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After the pelvis has been reperitonealized, some of the raw surfaces in the left lumbar gutter also can be covered if the tissues are sufficiently lax (Figure 18). Again, the sutures should be placed so as to avoid injuring the underlying ureters and gonadal vessels. To complete the total proctocolectomy, the anus is excised as described in the perineal section of abdominoperineal resection (Plates 73 and 74). The only exception is that it is not necessary to go wide on the levators when a simple extirpation of the sphincter muscles and bowel wall itself is carried out. The incision for the excision of the anus is shown in Figure 22. Primary closure with catheter suction can be used.
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The construction of the ileostomy is of major importance. The small intestine may be removed from the plastic bag and the site selected for ileostomy exposed. The location of the previously marked ileostomy site is evaluated. The midway point between the umbilicus and anterior iliac spine is again verified by a sterilized ruler. The ileostomy site is placed a little below the midway point (Figure 1, Plate 75). With Kocher clamps applied to the fascial edge of the incision after removal of the self-retaining retractor, a 3-cm circle of skin is excised. After the button of skin and the underlying fat have been removed, all bleeding points are controlled. Then, while applying traction against the abdominal wall from underneath with the left hand, the surgeon makes a stellate incision through the entire thickness of the abdominal wall. Any bleeding that is encountered, especially in the rectus muscle, is clamped and ligated. An opening large enough to admit two fingers easily is usually more than sufficient.
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Noncrushing vascular-type forceps are inserted through the ileostomy site and applied just proximal to the similar forceps on the terminal ileum (Figure 19). The original forceps are removed, and the ileum is withdrawn through the abdominal wall with the mesentery cephalad. At least 5 to 6 cm of mesentery-free ileum should be above the skin level so that an ileostomy of adequate length can be constructed. It may be necessary, especially in the obese patient, to undercut the terminal ileum under the mesenteric blood supply to attain this essential length. The viability is then reevaluated after the ileum is pulled up through the abdominal wall. The mesentery can be anchored to the abdominal wall or brought up into the subcutaneous tissue (Figure 20...