Plate 79

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.

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.

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 The original forceps are removed, and the ileum is withdrawn through the abdominal wall with the mesentery cephalad.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). It may be advisable to anchor the mesentery of the ileum to the parietes laterally before constructing the ileostomy, because of the possibility of interfering with the blood supply to the terminal ileum. The right lumbar gutter should be closed off to avoid the potential of a postoperative internal hernia. At times it may be difficult to approximate the mesentery of the right colon and ileum to the right lumbar gutter and effect a closure (Figures 20 and 21). The surgeon should palpate the right gutter repeatedly and place whatever sutures are necessary to close it completely or else leave it completely open. The completed ileostomy should extend upward from the skin level at least 2.5 to 3 cm. The mucosa is anchored with interrupted fine synthetic absorbable sutures to the serosal edge of the bowel at the level of the skin and then to skin (Figure 21). Likewise, the mesentery may be anchored to the peritoneum, but no sutures should be taken between the seromuscular coat of the terminal ileum and the peritoneum. When the terminal ileum is divided with a cutting linear stapler (GIA), the maturation of the stoma is delayed until after closure of the abdominal wounds, the staple line is excised, and the stoma matured as described.

A double-looped (0 or #1) delayed absorbable suture is used for running closure of the midline linea alba incision. In very large patients, two sutures are used that begin at either end of the incision. Interrupted fine absorbable sutures may be placed in Scarpa's fascia. The skin is closed with staples, although some prefer to use absorbable subcutaneous sutures followed by adhesive skin strips. At the end of the case, a dry sterile dressing covers the abdominal incision and an ostomy appliance is put about the ileostomy. In the presence of marked emaciation and prolonged steroid therapy, the use of retention sutures should be considered.

Blood should be replaced as it is lost during the procedure. Additional blood or colloids may be required on the afternoon of surgery and during the early postoperative period. Constant bladder drainage is traditionally maintained for at least 4 or 5 days. Some surgeons now remove the catheter on the first postoperative day. If the patient has been on steroid therapy, this is continued during the postoperative period. A transparent temporary-type ileostomy appliance is placed over the ileostomy before moving the patient to the recovery area. This permits frequent observations of the stoma to make sure it maintains a pink and viable color. A strict intake and output chart must be maintained at all times following an ileostomy. Likewise, daily electrolyte determinations are essential because of excessive losses of electrolyte-rich fluid. Excessive amounts of fluid are occasionally lost, and large amounts of intravenous fluids, electrolytes, and colloids will be required to maintain fluid balance. The nasogastric tube is removed early and oral intake of liquids advanced as tolerated. The drains should then be removed, with serial observations as described in the discussion of abdominoperineal resection (Plate 74). These patients require frequent and prolonged observation because of the tendency to a variety of complications ranging from abscess formation to intestinal obstruction. They should be in contact with an enterostomal therapist, who ideally may be available during office visits to the surgeon.