Keywords

Preference Card

  • Number 10-blade scalpel with handle

  • Abdominal wall retractor (surgeon preference, Bookwalter, Thompson, Balfour, large or extra-large wound protector)

  • Toothed and non-toothed forceps (Adson-Brown, DeBakey, rat tooth, Bonney)

  • Curved Metzenbaum and Mayo scissors

  • Electrocautery, vessel sealing device

  • Kocher, Allis, and Babcock clamps

  • Kelly, mosquito hemostats

  • Retractors (Richardson, Deaver, army navy)

  • Needle drivers

  • Linear cutting stapler

  • Curved cutting stapler (Contour®)

  • Circular stapler 28–33 mm

  • Flexible sigmoidoscope

  • Suction

  • Sutures

    • 2.0/3.0 polyglactin or catgut

    • 3.0 polydioxanone

    • 4.0 polyglecaprone

    • Skin stapler or 2-0 nonabsorbable sutures for skin closure

Patient Positioning/Operating Room Setup

  • Place patient in modified lithotomy position with legs in stirrups to provide easy access to perineal region; thighs are flexed (see Fig. 11.1).

  • Ensure that the patient is low enough on the table to have access to the rectum.

  • Abduct and secure arms on padded arm boards (max 90°).

  • Mark colostomy site bilaterally; ideally this should be done preoperatively with the patient awake in the sitting and supine position; however in emergency cases where this is not possible, it is done in the operating room at the time of surgery – bilateral markings are used in case there are any issues with reach.

  • Prep and drape both legs, the underbuttock area, and the abdomen.

  • The surgeon is positioned to patient’s right; the assistant is to the patient’s left; the second assistant can stand either to the left of the first assistant or between the patient’s legs (see Fig. 11.2).

  • The scrub nurse is to the right of the surgeon.

  • Insert Foley catheter.

Nodal Points

Type of Incision

  • Midline laparotomy (see Fig. 11.3)

Approach

  • Obtain controlled entry into the abdomen. If previous midline scar, attempt entry in an area above or below the scar to avoid any underlying adhesions.

  • Perform lysis of adhesions as needed to obtain good exposure.

  • Culture any fluid if present.

  • Position the abdominal wall retractor.

  • Explore the abdomen to assess for undiagnosed pathology.

Dissection, Resection, and Reconstruction Steps

Dissection, resection, and reconstruction steps are similar to the laparoscopic approach as described in Chap. 18.

Main steps are as follows:

  • Pancolonic mobilization

    • Ascending colon mobilization

    • Hepatic flexure mobilization

    • Transverse colon mobilization

    • Splenic flexure mobilization

    • Descending colon mobilization

  • Rectal mobilization down to the pelvic floor.

  • Identify and preserve the ileocolic artery and vein.

  • Divide the mesocolon close to the bowel wall.

  • Transect the terminal ileum and the distal rectum.

  • Construct the ileal J-pouch.

  • Perform the ileal J-pouch-anal anastomosis.

  • Create a diverting loop ileostomy.