It is assumed that laparoscopy can minimize some of these insults by limiting bowel manipulation and exposure of the peritoneal surface to potential irritants.28–30 Preliminary evidence
Trang 1A more difficult or dense adhesion can be approached from
differ-ent angles to help define the appropriate plane Oftdiffer-entimes, simpler
adhesions can be taken down on either side or even behind the
dense adhesion to help delineate the proper path of dissection
Placing one’s fingers on either side of the adhesion and palpating
can be of assistance to feel the plane and also sometimes stretch out
the adhesion for easier division Of course, one of the biggest keys
to success is proper traction and counter-traction If the traction is
too forceful though, tearing of the bowel may occur
If an enterotomy does occur, it should be repaired immediately
with absorbable sutures to minimize contamination If the case
is difficult and more injuries are predicted, temporary closure
can be employed until all adhesiolysis is complete A segment of
bowel with extensive injuries may be best resected Waiting until
all injuries have been identified and a plan made can save
sig-nificant time on unnecessary repairs Sometimes dissection can
be performed in an extraperitoneal plane to avoid bowel injury,
leaving peritoneum adherent to the bowel wall Other times a
small piece of bowel wall may be left behind, adherent to a more
critical structure, such as the ureter or iliac vessels, in order to
avoid morbid injury at these crucial sites Leaving devascularized
bowel serosa or muscularis in-situ is not a problem Any mucosa
left behind, however, should be desiccated with electrocautery to
prevent formation of mucoceles or malignancy
Consideration should be given in each case to preventing
adhe-sions, which lowers the risk of bowel obstruction and makes any
future surgeries easier Adhesion formation is a local response of the
peritoneum and pertonealized structures to ischemia, desiccation,
or trauma and may form as result of the primary disease process
or due to contact with surgical instruments, staples, suture, gloves,
sponges, and other irritants introduced at the time of surgery It
is assumed that laparoscopy can minimize some of these insults
by limiting bowel manipulation and exposure of the peritoneal
surface to potential irritants.(28–30) Preliminary evidence in this
regard can be found by noting that laparoscopic assisted ileocolic
resection is associated with reduced rate of bowel obstruction
when compared to open surgery.(31, 32) Adhesions to the anterior
abdominal wall are minimal or absent.(33) (See Figures 6.3 and
6.4) (34) Additionally, the CO2 pneumoperitoneum is felt to be
protective of certain types of injury.(35, 36) Initial hope for
elimi-nation of adhesive disease with the advent of laparoscopy (37) has
been replaced by the realization that adhesions do indeed form and
reform after laparoscopy, primarily in the operative field, (38, 39)
but to a lesser extent than with open surgery
Despite these advantages, bowel obstruction continues to
occur frequently in patients following laparoscopic surgery The
mechanism, severity, and risk of obstruction have shifted
how-ever In a report for the French Association for Surgical Research,
Duron (39) and colleagues noted that only 33% of postoperative
bowel obstructions following various laparoscopic surgeries were
due to multiple adhesions, while an additional 17% were due to
a single band Intestinal incarceration (in abdominal wall defect
or port site) (See Figures 6.5 and 6.6) was responsible for another
46% All told, 25% of patients required resection
A report from the Western Pennsylvania Hospital describes
unique mechanisms of bowel obstruction, such as internal hernia,
are common after laparoscopic bariatric surgery.(40) The reason for
this is assumed to be the result of a laparoscopy-related decrease in scar formation between newly apposed peritoneal surfaces which leaves defects open.(41) One can imagine this same phenomenon following laparoscopic colon resection Obstructions due to inter-nal hernias are associated with a high incidence of bowel threatening ischemia and therefore require a high index of suspicion and prompt surgical management The authors’ experience is that relaparoscopy,
in this patient population, is an excellent technique for diagnosing and managing these obstructions and other complications.(40) General principles to minimize adhesions include gentle han-dling of the tissue, hemostasis, and avoidance of infection and ischemia Products such as SeprafilmTM (Genzyme), a bioabsorb-able membrane of sodium hyaluronate, and carboxymethylcellu-lose, can be placed at the time of surgery to reduce the incidence
of adhesions.(42–44) It should be noted that these products should not be placed adjacent to a fresh anastomosis.(45)
A qualification must be maintained in the case of adhesions encountered when operating on a patient with a malignancy If the adhesions are between a cancer and another structure, they
Figure 6.3 Laparoscopic images demonstrating lack of adhesions in a patient
undergoing laparoscopic appendectomy for appendicitis 2 years after hand-assisted laparoscopic anterior resection for recurrent sigmoid diverticulitis (Courtesy of Thomas E Read, MD, Pittsburgh, PA).
