Plate 78

An incision is made down the left lumbar gutter, and because the thickened and vascular peritoneum has a tendency to contract, all bleeding points should be carefully ligated (Figure 13). The peritoneum is lifted up until the left gonadal vessels and ureter are identified. Both should be identified throughout most of their course down over the brim of the pelvis (Figure 14).

In total abdominal colectomy, without planned proctectomy, the rectosigmoid junction should now be divided. The remaining vasculature to the colon can be divided close to the bowel. The superior hemorrhoidal vessels and presacral space should not be violated. When a second procedure (either ileorectal anastomosis or proctectomy and ileoanal pouch reconstruction) is contemplated, these planes should be left as virgin territory to facilitate that subsequent procedure.

The remaining description applies to the completion of a single-stage total proctocolectomy. As shown in Figure 15, the mesentery is divided adjacent to the rectosigmoid rather than up over the iliac artery bifurcation, as would be done in carcinoma. The peritoneum adjacent to the bowel is divided after identification of the ureters on either side, and the peritoneum in the pouch of Douglas between the rectum and bladder or cervix is incised. This flap is carefully elevated. This dissection along with that into the presacral space is facilitated by using lighted deep pelvic retractors, a focused headlight on the surgeon, and an extra-long insulated electrocautery tip. The dissection proceeds into the same presacral space as the mesorectal dissection, but the surgeon can stay closer to the rectum laterally and anteriorly, as this operation does not require the wide margins necessary for a malignancy. At this point, the rectum may be divided with a cutting linear stapler (GIA) or endoscopic reticulating GIA stapler or it may be transected between clamps (Figure 16). The distal stump is then oversewn (Figure 17). At this time, sharp dissection about the rectum should be carried out to free it as low as possible in order to lessen the blood loss during the subsequent perineal excision.

In the presence of multiple polyposis, a segment of rectum can be retained 5 to 8 cm above the pouch of Douglas or at a distance that can be easily reached by the sigmoidoscope for subsequent fulguration of the multiple polyps. When this is done, the terminal ileum is anastomosed to the rectal pouch in a side-to-end manner.

Absorbable sutures are used to close the peritoneal floor. The location of the ureters should be ascertained from time to time to avoid injury during the reconstruction of the pelvic floor. As in abdominoperineal resection, a pedicled omental flap can often be constructed to fill the pelvis after excision of the rectum.

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