Combined 12 clinical training--surgical procedures

The Next Era in GI The Next Era in GI Surgery Surgery BioDynamixTM

AnastomosisThe Colon Ring

Clinical Training Team

TREATMENTTREATMENTSurgical ProceduresSurgical Procedures

Anastomoses – End-to-End

On the proximal side, the surgeon will insert the anvil and place a purse string suture.

On the distal side, he will open the circular device and penetrate the stump through or near the staple line with the trocar.

The anvil shaft and center rod are joined, and the anvil is closed against the center rod.

Anastomoses – End-to-End

The instrument is activated, joining the ColonRingTM to the anvil & approximating the two parts of the colon, while the circular blade cuts through the proximal colon, stapled rectal stump, & anvil head, creating the opening.

Following instrument removal, the excised tissue "donuts" are examined.

The anastomosis may be checked for competency.

There are variations on this technique:– Both sides of the colon can be closed by

purse string sutures (double purse string).– Both sides of the colon can be closed by

staplers without using a purse string at all, necessitating a piercing ancillary trocar on the anvil or an enterotomy in order to penetrate the staple line proximally (triple stapling).

Procedures – Not Appropriate

• Not appropriate for ColonRingTM use:

– Small bowel resection w/enteroenterostomy• Ring complex may not pass ileocecal valve

– Ileostomy closure• Ring complex may not pass ileocecal valve

– Transverse or Sigmoid Colostomy (separate procedure)• No anastomosis is performed

– Hartman procedure• No anastomosis is performed

Hartman Procedure

In performing a Hartman procedure, the pathologic specimen is resected, and an end sigmoid colostomy is created, leaving a rectal pouch for later closure.

– Proctocolectomy w/ileoanal anastomosis???

(if hand-sewn)• Anastomosis is hand-sewn

Coloanal Anastomosis – Hand-sewn

The anastomosis in this case is hand-sewn.

– Proctocolectomy w/ileoanal anastomosis??? (if hand-sewn)• Anastomosis is hand-sewn

– Abdominoperineal Resection• No anastomosis is performed

Abdominoperineal Resection

No anastomosis is performed—there is an end sigmoid colostomy with removal of the rest of the rectum and anus with perineal closure.

Abdominoperineal Resection (APR)

Procedures—Transanal Insertion (“Routine”)

These procedures are performed with a transanal insertion of the ColonRingTM applier following “routine” protocols:

• Left colectomy with coloproctostomy

Left Colectomy w/Coloproctostomy

• Sigmoid resection

Sigmoidectomy

• In sigmoidectomy for cancer, the surgeon must:– mobilize the descending colon;– devascularize the segment by ligating and

dividing the IMA distal to the origin of the Left Colic Artery, eliminating all the branches of the Sigmoidal Artery (“low take-down” of the IMA);

– to free the specimen, the Superior Rectal Artery and branches of the Marginal Artery are ligated and resected, too;

– the specimen is freed with all the meso of the sigmoid colon.

• If the operation is not for cancer, a much less radical approach is required.

• An anastomosis to the upper rectum is preferred over one to the distal sigmoid, which is prone to more problems.

Sigmoidectomy

• Anterior resection

Anterior Resection

• Anterior resections are used to treat malignant tumors of the middle and upper thirds of the rectum 6-14cm from the anal verge.

• Mobilization of the left colon and the rectum.

• Anastomosis between the Colon and Rectum.

• Low anterior resection

Procedures—Low Anterior Resection

Many surgeons will not specifically distinguish between Anterior and Low Anterior Resection. For our purposes, we will consider any anastomosis below 8 cm from the anal verge to be a Low Anterior Resection (anastomosis).

Low Anterior Resection with TME

Anterior resection with total mesorectal excision (TME) is the optimal treatment for low rectal cancer, except where the tumor is close to or involving the anal sphincter complex.

Mobilization of the left colon and the rectum is usually required.

An anastomosis between the descending colon and the rectum is performed.

• Low anterior resection

• Subtotal colectomy*** (may not be transanal)

Procedures—Transanal Insertion (“Special”)

• Hartman closure/reversal

These procedures, using transanal insertion of the ColonRingTM applier, require special considerations:

Hartman Reversal/Closure

There are several special considerations with this procedure.

Colostomy Closure

Colostomy closure (primarily Hartmann reversal)—

This procedure may frequently cause more potential problems than expected due to various factors mostly related to the delay between the initial operation and the subsequent closure.