Trang 2should be treated as an extension of the malignancy In other words, they should not be divided, but instead resected with the specimen This process might require partial resection of another structure such as another limb of bowel or abdominal wall Not all adhesions encountered during surgery for malignancy are malig-nant adhesions however Attention should be paid to the extent of the tumor such as growth through the full-thickness bowel wall and its relationship to the adhesions as well as the characteristic
of the adhesion
lesiOn lOcalizatiOn
Up to 22% of endoscopically unresectable colorectal neoplasms with benign histology on initial biopsy harbor invasive adeno-carcinoma Adhering to oncologically sound principles for these neoplasms is advised.(46) Many of these will not be easily palpable during surgery and even more difficult to localize laparoscopically For operative planning, particularly when considering a laparo-scopic approach, accurate localization of the tumor is imperative to avoid removal of the wrong segment of intestine.(47) Colonoscopy alone as a localizing technique is inaccurate (48) unless the tumor
is clearly noted to be in the direct proximity of to an unmistakable landmark such as the rectum or cecum As such, localization should
be more definitively accomplished preoperatively Endoscopic injection of India ink in three or four quadrants of bowel adjacent
to and distal to, but not through the tumor, is safe and reliable, and preferred in most centers (49, 50) (See Figure 6.7)
Other adjuncts for localization include endoscopic placement of clips and subsequent plain film of the abdomen (See Figure 6.8) Alternatively, barium enema or CT colography can be employed (51) Though more costly than India ink injection and associated with radiation exposure, these modalities offer the additional advantage of preoperative planning for room set up and patient positioning for left vs transverse vs right colectomy One disad-vantage of these approaches is they offer no direct intraoperative evidence of the lesion localization Therefore they may be most effectively used in conjunction with India ink marking
Some centers have reported success with preoperative endo-scopic clip placement followed by intraoperative laparoendo-scopic
Figure 6.4 Laparoscopic images demonstrating lack of adhesions in a patient
undergoing laparoscopic appendectomy for appendicitis 2 years after hand-assisted
laparoscopic anterior resection for recurrent sigmoid diverticulitis (Courtesy of
Thomas E Read, MD, Pittsburgh, PA).
Figure 6.6 A port site hernia causing a bowel obstruction and injury to the bowel.
Figure 6.5 A port site hernia causing a bowel obstruction and injury to the bowel.
Trang 3ultrasonography or intraoperative fluoroscopy.(52) These
intra-operative imaging modalities, though effective, tend to be
cum-bersome, resource intensive, and operator dependent
Due to the flexible nature of the colonoscope, the distance of
the tumor from the anal verge cannot be accurately measured on
colonoscopy When the tumor is obviously within the colon or is
palpable within the rectum, this limitation of the colonoscope is
not an issue Unfortunately, not uncommonly, a tumor reported
to be in the sigmoid colon by colonoscopy is actually much lower
and represents rectal cancer A rigid proctoscope is very useful to
accurately measure the distance of the tumor from the anal verge,
which not only helps in planning surgery but also determines if
the tumor is in a location that its stage might warrant preoperative
neoadjuvant therapy.(53)
Careful preoperative assessment and planning is the best way to ensure that the appropriate segment of the intestine is removed The most notable preventable cause includes assumptions made based on colonoscopic determination of a site that is not within the direct proximity to an unmistakable landmark such as the rectum or cecum Occasionally, however, despite our best efforts, localization attempts fail to identify lesions intraoperatively in
up to 12% of cases.(54) Failure to visualize a tattoo can result from disappearance of the tattoo compound, particularly when products other than India ink are used.(55) Additionally, failure
to inject the ink compound into the submucosal tissue plane can result in dissemination of the ink and imprecise localization or intraperitoneal injection Although this presents little direct risk
to the patient, it does present a problem with definitive intra-operative localization Techniques that have been described to minimize this occurrence include injecting saline to develop the submucosal plane before injection of ink.(56)
The surgeon must be prepared to deal with the case where local-ization efforts have failed Blind resection is not advised unless confidently guided by preoperative imaging Mobilization of the flexures and dissection of the omentum off the transverse colon may reveal a hidden tattoo mark During laparoscopy, palpation cannot be performed well but a hand assist device can be used to overcome this limitation Still there are cases where the lesion is too small to palpate and remains unfound Under such circumstances, intraoperative colonoscopy can permit localization.(57) Use of
