomy to reintroduce bowel continuity can be performed through just the ostomy site, minimizing the incision size for the patient.
A loop ostomy is made by first creating a quarter-size opening in the skin with the cut mode of the electrosurgical unit. The subcutaneous tissue is not removed and it is just pushed to the sides. The assistant or the nondominant hand pushes up from inside the abdomen and a cruciate incision is made in the fascia. A cruciate incision is used to decrease the chances of the fascia constricting the bowel. The fibers of the rectus are pushed apart (and not cut) to decrease parastomal hernia. The site for the opening in the bowel is marked by bluntly passing a vessel loop or small diameter Penrose drain through the mesentery just below the bowel wall. The previously identified site in the ileum is gently brought through the ostomy site using a combination of pushing from below and gentle traction with either a Babcock clamp or the vessel loop from above. Once the bowel is brought up through the ostomy above the skin level (5–6 cm), an ostomy bar is used to replace the vessel loop. The shortest possible ostomy bar should be used to facilitate appliance placement. The bar is sewn to the skin edge with an absorbable monofilament. Previously, authors have thought that sewing the small bowel to the skin created more problems, but this has been demonstrated not to be true. It is safe to create a rosebud ostomy with small intestine. The rosebud is created at the cardinal points with either a 3-0 absorbable monofilament (poliglecaprone 25 or glycolide/dioxanone/trimethylene carbonate) or 3-0 absorbable braided (polyglycolic acid or polyglactin) suture. The afferent loop will produce the effluent and the efferent limb acts as a mucous fistula.
Closure of a diverting ileostomy can be performed in a variety of ways. Classically, surgeon preference dictates which of the following 3 techniques is chosen: hand-sewn anastomosis without bowel resection, hand-sewn anastomosis with bowel resection, and stapled anastomosis. Gustavsson et al23 showed in a large series of patients that stapled anastomoses had a shorter hospital stay and less chance of small bowel obstruction than either of the hand-sewn methods.
The skin around the ostomy is incised with the electrical surgical unit on cut. The subcutaneous tissues are carefully dissected off of the bowel sparing the ileal mesentery. Once the fascia is reached, the bowel is carefully separated from the rectus fascia. This dissection allows mobilization of enough bowel to allow creation of a new lumen and restitution of bowel continuity in most cases. After mobilization, the ileum is pulled up and the antimesenteric edges are placed next to each other. Analogous to Figure 14-10, the 60- to 80-mm linear stapler/cutter (with a 2.5–3.8 mm staple load) is placed (one part in each lumen). Once the alignment is correct, the instrument is fired and a new anastomosis is created. The residual opening is again closed with a 30- to 60-mm linear stapler with a 3.5- to 4.8-mm staple load. Residual tissue is resected above the staple line.
If an end ileostomy is being reversed, a midline incision is first made. The ostomy is mobilized as above with the reversal of the loop ostomy. The ostomy itself is either closed with a linear stapler (Figure 14-11), or closed with a delayed absorbable 3-0 monofilament suture. This closure decreases chances of spilling succus entericus into the abdomen. Some surgeons prefer to leave the ostomy open. After mobilization (and closure) of the ostomy, the ileum is brought into the open abdomen. The distal bowel to which the segment will be reanastomosed is identified. Any adhesions are takedown with cautery or sharp dissection to allow there to be no tension on the anastomosis. The continuity of the bowel is restored as a side-to-side functional end-to-end anastomosis as previously described. Occasionally, the patient’s anatomy is more conducive to placing the proximal and distal bowel parallel to each other with their antimesenteric borders touching although this is more common in the colon (Figure 14-13). Stay sutures of a 3-0 delayed monofilament suture are placed to ease the procedure. This side-to-side anastomosis is performed similarly to the previously described gastrojejunostomy. Again the residual opening of the bowel is closed either a linear stapler (3.5–4.8 mm staple) or sewn closed with a 3-0 delayed absorbable suture in a careful running fashion.
Afferent and efferent limbs of the bowel are placed parallel to each other with their antimesenteric borders. Stay sutures of a 3-0 delayed monofilament suture are placed to ease the procedure. Side-to-side anastomosis is performed with linear stapler cutter (shown). The residual opening of the bowel is closed either a linear stapler (3.5–4.8 mm staple) or sewn closed with a 3-0 delayed absorbable suture in a careful running fashion.