Mucous plugs—

Fore-shortened segment—

“Strictured” areas—

Thick fibrotic tissue—

Refer to Problem Situations – Module 12b for additional information.

• Total colectomy w/ileoproctostomy

Total Colectomy w/Ileoproctostomy

Anvil placement in the small bowel requires special considerations due to the often decreased diameter of the ileum to <27 mm.

Procedures—Ileal Anvil Placement

Total Colectomy w/Ileoproctostomy

Anvil placement in the small bowel should be brought out the side of the ileum about 5 cm proximal to the end in order to avoid the potential for radial tension should the diameter of the ileum be <27 mm, either due to normal small lumen or subsequent spasm.

• Proctocolectomy w/ileoanal anastomosis***

(if not hand-sewn—rarely done)

• Proctocolectomy w/ileoanal anastomosis***(if not hand-sewn)

• Proctocolectomy w/ileal J-pouch

Proctocolectomy w/Ileoanal J-Pouch

Procedures—Ileoanal J-Pouch

• Proctocolectomy w/ileoanal anastomosis***(if not hand-sewn)

• Proctocolectomy w/ileal J-pouch

• Low anterior resection or Proctectomy w/colonic J-pouch

• The operation of low anterior resection with total mesorectal excision (TME) has become the gold standard for the treatment of cancer of the rectum, except where the tumor is adjacent to or involving the anal sphincter complex.

• There is a low incidence of local recurrence after this procedure, which has now been reported by several independent groups.

• The procedure has two main drawbacks:

– Firstly, there is a high risk of anastomotic breakdown (in the range of 5-15%), and many surgeons use a temporary diverting ileostomy to ameliorate the effects of this potential complication.

– Secondly, it can be associated with a high incidence of urgency and fecal leakage.

– On the basis of evidence from functional studies and randomized trials, it is becoming standard practice to fashion a short colopouch to improve functional results.

Procedures – Coloanal J-Pouch

Procedures – Coloplasty

A longitudinal incision is made along the tenia.

The longitudinal incision is closed transversely, enlarging the transverse diameter and creating a small pouch.

Longitudinal incision

Incision closed transversely

Protective, Diverting or Loop Ileostomy

Procedures – Non-Transanal Insertion

• Ileocecectomy

• Right Hemicolectomy

• Transverse Colectomy

• Splenic Flexure Resection

• Left Hemicolectomy

• Subtotal colectomy*** (may be transanal)

These procedures require special considerations because the applier is not introduced transanal, and a circular anastomotic device is often not routinely used.

Right Hemicolectomy

• A right hemicolectomy is done for inflammatory conditions, large polyps, and cancers of the cecum and ascending colon.

• The distal ileum is reconnected to the transverse colon.

• If the tumor is malignant, it is obligatory to also remove the tissue that contains the blood and lymph vessels that supply or drain the colon.

Right Hemicolectomy (Stapled)

• The two healthy stumps of bowel are joined together with a linear cutter in order to create a new lumen adjacent to right lateral staple line (functional end-to-end).

• Another possibility is to join the stumps in true side-to-side position with new lumen a few cms medial to the right lateral staple line.

Right Hemicolectomy (Stapled)

The opening is closed with a linear stapler or hand-sutured.

Tacking sutures are placed at the distal end of the anastomosis.

Right Hemicolectomy (ColonRingTM) Side-to-Side

• In performing a right hemicolectomy, the terminal ileum and transverse colon will be transected at the desired sites, preferably leaving the proximal ileal and distal colonic segments open (not stapled) or subsequently excise the staple lines. (Figs. A & B)

Figs. A & B

• In performing a right hemicolectomy, the terminal ileum and transverse colon will be transected at the desired sites, preferably leaving the proximal ileal and distal colonic segments open (not stapled) or subsequently excise the staple lines. (Figs. A & B)

• Side placement of the anvil in the ileum is recommended.