CO2 insufflation during the colonoscopy will minimize bowel dis-tention This is critical if laparoscopic assisted surgery is planned Requiring equipment, expertise, and time, this is best reserved as a back-up rather than a primary localization modality Regardless of the technique of localization, opening the specimen after resection
to confirm the presence of the lesion is recommended
abdOminal wall clOsure
Abdominal wall closure is required following laparotomy and at the specimen retrieval site for laparoscopic colectomy Wound-related complications such as acute wound failure (dehiscence), infection, and incisional hernia can result in significant morbid-ity Malnutrition, tobacco abuse, and/or requirement for systemic corticosteroids or chemotherapy will increase risk Ideally, these factors should be modified preoperatively whenever possible Intraoperatively, proper technique minimizes the risk of wound complication and will be the focus of this discussion
Acute wound failure, defined as an early separation of the abdominal musculoaponeurotic layers, occurs at an incidence of approximately 1.2% (range 0–2.3%), (58–62) with the majority occurring between the 6th and 9th postoperative days.(63, 64) The most common cause is felt to be suture tearing through the fascia but may also occur as a result of abdominal wall rupture away from the incision or excessive suture interval Suture break-age and knot slippbreak-age are rare.(58, 6, 65–70)
An incisional hernia is failure of complete abdominal wall heal-ing followheal-ing abdominal surgery, resultheal-ing in a myofascial defect The reported incidence of incisional hernias in the literature varies from 9–19% They often require repair, with recurrence rates as high as 45%, causing further complications The ideal abdominal wound closure should minimize this complication
Figure 6.8 A plain film of the abdomen after endoscopic placement of clip
(arrow) can provide valuable information about the location of the lesion and aid
in preoperative planning.
Figure 6.7 India ink injected endoscopically before laparoscopy provides excellent
lesion localization.
Trang 4technique
Numerous studies have demonstrated mass closure to be superior
to layered closure in clinical practice (71–73), since incorporating
large bites of tissue reduces the pressure per unit area caused by
the suture and decreases the risk of suture cut-through (74, 75)
Although a randomized trial of mass versus layered closure showed
no significant difference in wound rupture, (76) and most
clini-cal studies comparing mass closure to layered abdominal closure
have not revealed a difference in the incidence of incisional hernia
formation, (73, 77) mass closure of the abdominal wall is currently
favored because of its safety, efficacy, and speed It is important to
note that peritoneum heals by regeneration of the layer over the
entire defect, and not in incremental advancement from the wound
edge.(78, 79) Randomized studies revealed no difference between
a one-layered closure (peritoneum not sutured) and a two-layered
closure (peritoneum sutured) in midline and paramedian
inci-sions.(73, 80) Peritoneal closure is therefore not vital in abdominal
closures and may contribute to adhesion formation
Experimental models and cadaveric studies have shown that
continuous abdominal wall closure provides the greatest wound
security in terms of abdominal dehiscence.(81, 82) Continuous
suturing is thought to equalize the tension differences between
individual stitches and distributes the tension along the suture
line, thus reducing the risk of tissue strangulation and late
cut-through.(65, 81, 83, 84) The number of knots and therefore the
likelihood of knot slippage may be minimized A meta-analysis
comparing six randomized controlled trials of continuous versus
interrupted closure (irrespective of suture type) found the
inci-dence of incisional hernias to be significantly less with continuous
closure.(85)
There is a zone of collagenolysis and matrix degradation that
extends out 0.75 cm from each wound edge.(86, 87) Further, fascia
strength near its cut edge decreases by 50% during the first 48 hours
after an operation.(88) Experimental models have demonstrated
a continuous closure while maintaining a 1 cm stitch interval and
a 1 cm tissue bite reduces dehiscence rate as compared to smaller
tissue bites by minimizing the risk of suture cut-through.(89)
suture material
Slowly resorbed monofilaments (polydioxanone: PDS® and
polygly-conate: Maxon®) are the strongest sutures in the fresh state, followed
by the nonresorbable monofilaments (nylon: Ethilon® and
polypro-pylene: Prolene®), and then the braided sutures (polyglactin: Vicryl®,
polyglycolic acid: Dexon®).(90) Silk and chromic catgut, are not
appropriate.(91, 66, 92, 93)
With regard to incisional hernia formation, it is known from
experimental studies that the abdominal fascia continues to gain
