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Technical Aspects

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Complexities in Colorectal Surgery

Abstract

The practice of surgery requires the surgeon to have a broad skill as well as the ability to constantly learn and adapt to increasingly complex procedures. Every operative case represents an opportunity to be challenged technically. Whether it is a hostile reoperative abdomen or a stapler misfire on a low rectal cancer, there will be situations in the operating room that are low frequency but high acuity that require a breadth and depth of skills and decision-making. In this chapter, we review these technical challenges that occur infrequently and offer an approach that has proven successful in our experience.

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References

  1. Neutzling CB, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2012;2:CD003144.

    Google Scholar 

  2. Lustosa SA, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2001;(3):CD003144.

    Google Scholar 

  3. Ballantyne GH. Intestinal suturing. Review of the experimental foundations for traditional doctrines. Dis Colon Rectum. 1983;26(12):836–43. Review. PubMed PMID: 6357675.

    Google Scholar 

  4. Burch JM, et al. Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg. 2000;231(6):832–7.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  5. Sarin S, Lightwood RG. Continuous single-layer gastrointestinal anastomosis: a prospective audit. Br J Surg. 1989;76(5):493–5.

    Article  CAS  PubMed  Google Scholar 

  6. Law WL, et al. Single-layer continuous colon and rectal anastomosis using monofilament absorbable suture (Maxon): study of 500 cases. Dis Colon Rectum. 1999;42(6):736–40.

    Article  CAS  PubMed  Google Scholar 

  7. Hastings JC, et al. Effect of suture materials on healing wounds of the stomach and colon. Surg Gynecol Obstet. 1975;140(5):701–7.

    CAS  PubMed  Google Scholar 

  8. Trimpi HD, et al. Advances in intestinal anastomosis: experimental study and an analysis of 984 patients. Dis Colon Rectum. 1977;20(2):107–17.

    Article  CAS  PubMed  Google Scholar 

  9. Munday C, McGinn FP. A comparison of polyglycolic acid and catgut sutures in rat colonic anastomoses. Br J Surg. 1976;63(11):870–2.

    Article  CAS  PubMed  Google Scholar 

  10. Lord MG, Broughton AC, Williams HT. A morphologic study on the effect of suturing the submucosa of the large intestine. Surg Gynecol Obstet. 1978;146(2):211–6.

    CAS  PubMed  Google Scholar 

  11. Koruda MJ, Rolandelli RH. Experimental studies on the healing of colonic anastomoses. J Surg Res. 1990;48(5):504–15.

    Article  CAS  PubMed  Google Scholar 

  12. Didolkar MS, et al. A prospective randomized study of sutured versus stapled bowel anastomoses in patients with cancer. Cancer. 1986;57(3):456–60.

    Article  CAS  PubMed  Google Scholar 

  13. Kracht M, et al. Ileocolonic anastomosis after right hemicolectomy for carcinoma: stapled or hand-sewn? A prospective, multicenter, randomized trial. Int J Colorectal Dis. 1993;8(1):29–33.

    Article  CAS  PubMed  Google Scholar 

  14. Choy PY, et al. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev. 2011;9, CD004320.

    PubMed  Google Scholar 

  15. Suturing or stapling in gastrointestinal surgery: a prospective randomized study. West of Scotland and Highland Anastomosis Study Group. Br J Surg. 1991;78(3):337–41.

    Google Scholar 

  16. Docherty JG, et al. Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group. Ann Surg. 1995;221(2):176–84.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  17. Simillis C, et al. A meta-analysis comparing conventional end-to-end anastomosis vs. other anastomotic configurations after resection in Crohn’s disease. Dis Colon Rectum. 2007;50(10):1674–87.

    Article  PubMed  Google Scholar 

  18. Resegotti A, et al. Side-to-side stapled anastomosis strongly reduces anastomotic leak rates in Crohn’s disease surgery. Dis Colon Rectum. 2005;48(3):464–8.

    Article  PubMed  Google Scholar 

  19. Yamamoto T, et al. Stapled functional end-to-end anastomosis versus sutured end-to-end anastomosis after ileocolonic resection in Crohn disease. Scand J Gastroenterol. 1999;34(7):708–13.

    Article  CAS  PubMed  Google Scholar 

  20. Balik E, et al. Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series. Clinics (Sao Paulo). 2011;66(11):1935–41.