Figs. A & B

Procedures—Ileal Anvil Placement

• In performing a right hemicolectomy, the terminal ileum and transverse colon will be transected at the desired sites, preferably leaving the proximal ileal and distal colonic segments open (not stapled). (Figs. A & B)

• Side placement of the anvil in the ileum is recommended.• The anvil should be inserted shaft first into the lumen of the

proximal ileal segment and brought out the side of the ileum through an enterotomy approximately 5cm from the end. (Fig. C)

Figs. A & B

Fig. C

• In performing a right hemicolectomy, the terminal ileum and transverse colon will be transected at the desired sites, preferably leaving the proximal ileal and distal colonic segments open (not stapled). (Figs. A & B)

• Side placement of the anvil in the ileum is recommended.• The anvil should be inserted shaft first into the lumen of the proximal

ileal segment and brought out the side of the ileum through an enterotomy approximately 5cm from the end. (Fig. C)

• Secure the anvil with a “quick” purse string to prevent tearing during manipulation. (Fig. D)

Figs. A & B

Fig. C

Fig. D

• The ColonRing TM applier should be brought through the open distal colonic segment, opening the trocar through the bowel wall approximately 5cm distal to the proximal end. (Fig. A)

• The anvil should then be mated to the trocar, the applier closed in the usual fashion to, and then past, the click; and the cutting trigger and handle depressed to complete the anastomosis. (Fig. B)

• The anastomosis may then be visually inspected through the open lumen, the open ends closed with staples or sutures, and a few “safety” stitches placed on each side of the anastomosis to prevent excess tension from the dependent proximal ileum. (Fig. C)

Fig. A Fig. B Fig. C

Right Hemicolectomy (ColonRingTM) Side-to-End

• Alternatively, for side-to-end approach, the terminal ileum and transverse colon will be transected at the desired sites, preferably leaving the proximal ileal and distal colonic segments open (not stapled). (Figs. A & B)

• The anvil should be inserted shaft first into the lumen of the proximal ileal segment and brought out through the side through an enterotomy approximately 5 cm from the end. (Fig. C)

• Secure the anvil with a “quick” purse string to prevent tearing during manipulation.(Fig. D)

• The ileal end may then be closed by suture or staples.

Figs. A & B

Fig. C

Fig. D

• The ColonRing TM applier may then be brought retrograde through a distal colonic enterotomy.(Fig. A)

• The trocar will be brought out proximally, either through or adjacent to a stapled end or secured by purse string around the trocar shaft.(Figs. B&C)

• The anvil should then be mated to the trocar (side-to-end), the applier closed in the usual fashion to, and then past, the click; and the cutting trigger and handle depressed to complete the anastomosis.(Fig. D)

• Appropriate “safety” stitches should be placed on each side of the anastomosis to prevent excess tension from the dependent proximal ileum, and the enterotomy should be closed.(Fig. E)

Right Hemicolectomy (ColonRingTM) Side-to-End

Fig. A

Fig. B

Fig. C

Enterotomy

Stapled end

Purse string

Fig. DFig. E

Ileal end w/side anvil

Tacking sutures

Extended Right Hemicolectomy

• An extended right hemicolectomy is done for cancers of the hepatic flexure or transverse colon. The distal ileum is anastomosed to the descending colon.

Transverse Colectomy

The proximal segment is usually anastomosed end-to-end or side-to-side to the distal segment.

High Left Colectomy/Hemicolectomy

The proximal segment is usually anastomosed end-to-end or side-to-side to the distal segment.

Segmental and High Left Hemicolectomy

• Similarly, extended right, segmental, transverse, and high left colectomies may be performed with the ColonRingTM, if desired, following the techniques described previously for right hemicolectomy.

• Where small bowel is not involved, the anvil may be brought through the end of the desired lumen.

• If the bowel segment in which the anvil is to be placed is enlarged (perhaps >33-35 mm), it may be appropriate to consider bringing it through the side wall to avoid “bunching” the excess tissue around a purse string.

• In some cases, it may be more advantageous technically to place the anvil in the distal lumen.

Segmental and High Left Hemicolectomy

• In those cases in which the anvil is placed in the distal lumen, the anastomosis may be performed either end-to-end or side-to-end.

• For end-to-end, the applier may be brought either a proximal enterotomy with the trocar being brought out through a stapled or purse stringed end.(Fig. A)

• For side-to-end, the applier may be brought retrograde through the end of the proximal segment with the trocar being brought out through the side of the proximal segment at the desired site of anastomosis.(Fig. B)

• The excess end of the proximal segment may then be resected, leaving a small pouch adjacent to the anastomosis.(Fig. C)

Fig. A Fig. B Fig. C

Enterotomyclosed

Anastomosis

Segment to be resected

Anastomosis

Residualpouch

Enterotomy

Combined 12 clinical training--surgical procedures

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