strength up to 3 months after surgery.(94) Nylon (Ethilon®)
loses approximately 20% strength per year while Polypropylene,
Surgilene®, Ethibond®, Tevdek®, and polybutester (Novafil®) seem
to retain their strength indefinitely.(95) Catgut, Dexon®, and
Vicryl® have tensile strength half-lives in the range of 1–4 weeks,
and are not suitable for fascial closure Vicryl®,compared with
nonresorbable sutures (Prolene®), is associated with an increased
rate of wound failure and incisional hernias (85) This is in
con-tradistinction to more slowly resorbed materials, such as
poly-dioxanone (PDS®), that do not appear to increase the rate of
incisional hernia (85) Multiple randomized trials have failed to demonstrate a difference in dehiscence rates between resorbable and nonresorbable sutures.(58, 96, 97) Additionally, persistent sinus formation and chronic wound infection can be virtually eliminated with the use of resorbable suture.(73, 98)
Multiple clinical studies implicate wound sepsis as the most important factor associated with incisional herniation Multifilament sutures provide a better growth environment for bacteria and are associated with a higher incidence of wound infection compared to monofilament sutures.(77, 99, 100)
In summary, a continuous, mass closure using slowly-resorbable monofilament suture with a 1 cm tissue bite and a 1 cm interval is likely the best technique for primary abdominal wall closure.(101)
It is assumed that minimizing abdominal wall trauma vis-à-vis laparoscopic approaches may minimize wound related morbidity
retentiOn sutures
Retention sutures are thought to aid abdominal closure by prevent-ing wound necrosis and avoidprevent-ing evisceration However, problems associated with retention sutures are several and include exacer-bation of the intraabdominal hypertension when the viscera are forcibly contained, and abdominal wall ischemia when the sutures become too tight Furthermore, several studies have implicated retention sutures in the development of enterocutaneous fistu-lae even when they are placed extraperitoneally With caution, retention sutures may be considered in abdominal wall closure in the patient with multiple risk factors for delayed wound healing; they are not recommended for those at risk for development of abdominal compartment syndrome
If loss of abdominal domain does not permit a tension free fascial closure, one can consider relaxing incisions to permit medial mobilization of the rectus This requires dissection above the fascia laterally to the lateral edge of the anterior rectus sheath, which is then incised in the sagittal plane, similar to the technique for separation of parts This technique should be used cautiously
in patients at risk for abdominal compartment syndrome and those at above average risk for wound infection
synthetic prOstheses
The use of synthetic mesh has been a popular technique in abdominal wall closures and reconstructions for many years and the most extensive experience is with polypropylene mesh (Prolene® and Marlex®).(102) Multiple reports in the literature cite the advantages of this permanent material, which include availability, ease of use, high tensile strength and durability, maintenance of abdominal wall compliance, potential avoid-ance of future reconstruction, and permeability allowing for peritoneal drainage However, several investigators have pointed out the many long-term complications related to polypropylene mesh Most notably, the mesh acts as a nidus of infection and
is associated with severe foreign body reactions leading to mesh extrusion and enterocutaneous fistulae with an incidence on the order of 23%.(103) The placement of omentum between the mesh and the viscera has been shown to reduce the early fistula rate to 1–4%.(104) Recently mesh with an adhesion preventative film bonded to it (e.g., Sepramesh® (Genzyme)) has been intro-duced The adhesive reductive film may reduce the problem of
Trang 5small bowel adherence to the underside of the mesh, which may
reduce complications such as enterocutaneous fistulae and allow
for an easier re-exploration or mesh removal
Use of polytetrafluoroethylene mesh (PTFE, Gore-Tex®) decreases
the incidence of fistulization and mesh extrusion However, PTFE
impedes the free egress of abdominal fluid and may contribute to
abdominal compartment syndrome and seroma formation After
appropriate consideration, polypropylene, or
polytetrafluoroeth-ylene mesh may be considered for abdominal wall reconstruction
when there is tissue loss
Resorbable meshes, polyglactin acid (Vicryl®) and polyglycolic
acid (Dexon®), may provide a temporary solution in the
man-agement of the difficult abdominal wall In experimental studies,
Dexon® is 50–70% absorbed and Vicryl® is almost fully absorbed by
10 weeks Resorbable mesh offers the early advantages of permanent
mesh without the late complications and allows for egress of fluid
reducing the chances of intraabdominal hypertension However,
not surprisingly, the reported incidence of hernia is unacceptably