    Google Scholar 

  21. Leung TT, et al. Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis. J Gastrointest Surg. 2008;12(5):939–44.

    Article  PubMed  Google Scholar 

  22. Ritchey ML, Lally KP, Ostericher R. Comparison of different techniques of stapled bowel anastomoses in a canine model. Arch Surg. 1993;128(12):1365–7.

    Article  CAS  PubMed  Google Scholar 

  23. Zilling T, Walther BS. Are intersecting staple lines a hazard in intestinal anastomosis? Dis Colon Rectum. 1992;35(9):892–6.

    Article  CAS  PubMed  Google Scholar 

  24. Goto T, et al. Evaluation of the mechanical strength and patency of functional end-to-end anastomoses. Surg Endosc. 2007;21(9):1508–11.

    Article  CAS  PubMed  Google Scholar 

  25. Munoz-Juarez M, et al. Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn’s disease. Dis Colon Rectum. 2001;44(1):20–5.

    Article  CAS  PubMed  Google Scholar 

  26. Chung RS. Blood flow in colonic anastomoses. Effect of stapling and suturing. Ann Surg. 1987;206(3):335–9.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Nakayama S, et al. The importance of precompression time for secure stapling with a linear stapler. Surg Endosc. 2011;25(7):2382–6.

    Article  PubMed  Google Scholar 

  28. Morita K, et al. Effects of the time interval between clamping and linear stapling for resection of porcine small intestine. Surg Endosc. 2008;22(3):750–6.

    Article  CAS  PubMed  Google Scholar 

  29. Saklani A, et al. Internal herniation following laparoscopic left hemicolectomy: an underreported event. J Laparoendosc Adv Surg Tech A. 2012;22(5):496–500.

    Article  PubMed  Google Scholar 

  30. Cabot JC, et al. Long-term consequences of not closing the mesenteric defect after laparoscopic right colectomy. Dis Colon Rectum. 2010;53(3):289–92.

    Article  PubMed  Google Scholar 

  31. Causey MW, Oguntoye M, Steele SR. Incidence of complications following colectomy with mesenteric closure versus no mesenteric closure: does it really matter? J Surg Res. 2011;171(2):571–5.

    Article  PubMed  Google Scholar 

  32. Marderstein E, Trunzo J, Stulberg J, Champagne B, Reynolds H, Delaney CP. Analysis of stapler misfire during colorectal surgical procedures using a National Event Report Database. 2007. Available from: http://www.casesurgery.com/research/Abstract08WEB.pdf.

  33. Pandya S, et al. Laparoscopic colectomy: indications for conversion to laparotomy. Arch Surg. 1999;134(5):471–5.

    Article  CAS  PubMed  Google Scholar 

  34. Kirat HT, et al. Influence of stapler size used at ileal pouch-anal anastomosis on anastomotic leak, stricture, long-term functional outcomes, and quality of life. Am J Surg. 2010;200(1):68–72.

    Article  PubMed  Google Scholar 

  35. Polese L, et al. Risk factors for colorectal anastomotic stenoses and their impact on quality of life: what are the lessons to learn? Colorectal Dis. 2012;14(3):e124–8.

    Article  CAS  PubMed  Google Scholar 

  36. Kyzer S, Gordon PH. Experience with the use of the circular stapler in rectal surgery. Dis Colon Rectum. 1992;35(7):696–706.

    Article  CAS  PubMed  Google Scholar 

  37. Detry RJ, et al. Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team. Surgery. 1995;117(2):140–5.

    Article  CAS  PubMed  Google Scholar 

  38. Moore JW, Chapuis PH, Bokey EL. Morbidity and mortality after single- and double-stapled colorectal anastomoses in patients with carcinoma of the rectum. Aust N Z J Surg. 1996;66(12):820–3.

    Article  CAS  PubMed  Google Scholar 

  39. Yamamoto H, et al. Feasibility of end-to-anterior wall anastomosis in conversion of the double-stapling technique during laparoscopically assisted surgery. Surg Endosc. 2010;24(9):2178–81.

    Article  PubMed  Google Scholar 

  40. Nakada I, et al. Abdominal stapled side-to-end anastomosis (Baker type) in low and high anterior resection: experiences and results in 69 consecutive patients at a regional general hospital in Japan. Colorectal Dis. 2004;6(3):165–70.

