Plate 66

Following the approximation of the mucosal layer, all contaminated instruments are discarded. The field is covered with fresh moist gauze sponges and towels. It is desirable for the members of the surgical team to change gloves. The anastomosis is further reinforced by an anterior serosal layer of interrupted 000 silk sutures (Figure 12). It is sometimes advisable to reinforce the mesenteric angle with one or two additional mattress sutures. Any remaining opening of the mesentery is then closed with interrupted sutures of fine silk. If there is a great deal of fat in the mesentery, which tends to hide the location of blood vessels, it is unwise to pass a needle blindly through it lest a hematoma form between the leaves of the mesentery. It is safer to grasp the peritoneal margins of the mesentery with small, pointed clamps and effect a closure by simple ligation of their contents. Finally, adequacy of the blood supply to the site of the anastomosis should be inspected. Active, pulsating vessels should be present adjacent to the anastomosis on both sides (Figure 13). If the blood supply appears to be interfered with and the color of the bowel is altered, it is better to resect the anastomosis rather than risk leakage and potentially fatal peritonitis. The patency of the stoma is carefully tested by compression between the thumb and index finger (Figure 14). It is usually possible to obtain a two-finger stoma.

To ensure easy approximation of the open ends of the large bowel, especially if the lesion is located near the splenic flexure, it is necessary to free the intestine from adjacent structures. The abdominal incision may have to be extended up to the costal margin, since exposure of the uppermost portion of the splenic flexure may be difficult. After the relatively avascular peritoneal attachments to the descending colon have been divided, it is necessary to free the splenic flexure from the diaphragm, spleen, and stomach. The splenocolic ligament is divided between curved clamps, and the contents are ligated to avoid possible injury to the spleen, with troublesome hemorrhage (Figure 15). Following this, a pair of curved clamps is applied to the gastrocolic ligament for the necessary distance required to mobilize the bowel or remove sufficient intestine beyond the growth. Sometimes, in the presence of growths in this area, it is necessary to carry the division adjacent to the greater curvature of the stomach. The surgeon should not hesitate to remove a portion of the left gastroepiploic artery, if indicated, since the stomach has such a good collateral blood supply. In some instances, a true phrenocolic ligament can be developed, which must be divided to free the splenic flexure (Figure 16).

If it is necessary to free a portion of the transverse colon, the omentum may be freed from the bowel by incising its avascular attachments adjacent to the colon (Figure 17; see also Plate 28). In some instances, omentum may be involved with the growth, and it may be desirable to remove all or part of it. The splenic flexure is reflected medially following the division of its attachments, and care is taken to avoid the kidney and the underlying ureter. It is usually necessary to divide a portion of the transverse mesocolon (Figure 18). This should be done carefully, taking into consideration possible injury to the underlying jejunum in the region of the ligament of Treitz. The large inferior mesenteric vein will also require division and double ligation as it dips down under the inferior margin of the body of the pancreas to join the splenic vein. The bowel is freed of all fatty attachments at the site selected for anastomosis. Noncrushing clamps are applied, and the bowel is divided (Figure 19). Arterial pulsations in the mesentery on both sides should be verified. The anastomosis is carried out as previously described. If it becomes necessary to ligate the middle colic artery, the entire transverse colon, including the hepatic and splenic flexures, may need to be resected to ensure an adequate blood supply at the site of anastomosis. In this situation the viability of the colon depends upon the right colic artery on one side and the left colic artery on the other.

The closure is made in the usual manner.

The patient is encouraged to cough, sit up, and ambulate as soon as possible. The nasogastric tube provides decompression until bowel activity returns, usually on the first or second day after surgery. Oral intake of clear liquids is begun and advanced as tolerated, whereupon intravenous hydration and electrolytes are discontinued.