high with the use of resorbable synthetic mesh.(105)
biOlOgic meshes
There are several commercially available meshes (either allografts
or xenografts) that are derived from naturally occurring sources
of collagen and related connective tissues The most extensively
studied of these is Alloderm (Lifecell) (acellular dermal matrix
derived from donated human skin) (106–109) and Permacol
(Tissue Science Laboratories) (intact porcine dermal collagen)
(110) Other variations on the theme include Collamend (Bard)
(cross-linked acellular porcine dermal collagen and its
constitu-ent elastin fibers), Allomax® (Bard) (human dermal collagen), and
Strattice® (Lifecell) (acellular dermal matrix derived from porcine
skin) The purported advantage of all of these agents is a low risk of
mesh infectious complication in contaminated fields In the case
of acellular dermal matrix, extracellular material provides a
sig-nal for fibroblast incorporation, collagen deposition, and
matu-ration resulting in tissue that cannot be differentiated from fascia
(111–113) Long-term data are lacking
cOnclusiOns
The colorectal surgeon can be faced with any number of potential
disasters Proper preparation and maintenance of a diverse
tool-box of solutions can help avert or salvage even the most dramatic
of these
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72 Ellis H, Heddle R Closure of the Abdominal Wound J Royal
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73 Humphries Al, Corley WS, Moretz WH Massive closure vs
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74 Dudley HAF Layered and mass closure of the abdominal
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75 DeBruin ThR Prevention of abdominal disruption and
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76 Ausobsky JR, Evans M, Pollock AV Does mass closure of
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77 Bucknall TE, Cox PJ, Ellis H Burst abdomen and incisional
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79 Hubbard TB Jr, Khan MZ, Carag VR et al The pathology of peritoneal repair: its relation to the formation of adhesions Ann Surg 1967; 165: 908
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81 Rodeheaver GT, Nesbit WS, Edlich RF Novafil A dynamic suture for wound closure Ann Surg 1986; 204: 193–9
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Trang 97 Postoperative anastomotic complications
Daniel L Feingold
challenging case
A 64-year-old man is 10 days status postlow anterior resection He
complains of pelvic pressure and pain His abdominal exam
dem-onstrates mild suprapubic tenderness, but no peritoneal signs He
has a low-grade fever and a white blood count of 15,000
case management
A CT scan with oral, rectal, and intravenous contrast
demon-strates a contained anastomotic leak The patient is managed with
pecutaneous drainage and intravenous antibiotics
intRODUctiOn
Surgical research over the past three decades has vastly enhanced
our technical abilities and knowledge with respect to creating
col-orectal anastomoses The Miles operation, considered state of the
art for many years after its description in 1908, has been supplanted
by sphincter-saving operations which are now considered the gold
standard for the majority of patients with rectal cancer The era of
anal sphincter salvage was ushered in with the commercialization of
mechanical staplers that permitted colorectal surgeons to resect
can-cers even in the distal rectum and maintain intestinal continuity.(1)
In 1979, Heald articulated the concept of total mesorectal
exci-sion for rectal cancer resection which was subsequently validated and
popularized adding a new dimension to our understanding of curative
rectal cancer surgery.(2) In addition, appreciation of the distal mural
spread of rectal cancer allowed for closer distal margins without
com-promising oncologic adequacy Concomitantly, chemoradiation was
demonstrated to be an effective adjuvant therapy and became part of
the armamentarium routinely used to treat patients with rectal cancer
With the ushering in of the era of low, stapled colorectal
anastomo-ses, and sphincter preservation, experience was gained diagnosing and
treating patients in whom complications of these operations arise
The most common complications related to colorectal
anasto-mosis are dehiscence and stricture The following chapter reviews
the relevant surgical literature with emphasis on diagnosis,
treat-ment, and prevention of these complications Less-common
complications such as anastomotic cancer recurrence and
anas-tomotic hemorrhage and other forms of intestinal anastomoses
(ileorectal, ileal pouch anal) will not be reviewed
Leaks and strictures are uncommon events and many of the
studies describing these complications present conflicting results,
are not definitive, or are statistically under-powered For a more
thorough understanding of the literature, this chapter relies
fre-quently on meta-analysis that combines independent clinical
tri-als to come to a statistical consensus supporting evidence-based