In Hoskins’ 1987 description of right ileocolic resection for radiation injury,24 a hand sewn end-to-end anastomosis was the most common type performed. As staplers have improved, this trend has changed and more stapled anastomoses are being performed.25 Most of these stapled anastomoses are side-to-side functional end-to-end anastamoses.25 Key steps in the resection are mobilization of the right colon by finding the white line of Toldt on the right. This overlap of the visceral and parietal peritoneum allows the colon to be medialized and pulled off of Gerota fascia of the kidney, off the duodenum, and off the right ureter. If resecting the entire right colon, then the right lateral omentum must be mobilized off the transverse colon if not previously removed. In addition, the hepatocolic ligament will be incised to free the colon. The ileocolic and right colic arteries should be identified and transected. All of this is done with constant awareness of the location of the right ureter.
A side-to-side functional end-to-end anastomosis is performed by aligning the distal and proximal bowels’ 2 antimesenteric sides that are to be connected. These can be held in place with stay sutures or just carefully approximated. A small opening is made through the previous staple lines on the side closest to the other piece of bowel with heavy scissors. A 60- to 80-mm linear stapler/cutter is used to recreate the lumen (Figure 14-10A, B). The right side of the figure demonstrates the residual opening. The bowels are now connected in a side-to-side functional end-to-end anastomosis. The edges of the opening are grasped carefully with Allis or Babcock clamps, and all the edges are brought above the future staple line of the linear stapler. The residual opening is closed with a linear stapler 30- to 60-mm in length with a 3.5- or 4.8-mm load (see Figure 14-10B). Again any tissue above the staple line is removed with a pair of heavy scissors.
Alternatively, the whole procedure can be done by hand. A Cochrane Database review of hand-sewn versus stapled anastomoses in cancer patients has shown that stapled techniques lead to fewer anastomotic leaks.26,27 This difference was more important in small bowel and small bowel to colon surgery than in colorectal surgery.
Another option is an end-to-end anastomosis with a combination of hand sewing and stapled triangular closure. The area to be resected is identified. Good, healthy areas of bowel are identified proximal and distal to the site to be resected. A window is made just below the bowel wall and bowel clamps (Figures 14-14 and 14-15) are carefully passed just below the bowel edge. A total of four bowel clamps are used so that there is minimal spillage of succus entericus. The bowel is divided with heavy scissors or an electrosurgical unit on cut. The bowel is clamped, cut, and tied with 2-0 or 3-0 braided silk suture on a passing instrument. The resected piece is now handed off and attention is paid to the area to be hand-sewn. A 3-0 delayed absorbable suture is used on the posterior aspect (mesenteric side) of the area to be anastomosed. The bowel wall is inverted. A running suture technique is used for the posterior aspect (one-third to one-half of anastomosis). These stitches are full thickness. The knots can be extraluminally or intraluminally tied. The remaining portion of the anastomosis is sewn with full thickness bites, inverting the mucosa. If the anastomosis appears to be too small, a slit can be made full thickness in the antimesenteric portion of both limbs (spatulating the bowel; Figure 14-16). A triangular closure is then used. The linear stapler linear 30 to 60 mm in length with a 3.5- or 4.8-mm load is used to close 3 times starting on the mesenteric side with the mucosa raised (Figure 14-17). This side has the only staple line on the inside of the lumen. The other parts of the triangle are closed with overlapping staple lines on the external surface (Figures 14-18 and 14-19). This allows the anastomosis to be larger diameter than the actual bowel, which is being joined. Imbricating delayed absorbable sutures can be placed to protect the anastomotic integrity if desired by the surgeon.
Curved (upper) and straight (lower) linen shod bowel clamps. The linen helps protect the bowel from crush injury.
(A) Three different Glassman-type bowel clamps are shown. The upper is angled at < 45 degrees. The center clamp is at a right angle. The lower clamp is straight. (B) A close up of the small nonpenetrating teeth on the Glassman-type bowel clamps.
The steps involved in a triangulation technique used to anastomose pieces of bowel that are at risk for stricture is shown in this figure and Figures 14-17,18,19. This illustration shows the spatulation of the bowel by cutting an antimesenteric slit to expand the surface being connected.
The 2 lengths of bowel are brought together with stay sutures prior to the closure of the base of the triangle (mesenteric side of bowel). Both limbs of bowel have an inverted portion that will be stapled together. Note that this is the only staple line that will be intraluminal.
Two sides of the triangular closure are completed. The unseen posterior aspect is intraluminal. A linear stapler has been used to close side 2, and the linear stapler is in place with another load ready to close the final portion of the new anastomosis.