    Article  CAS  PubMed  Google Scholar 

  41. Levine RA, Kadro O. When staplers misfire: endoscopic rescue of low pelvic anastomoses. Tech Coloproctol. 2010;14(4):349–51.

    Article  CAS  PubMed  Google Scholar 

  42. Beard JD, et al. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77(10):1095–7.

    Article  CAS  PubMed  Google Scholar 

  43. Yalin R, et al. Importance of testing stapled rectal anastomoses with air. Eur J Surg. 1993;159(1):49–51.

    CAS  PubMed  Google Scholar 

  44. Ricciardi R, et al. Anastomotic leak testing after colorectal resection: what are the data? Arch Surg. 2009;144(5):407–11; discussion 411–2.

    Article  PubMed  Google Scholar 

  45. Schmidt O, Merkel S, Hohenberger W. Anastomotic leakage after low rectal stapler anastomosis: significance of intraoperative anastomotic testing. Eur J Surg Oncol. 2003;29(3):239–43.

    Article  CAS  PubMed  Google Scholar 

  46. Offodile 2nd AC, et al. High incidence of technical errors involving the EEA circular stapler: a single institution experience. J Am Coll Surg. 2010;210(3):331–5.

    Article  PubMed  Google Scholar 

  47. Brennan DJ, et al. Routine mobilization of the splenic flexure is not necessary during anterior resection for rectal cancer. Dis Colon Rectum. 2007;50(3):302–7; discussion 307.

    Article  CAS  PubMed  Google Scholar 

  48. Park JS, et al. Laparoscopic versus open resection without splenic flexure mobilization for the treatment of rectum and sigmoid cancer: a study from a single institution that selectively used splenic flexure mobilization. Surg Laparosc Endosc Percutan Tech. 2009;19(1):62–8.

    Article  PubMed  Google Scholar 

  49. Chand M, Miskovic D, Parvaiz AC. Is splenic flexure mobilization necessary in laparoscopic anterior resection? Dis Colon Rectum. 2012;55(11):1195–7.

    Article  PubMed  Google Scholar 

  50. Marsden MR, et al. The selective use of splenic flexure mobilization is safe in both laparoscopic and open anterior resections. Colorectal Dis. 2012;14(10):1255–61.

    Article  CAS  PubMed  Google Scholar 

  51. Masoomi H, et al. Predictive factors of splenic injury in colorectal surgery: data from the Nationwide Inpatient Sample, 2006–2008. Arch Surg. 2012;147(4):324–9.

    Article  PubMed  Google Scholar 

  52. Kim HJ, Kim CH, Lim SW, Huh JW, Kim YJ, Kim HR. An extended medial to lateral approach to mobilize the splenic flexure during laparoscopic low anterior resection. Colorectal disease: the official journal of the Association of Coloproctology of Great Britain and Ireland. 2012. Epub 2012/10/16. doi: 10.1111/codi.12056. PubMed PMID: 23061515.

  53. Kanemitsu Y, et al. Survival benefit of high ligation of the inferior mesenteric artery in sigmoid colon or rectal cancer surgery. Br J Surg. 2006;93(5):609–15.

    Article  CAS  PubMed  Google Scholar 

  54. Chin CC, et al. The oncologic benefit of high ligation of the inferior mesenteric artery in the surgical treatment of rectal or sigmoid colon cancer. Int J Colorectal Dis. 2008;23(8):783–8.

    Article  PubMed  Google Scholar 

  55. Titu LV, Tweedle E, Rooney PS. High tie of the inferior mesenteric artery in curative surgery for left colonic and rectal cancers: a systematic review. Dig Surg. 2008;25(2):148–57.

    Article  CAS  PubMed  Google Scholar 

  56. Rutegard M, et al. High tie in anterior resection for rectal cancer confers no increased risk of anastomotic leakage. Br J Surg. 2012;99(1):127–32.

    Article  CAS  PubMed  Google Scholar 

  57. Karanjia ND, et al. Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Br J Surg. 1994;81(8):1224–6.

    Article  CAS  PubMed  Google Scholar 

  58. Lange MM, et al. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum. 2008;51(7):1139–45.

    Article  PubMed Central  PubMed  Google Scholar 

  59. Buunen M, et al. Level of arterial ligation in total mesorectal excision (TME): an anatomical study. Int J Colorectal Dis. 2009;24(11):1317–20.