practice While meta-analysis is not an infallible tool, a well
con-ducted meta-analysis can allow for more objective appraisal of
the evidence, which may lead to resolution of uncertainty and
disagreement and may reduce the probability of false negative
results (i.e., lower the rate of a type II error)
anastOmOtic Dehiscence
Anastomotic leak is the most serious complication of colorectal operations as the clinical outcome due to anastomotic disruption can be catastrophic The risk of death within 30 days of colorectal resection is significantly higher in patients who suffered a leak and mortality has been reported as high as 36% in some series.(3, 4) For patients who survive the acute physiologic trespass of an anas-tomotic leak, there may be formidable, far-reaching implications in terms of long-term survival, quality of life, and function.(5–7)
geneRal cOnsiDeRatiOns
The incidence of anastomotic dehiscence is about 10% for col-orectal anastomoses within 7 cm of the anal verge.(8) The lack
of a standardized definition of what actually constitutes a leak makes it difficult to compare series and draw meaningful conclu-sions.(9) Absence of a universal definition and the low frequency
of leak events may explain why the surgical literature has so many similarly constructed trials with contradictory results supporting conflicting conclusions with regard to leaks
Common definitions include leaks identified by reoperation for peritonitis, demonstration of extraluminal contrast during an imaging study or observation of colonic contents through a pel-vic drain or through the vagina When reviewing the literature, it
is important to differentiate between patients with clinically rel-evant leaks and asymptomatic patients who have only radiologic evidence of leak as they have different clinical consequences and are treated differently
Due to the potentially devastating consequences of anasto-motic leak, there has been significant research investigating the causes of leaks as well as techniques to reduce the likelihood of anastomotic failure A number of technical factors considered to contribute to the occurrence of anastomotic leak are subjective assessments made at the time of surgery and are difficult, if not impossible, to quantify objectively
Adequate blood supply to the ends of the bowel to be anas-tomosed is of critical importance The mesentery and epiploic appendages should be stripped only enough to allow adequate visualization to permit anastomosis Overzealous cleaning of the bowel compromises the blood supply to the anastomosis and must be avoided
In terms of the blood supply to the colon proximal to the anas-tomosis, preserving the left colic artery by transecting the main sigmoidal artery versus ligating the actual inferior mesenteric artery before the takeoff of the left colic (i.e., a high ligation) is oncologically sound but has not been shown to decrease the risk
of leak.(8, 10) Rather than dogmatically coming across a specific named blood vessel, the level of transection along the mesenteric blood supply in a particular operation should be chosen to allow
a tension-free anastomosis.(11) In cases where a colostomy is cre-ated for proximal diversion, care should be taken to preserve the
Trang 10marginal artery blood supply to the distal colon; this is especially
important if the inferior mesenteric artery is transected Although
a variety of methods can be used to assess the blood supply to
the anastomosis including Doppler ultrasound and intravenous
fluorescein visualized with a Wood’s lamp, in the vast majority of
cases, straightforward clinical assessment by inspection and
pal-pation is sufficient for this determination
In an effort to improve the blood supply to the rectal side of
the anastomosis (and to potentially better protect the hypogastric
nerves), it is possible to spare the superior hemorrhoidal artery
Preserving the inferior mesenteric arterial supply to the rectum
by transecting the individual sigmoidal branches mid-mesentery
may be useful in cases of diverticulitis but would be wholly
inap-propriate in cancer cases where mesenteric clearance and lymph
node harvest are paramount While sparing the superior
hemor-rhoidal artery, there may be a tendency to avoid dissecting out
the proximal presacral space in order to prevent injury to the
artery In operations for diverticulitis, the proximal rectum must
be mobilized in order to ensure complete resection of the sigmoid
colon and to facilitate passage of the trans-anal circular stapler
to the stapled end of the rectum In theory, sparing the superior
hemorrhoidal artery may preserve blood supply to a colorectal
anastomosis but data regarding a potential reduction in the leak
rate is lacking
Tension across the anastomosis can decrease blood supply and
physically disrupt the anastomosis Care must be taken to
suffi-ciently mobilize the bowel to eliminate or minimize any tension
at the anastomosis Technically, this may require division of the
inferior mesenteric vein at the level of the pancreas to adequately
release the descending colon mesentery to permit the colon to