The new anastomosis created in this manner (antimesenteric slits with triangular closure) is larger than either bowels diameter.
1. Right hemicolectomy/ileocolic resection
A right hemicolectomy (ascending colectomy) with ileotransverse anastomosis is described in the section on ileocolic resection above. The resection and anastomosis can be performed either with staplers or by hand.
A transverse colectomy with right-left colonic anastomosis can be performed for debulking or creation of transverse colon incontinent urinary diversion (discussed in Chapter 11). In either situation, if the omentum is present, it must be taken off the colon by going through the avascular plane connecting the omentum to the transverse colon. The hepatocolic and the splenocolic ligaments are transected mobilizing the hepatic and splenic flexures, respectively. The transverse colon is pulled up by gently grasping the bowel with a gloved hand or a gloved hand wrapped with a surgical laparotomy sponge. The middle colic vessels are identified and the area to be resected is identified. Care is made to make sure that the resection margins have a good blood supply. For debulking of a gynecologic malignancy, the middle colic vessels are resected as distally as possible so as not to compromise blood flow to the remaining bowel.
A left hemicolectomy is very similar to a right hemicolectomy but mobilization is even more important so that there is no tension on the anastomosis. Key steps in the resection are mobilization of the left colon by finding the white line of Toldt on the left. If this resection is being performed with a primary debulking of ovarian cancer, then the white line is most easily found by cephalically extending the opening of the posterior broad ligament. This overlap of the visceral and parietal peritoneum allows the colon to be medialized and pulled off of Gerota fascia of the kidney and off the left ureter. If resecting the entire left colon, then the left lateral omentum must be mobilized off the transverse colon if not previously removed. In addition, the splenocolic ligament will be transected to free the colon. Performing the above-described efforts of mobilization will help dramatically when it comes time to anastomose the colon. The inferior mesenteric artery (IMA) and its tributaries are identified. The vessels are ligated as distal as possible since this surgery is for debulking and not for resection of a primary colon cancer. This preservation helps maintain the vascular integrity of the colon. All of this is done with constant awareness of the location of the left ureter. With the descending (left) colon placed medially, the procedure can be performed predominantly from the lateral/retroperitoneal perspective.
While general surgeons often take an intraperitoneal approach, we find a retroperitoneal approach is very quick and allows us to identify the ureters most easily. The retroperitoneum is entered by ligating the round ligaments or by tenting up the peritoneum of the pelvis and entering it. The paravesical and pararectal spaces are opened bilaterally. This action identifies the ureters, isolates the sigmoid, and ascertains the position of the sigmoidal vessels. The 60- to 80-mm linear stapler/cutter with a 2.5- to 3.8-mm stapler is fired at the distal resection margin after placing it carefully through a window just below the serosal edge of the bowel. This allows the bowel to remain closed and decreases chance of spillage. If the pelvis is too small to allow a linear stapler/cutter to be used, then a linear stapler 45 to 60 mm in length with 3.5- to 4.8-mm staples can be used. This would have to be used twice and the bowel cut in between the placement of the 2 loads because this device does not have a knife. Alternatively, the surgeon could choose to leave the resected area open and just cut proximal to the distal staple line. Attention is then paid to the proximal point of resection. Ideally, this proximal resection should take place upstream to the critical area of Sudeck. This point where the last branch of the IMA is joined by the superior hemorrhoidal artery from the internal iliac artery is a watershed area and an area of possible ischemia. A 60- to 80-mm linear stapler/cutter with a 2.5- to 3.8-mm stapler is placed and fired at the proximal margin of resection. The mesentery of the sigmoid is resected and the specimen is sent to pathology (Figure 14-20).
Small section of sigmoid colon is shown. Near the left side (away from scissors) is a circumferential ovarian cancer metastasis to the bowel mucosa.