    Article  PubMed Central  PubMed  Google Scholar 

  60. Kim J, Choi DJ, Kim SH. Laparoscopic rectal resection without splenic flexure mobilization: a prospective study assessing anastomotic safety. Hepatogastroenterology. 2009;56(94–95):1354–8.

    PubMed  Google Scholar 

  61. Hall NR, et al. High tie of the inferior mesenteric artery in distal colorectal resections–a safe vascular procedure. Int J Colorectal Dis. 1995;10(1):29–32.

    Article  CAS  PubMed  Google Scholar 

  62. Nelsen TS, Anders CJ. Dynamic aspects of small intestinal rupture with special consideration of anastomotic strength. Arch Surg. 1966;93(2):309–14.

    Article  CAS  PubMed  Google Scholar 

  63. Shikata J, Shida T. Effects of tension on local blood flow in experimental intestinal anastomoses. J Surg Res. 1986;40(2):105–11.

    Article  CAS  PubMed  Google Scholar 

  64. Howes EL, Sooy JW, Samuel HC. The healing of wounds as determined by their tensile strength. JAMA. 1929;92(1):42–5.

    Article  Google Scholar 

  65. Deloyers L. Suspension of the right colon permits without exception preservation of the anal sphincter after extensive colectomy of the transverse and left colon (including rectum). Technic -indications- immediate and late results. Lyon Chir. 1964;60:404–13.

    CAS  PubMed  Google Scholar 

  66. Manceau G, et al. Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes. Dis Colon Rectum. 2012;55(3):363–8.

    Article  PubMed  Google Scholar 

  67. Material Safety Data Sheet: FREDâ„¢ Anti-Fog Solution. North Haven, C.U.S.S. Material Safety Data Sheet: FREDâ„¢ Anti-Fog Solution. North Haven: United States Surgical. 2004. Available from: http://www.autosuture.com/imageServer.aspx?contentID=6591&contenttype=application/pdf.

  68. DHELP. Visualization challenges and solutions in laparoscopic surgery 2010. Available from: http://www.newwavesurgical.com/sites/default/files/imce-uploads/value_analysis_final_9.7.2012.pdf.

  69. Ott DE, et al. Reduction of laparoscopic-induced hypothermia, postoperative pain and recovery room length of stay by pre-conditioning gas with the Insuflow device: a prospective randomized controlled multi-center study. JSLS. 1998;2(4):321–9.

    CAS  PubMed Central  PubMed  Google Scholar 

  70. Binnebosel M, et al. Influence of small intestinal serosal defect closure on leakage rate and adhesion formation: a pilot study using rabbit models. Langenbecks Arch Surg. 2011;396(1):133–7.

    Article  PubMed  Google Scholar 

  71. Wu MP, et al. Complications and recommended practices for electrosurgery in laparoscopy. Am J Surg. 2000;179(1):67–73.

    Article  CAS  PubMed  Google Scholar 

  72. Tucker RD. Laparoscopic electrosurgical injuries: survey results and their implications. Surg Laparosc Endosc. 1995;5(4):311–7.

    CAS  PubMed  Google Scholar 

  73. Chino A, et al. A comparison of depth of tissue injury caused by different modes of electrosurgical current in a pig colon model. Gastrointest Endosc. 2004;59(3):374–9.

    Article  PubMed  Google Scholar 

  74. Joniau SG, et al. Complications and functional results of surgery for locally advanced prostate cancer. Adv Urol. 2012;2012:706309.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  75. Yildirim M, et al. Rectal injury during radical prostatectomy. Ulus Travma Acil Cerrahi Derg. 2012;18(3):250–4.

    Article  PubMed  Google Scholar 

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Correspondence to Janice F. Rafferty MD .

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The hostile abdomen (Video by Amir Bastawrous, MD) (MOV 52032 kb)

Laparoscopic Baker (end-to-side) anastomosis (MOV 113169 kb)

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Davis, B., Rafferty, J.F. (2014). Technical Aspects. In: Steele, S.R., Maykel, J.A., Champagne, B.J., Orangio, G.R. (eds) Complexities in Colorectal Surgery. Springer, New York, NY. https://doi.org/10.1007/978-1-4614-9022-7_33

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  • DOI: https://doi.org/10.1007/978-1-4614-9022-7_33

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