reach to the low pelvis Similarly, the inferior mesenteric artery
may be divided proximal to the takeoff of the left colic artery so
that the left colic does not tether the colon up in the abdomen
In addition, splenic flexure release should be performed to afford
tension-free reach of the colon to the pelvis when required, as
is most commonly the case Although not mandatory from an
oncologic perspective, splenic flexure takedown is only omitted
from curative resections when patient anatomy and tumor
loca-tion permit.(12)
To further reduce the chance of leak, the bowel to be
anas-tomosed should be healthy Inflammation, edema, radiation
changes, and thickened bowel wall due to chronic obstruction
each influence the risk of leak Under these suboptimal
condi-tions, the bowel should be resected to normal, healthy tissue to
allow safe anastomosis; otherwise, a primary anastomosis should
be avoided If unhealthy tissue precludes safe stapled
anastomo-sis, then the anastomosis should not be handsewn; tissue unfit for
staples is unfit for sutures
When preparing the colon for anastomosis, it is important to
note the presence of any diverticula as incorporating a
divertic-ulum into the staple line jeopardizes the anastomosis To avoid
this, it is helpful to suture the diverticulum in toward the anvil of
the stapler so that the diverticulum ends up in the tissue donuts
Alternatively, the diverticulum can be eliminated by resecting
additional colon
When marrying the circular stapler, it is important to
pre-vent any extraneous tissue (i.e., vagina, adnexa, bladder, epiploic
appendages, etc.) from catching in the stapler This tissue can interfere with the firing mechanism of the stapler and increases the risk of anastomotic failure Once the anastomosis is created, air testing with the pelvis under saline should be performed rou-tinely to identify occult defects requiring repair Once a defect demonstrated by a leak test has been repaired, as evidenced by a negative repeat on-table leak test, the risk of postoperative anas-tomotic leak is not increased.(13) Similarly, in situations where the anastomotic donuts are incomplete but the leak test is nega-tive, the risk of anastomotic leak is not increased.(14)
PROximal DiveRsiOn
Many surgeons divert patients undergoing low anterior resection with total mesorectal excision in the hopes of influencing the leak rate and/or the clinical consequences of a leak.(15, 16) Given the low frequency of anastomotic leak, in order to determine whether fecal diversion protects patients from leaking, large, well-designed, multiinstitution trials with homogenous study popula-tions are required Nonrandomized studies testing the hypothesis that diversion decreases anastomotic failure are inherently biased because of patient selection as surgeons are more likely to divert patients in whom complications are anticipated
The Rectal Cancer Trial On Defunctioning Stoma in Sweden, a large, prospective trial including 234 patients, randomly assigned patients undergoing stapled colorectal anastomosis within 7 cm
of the anal verge to have proximal fecal diversion.(17) The clinical leak rate in the diverted and nondiverted groups was 10.3% and
28%, respectively (p < 0.001) In addition, the need for urgent
re-operation in the diverted and nondiverted groups was 8.6%
and 25.4%, respectively (p < 0.0001) To further evaluate the
pos-sible utility of a proximal stoma, a meta-analysis was performed evaluating the role of a defunctioning stoma in low rectal cancer surgery including the Swedish trial and three other smaller ran-domized, controlled trials.(18) The odds ratios for clinical leak and for re-operation due to a leak in diverted patients were 0.32
and 0.27, respectively (p < 0.001) While this meta-analysis and
a few other studies demonstrate significant benefits in terms of decreasing the occurrence of leak, much of the remaining litera-ture only supports the concept that proximal diversion amelio-rates the septic consequences of leak but does not influence the actual rate of leak.(14, 19–22)
Temporary fecal diversion is not without its own ramifications
It is difficult to predict which individual patients will develop a leak and routine stoma creation will reduce the quality of life
in patients in whom no anastomotic complication would have occurred Moreover, a certain percentage of diverted patients will, inevitably, never have intestinal continuity restored; although,
a “temporary” diversion is more likely to become permanent
in patients who have experienced a leak.(17, 23) Finally, stoma creation carries its own morbidity rate (i.e., increased wound infection rate at the original operation, stoma complications, morbidity of the reversal operation, etc.) and consumes signifi-cant healthcare resources.(20)
Although there is no consensus regarding which patients should undergo proximal fecal diversion at the time of colorectal anasto-mosis, many surgeons routinely consider diversion in the setting
of low pelvic anastomoses as these are more likely to leak.(5, 24)