5. Low colorectal resection (Low anterior resection)
In gynecologic oncology, a low colorectal resection/low anterior resection may be performed for a variety of reasons, including debulking, bowel obstruction, fistula repair, and pelvic exenteration.28,29 To most easily perform this operation, the patient should be in low lithotomy position with Allen-type stirrups. The vertical abdominal incision is extended from the pubic symphysis into the upper abdomen. Small bowel is packed away. As described in the section of sigmoid colectomy, the retroperitoneum is entered and the paravesical and pararectal spaces are created. The procedure can either be performed en bloc with the uterus or independently. The rectum needs to be isolated posteriorly, laterally, and anteriorly. Only the anterior dissection is changed by the presence of the uterus. With the opening of the retroperitoneum, the dissection is made much easier. Posteriorly, the rectum is separated from Waldeyer’s fascia. This is most easily accomplished by dividing the rectococcygeal ligament (anterior-posterior orientation) with an endoscopic linear stapler/cutter 45-60 mm long with a 2.5-mm staple load. Bilaterally, the rectal pillars comprise the rectal (hemorrhoidal) vessels and the corresponding ligaments. These are isolated with gentle blunt dissection anterior and posteriorly on each side and an endoscopic linear stapler/cutter 45 to 60 mm long with a 2.5-mm staple is placed and fired on both sides. This action is repeated until the caudal extent of the dissection is reached. Anteriorly, if the uterus is being spared, the posterior peritoneum just below the cervix is entered. Denonvilliers fascia is identified and pushed anteriorly separating the vagina from the rectum. Once the caudal margin of resection is identified a linear stapler 45 mm in length with a 3.5- or 4.8-mm load is placed and fired. If the surgeon wants the bowel closed, then the 45-mm linear stapler with a 3.5- or 4.8-mm load is placed and fired, and the bowel is cut with scissors in between the staple lines. The specimen is then sent to pathology for examination.
6. Colorectal anastomosis
End-to-end anastomosis can be performed for low anterior resection with colorectal re-anastomosis. Although a large meta-analysis demonstrated no difference in anastomotic leak rated comparing staplers to hand-sewn, the same analysis did show that stapled anastomoses are performed more quickly.27 A sizing device from 25 to 31 mm is used to determine the correct size that should be used. The circular stapler/cutters used for end-to-end anastomoses range from an external diameter of 21 to 33 mm with staples from 3.5 to 4.8 mm. Too large a diameter device will thin the bowel and lead to breakdown. Too small a diameter device will lead to stricture. Figure 14-12 shows the anvil, which is placed in the proximal bowel lumen. The opening is then closed with a 3-0 monofilament suture in a purse string technique. Because this suture will be removed by the anastomosis, it does not matter whether the monofilament suture is absorbable or not. The end of the hand piece with the spike retracted is gently advanced through anus and into the rectum. It is guided until the ring of the hand piece can be seen near the previous distal limb staple line. The spike in the hand piece is advanced until it passes either through or near the previous staple line. Once it is fully advanced, the sharp spike can be carefully removed and the anvil (in the proximal loop of bowel) and receiving piece attached to the hand piece are engaged with an audible click. The device is then closed by twisting until a green line appears in the window of the hand piece. At this point the stapler/cutter is fired, and the device is carefully opened approximately one and one half turns. The device is removed along with the anvil from the proximal limb of bowel by gently rotating the hand piece 90 to 180 degrees back and forth until the entire device is removed from the rectum and anus. Now the two tissue rings or “doughnuts” are examined to make sure they are complete. The “flat tire test” is performed to check the integrity of the anastomosis by filling the pelvis above the level of the anastomosis with warm water. The bowel proximal to the ring anastomosis is occluded with a hand gently. A red rubber catheter with a large 60 to 120 mL wide mouth syringe is advanced to just distal to the anastomosis. Air in the syringe is pushed quickly into the bowel lumen, and the presence of an anastomotic leak will be detected by bubbles appearing in the water. This can be performed 1 to 3 times to be certain. If a leak is detected, an imbricating layer of 3-0 delayed absorbable sutures can be placed and the flat tire test repeated. Alternatively, the anastomosis can be taken down and redone if the leak is more than 25% of the anastomotic diameter.30
If a large portion of the rectum or the entire rectum is resected, then a j-pouch can be made using colon or ileum (see Figure 14-1).9 To do this type of anastomosis, the remaining colon is mobilized until the residual proximal large intestine can be brought without tension into the pelvis. The apex to which the distal bowel is going to be anastomosed to is identified. This technique will be described in further detail in Chapter 15.
Colostomies, like ileostomies, may be placed in patients to protect more distal anastomoses or as an end ostomy. Similar to the small intestine, diverting ostomies can either be an end or a loop ileostomy. Loop ostomies add the benefit that a closure of the ostomy to reintroduce bowel continuity can be performed in a minimally invasive manner through just the ostomy site.
