Plate 85

After the mesenteric vessels have been ligated and the rectum has been mobilized adequately, a Pace-Potts noncrushing clamp is applied across the bowel at least 5 to 10 cm below the tumor (Figure 10A). The position of both ureters should once again be identified before the clamp is applied. A straight clamp is applied 1 cm proximal to the noncrushing clamp, and the bowel is divided (Figure 10B). As soon as possible the specimen is wrapped in a large pack held in place by encircling ties (Figure 11).

It is reassuring for the surgeon, especially in obese patients, to see active pulsations at the anastomotic site, and the surgeon should take the time to free the mobilized colon and to loosen any tension on the middle colic vessels. Procaine, 1 percent, can be injected into the mesentery to strengthen pulsations in elderly patients or in the presence of large fat deposits in the mesentery (Figure 11). The Doppler apparatus may be used to verify the adequacy of the blood supply. The small bowel should be returned to the abdomen from the plastic bag, since the base of the mesentery of the small intestine can compress the middle colic vessels, particularly if the small intestine is placed on the abdominal wall above and to the right of the umbilicus (Figure 12). The blood supply improves as the colon resection nears the middle colic vessels, since the descending colon is now dependent upon the marginal vessels of Drummond arising from the middle colic vessels (Figure 12). The entire transverse colon as well as the right colon may be mobilized by detaching the omentum and the peritoneal attachments as indicated by the dotted line (Figure 12).

The mesentery is divided up to the bowel wall (Figure 13) where active pulsations have been identified. The mesentery to the sigmoid is further mobilized and divided until a sufficient amount of bowel has been isolated proximal to the lesion.

The remaining colon must be sufficiently mobilized then to reach the rectal stump loosely and without tension. Extra mobility is mandatory, since postoperative distention of the bowel and subsequent tension on the suture line must be anticipated.

A decision is made for an end-to-end anastomosis with or without a stapling instrument or a side-to-end anastomosis. The adequacy of the exposure, the amount of omental fat, and finally, the discrepancy between the sizes of the upper and lower lumens may influence the final technical approach.

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