A loop ostomy is made by first creating a quarter-size opening in the skin with the cut mode of the electrosurgical unit. The subcutaneous tissue is not removed and it is just pushed to the sides. The assistant or the nondominant hand pushes up from inside the abdomen and a cruciate incision is made in the fascia. A cruciate incision is used to decrease the chances of the fascia constricting the bowel. The fibers of the rectus are pushed apart (and not cut) to decrease parastomal hernia. The site for the opening in the bowel is marked by bluntly passing a vessel loop or small diameter Penrose drain through the mesentery just below the bowel wall. The previously identified is gently brought through the ostomy site using a combination of pushing from below and gentle traction with either a Babcock clamp or the vessel loop from above. Once the bowel is brought up through the ostomy above the skin level (5–6 cm), an ostomy bar is used to replace the vessel loop. As small a length bar as possible is used to ease ostomy appliance placement. The bar is sewn to the skin edge with an absorbable monofilament. Often, the ostomy is not matured until the vertical skin incision is closed. The rosebud is created at the cardinal points with either a 3-0 absorbable monofilament or a 3-0 absorbable-braided suture.
The closure of a diverting or end colostomy is very similar to the closure of the analogous ileostomy and is covered in that section. A few minor differences exist. First, the larger length linear stapler/cutter with thick staples is often needed.
Box 14-3 PERIOPERATIVE MORBIDITY
Bowel Obstruction or Ileus
Either a mechanical bowel obstruction or a paralytic ileus can occur after any surgery in the abdominal cavity. Although ileus is a loss of functional activity anywhere from the stomach to the colon, bowel obstruction is a mechanical blockage. These mechanical obstructions are often caused by adhesive scar tissue. The use of hyaluronic acid/carboxymethyl cellulose membrane reduces the incidence, extent, and severity of adhesions in the abdomen. However, it does not decrease the rate of intestinal obstruction or need for operative intervention. Hyaluronic acid/carboxymethyl cellulose membrane should not be wrapped around an anastomosis because there may be an increased risk of leak.31
Ileus in the stomach is often referred to as gastroparesis. It is especially common in women with glucose intolerance, hyperglycemia, or overt diabetes. Some level of postoperative gastroparesis exists in most patients after exploratory laparotomy for 24 to 48 hours after surgery. For mild-to-moderate cases, dietary management (small amounts at a time) is the mainstay of treatment.32
After elective major gynecologic abdominal surgery, it has been shown that oral intake may be safely started on postoperative day 1.33 Starting feeding results in quicker release from the hospital, but may also result in increased postoperative nausea. Because bowel obstruction and adynamic ileus are both significant causes of prolonged hospital stay and increased cost, many trials have been performed utilizing the routine use of prokinetic agents. In general, the routine use of erythromycin, cholecystokinin, cisapride, dopamine-antagonists, propranolol, or vasopressin has not been shown to be effective or the side effects are too great (cisapride).34 More data are needed regarding the routine use of neostigmine or intravenous lidocaine. Evidence does support the use of neostigmine 2 mg intravenously for the specific treatment of Ogilvie syndrome.35
Identification of ileus versus small bowel obstruction can be undertaken by the use of computed tomography (CT) or flat plate roentgenograms. CT not only gives better resolution in diagnosis, but it may offer a therapeutic benefit when water soluble contrast is used.36,37 Once ileus is diagnosed, the current mainstay of treatment is use of nasogastric tube, intravenous fluids, or parenteral nutrition if without food for at least 7 days, and patience. Some data have shown benefit to the therapeutic ingestion of water-soluble contrast.36
When a bowel obstruction is diagnosed, the acuity of the patient needs to be determined. If the patient is stable and does not require emergent surgical intervention, then patience is the operative word along with a nasogastric tube and either intravenous fluids or parenteral nutrition if without food for at least 7 days. CT with water-soluble contrast can be performed 3 to 5 after diagnosis of the obstruction.37 Conflicting data exist as to how long one can wait for spontaneous resolution to occur, in general, patience and time can be used for resolution if the patient’s acuity does not change.
Abscesses and Anastomotic Leaks
The actual reported rate of intestinal anastomotic leaks varies greatly by the reports and whether the paper is describing testing all anastomoses with water soluble contrast (≤ 50% leaks found) or leaks that present themselves clinically (1%–30%).2 So, although a small leak may be present in up to half and not clinically significant, a clinically significant leakage should be treated with broad spectrum and percutaneous drainage. If this fails after 24 to 48 hours, then repeat water-soluble contrast-based CT imaging should be repeated. If further CT guided drain placement is not of value, or peritonitis develops, then laparotomy and drainage is required for a patient who would survive the repeat surgery.
Abscesses can develop postoperatively because of anastomotic leaks, anastomotic hemorrhage, fecal spill at surgery, or hematoma formation. The most common time of formation is 1 to 2 weeks but they have been reported up to 6 weeks after anastomosis. Typical signs and symptoms at presentation are abdominal pain; malaise; intermittent fever; diarrhea, constipation, or ileus; elevated or severely decreased white blood count; a poor defined pelvic mass. Again, CT with water-soluble oral and rectal contrast allows both identification and possible placement of a drain if feasible. Broad-spectrum antibiotics are used until cultures identify a more specific choice. Surgery can now usually be avoided due to radiologic placement of drains. Strictures can develop on their own or after a complication such as these and so one should watch for them after a complication.
Box 14-4 DELAYED COMPLICATIONS
Absorption problems can arise if too much distal ileum has to be removed for obstruction or debulking. Because the terminal portion of the ileum is responsible for absorption of fat-soluble vitamins (A, D, E, K) plus vitamin B12, patients may need parental supplementation of these vitamins if resected. If the patient further develops a difficulty in absorbing high-molecular-weight fats (especially after pelvic radiation), intractable diarrhea can ensue. Diarrhea can also occur for a different reason if a large amount of colon is removed. Walter and Silver have both discussed the role of bulking agents and antidiarrheals in this patient to decrease stool frequency and increase control.9,10
Enterocutaneous, enterovaginal, and/or enterovesical fistulas are uncommon complications that are dreaded by most surgeons. Once a fistula is considered, a patient is started on intravenous broad-spectrum antibiotics to decrease infection. The patient is not allowed to eat (NPO) pending results of the work-up. The first step in working up a fistula from the gastrointestinal tract is determining the site of origin. Because fistulas can be either simple (bowel directly to skin or vagina) or complex (bowel to cavity to skin or vagina), one cannot always tell the origin of the fistula by the appearance of the effluent. We recommend starting with a Gastrografin enema or CT of the abdomen and pelvis with intravenous, water-soluble oral, and water-soluble rectal contrast. If you do not start with rectal contrast, then it may be days before you are able to tell if it is a colonic fistula.
If a small intestine fistula is found, then the next step is determining the amount of output. Low output fistulas (< 100 mL/day) may heal rapidly with complete bowel rest, either intravenous fluids or parenteral nutrition if without food for at least 7 days, and careful isolation of the effluent in an ostomy appliance if possible. It is much easier to control the effluent in an enterocutaneous than an enterovaginal fistula. High output fistulas can be changed into low output fistulas by the use of subcutaneous or intravenous somatostatin or somatostatin analogues.38 Using low doses of the somatostatin analogues do not appear to be effective in helping close a fistula, but high doses (up to 1500 mcg subcutaneous every 8 hours) can be tolerated and effective knowing that hyperglycemia may occur.38 Rahbour et al39 have shown in a large meta-analysis that intravenous continuous somatostatin may be better than separate subcutaneous, intravenous, or intramuscular somatostatin analogue (ie, octreotide) injections but this needs to be confirmed by randomized trial.
If a fistula does not close either spontaneously or with bowel rest and somatostatin, then the reason for failure need to be considered (Table 14-1). This simple mnemonic “FRIEND” explains the common reasons for failure of a fistula to close. Often in bowel surgery, a staple in an anastomotic line may be the foreign body causing the fistula to remain open. If the reason can be reversed, then the fistula can be closed. There are currently multiple options available for attempted closure from open surgical to laparoscopic to endoscopic or percutaneous closure. Little data other than case reports and case studies exist, so the gynecologic oncologist at this point should rely on experience to determine the best method for their patient.
Table 14-1.Reasons for failure of a fistula to close without surgery. ||Download (.pdf) Table 14-1. Reasons for failure of a fistula to close without surgery.
|F ||Foreign bodies |
|R ||Radiation injury |
|I ||Infection or inflammation |
|E ||Epithelialization of the tract |
|N ||Neoplasia |
|D ||Distal obstruction |
The optimal treatment for women initially presenting with epithelial ovarian, fallopian tube, or peritoneal cancer is radical debulking followed by adjuvant chemotherapy.40 Although some recommendations regarding CT features suggestive of unresectability exist, there are no readily agreed upon objective criteria that enable gynecologic oncologists to determine whom would be best directed to undergo neoadjuvant chemotherapy because of a high risk of major morbidity or mortality from primary debulking.41 To maximally debulk, bowel resections are often needed. With proper patient selection, preoperative, intraoperative, and postoperative care, multiple bowel resections can be tolerated by the patient.
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