Cirugia Anatomica Del Intestino Grueso
-
Upload
wildor-herrera-guevara -
Category
Documents
-
view
4 -
download
0
description
Transcript of Cirugia Anatomica Del Intestino Grueso
Los TERRYbles BooK TeaM
SURGICAL ANATOMY OF LARGE INTESTINE
Several important anatomic facts influence the technique of surgery in the large intestine. As
a consequence of its embryologic development, the colon has two main sources of blood
supply. The cecum, ascending colon, and proximal portion of the transverse colon are
supplied with blood from the superior mesenteric artery, while the distal transverse colon,
splenic flexure, descending colon, sigmoid, and upper rectum are supplied by branches of the
inferior mesenteric artery (see Figure 1).
Advantage may be taken of the free anastomotic blood supply along the medial border of the
bowel by dividing either the inferior mesenteric artery or the middle colic artery and by
depending upon the collateral circulation through the marginal artery of Drummond to
maintain the viability of a long segment of intestine. The peritoneal reflection on the lateral
aspect of the colon is practically bloodless, except at the flexures or in the presence of
ulcerative colitis or portal hypertension, and may be completely incised without causing
bleeding or jeopardizing the viability of the bowel. When the lateral peritoneum is divided and
the greater omentum freed from the transverse colon, extensive mobilization is possible,
including derotation of the cecum into the right or left upper quadrant. Care should be taken to
avoid undue traction on the splenic flexure lest attachments to the capsule of the spleen be
torn and troublesome bleeding occur. In the presence of malignancy of the transverse colon,
the omentum is usually resected adjacent to the blood supply of the greater curvature of the
stomach.
After the colon has been freed from its attachments to the peritoneum of the abdominal wall,
the flexures, and the greater omentum, it can be drawn toward the midline through the
surgical incision limited only by the length of its mesentery. This mobility of the colon renders
the blood supply more accessible and often permits a procedure to be performed outside the
Los TERRYbles BooK TeaM
peritoneal cavity. The most mobile part of the large bowel is the sigmoid, because it normally
possesses a long mesentery, whereas the descending colon and right half of the colon are
fixed to the lateral abdominal wall.
The lymphatic distribution of the large bowel conforms to the vascular supply. A knowledge of
this is of great surgical importance, especially in the treatment of malignant neoplasm,
because an adequate extirpation of potentially involved lymph nodes requires the sacrifice of
a much larger portion of the blood supply than would at first seem essential. The lymphatic
spread of carcinoma of the large intestine along the major vascular supply has been
responsible for the development of classic resections. Local "sleeve" resection for malignancy
may be indicated in the presence of metastasis or because of the patient's poor general
condition.
When a curative resection is planned, the tumor and adjacent bowel must be sufficiently
mobilized to permit removal of the immediate lymphatic drainage area.
Basically, the resections of the colon should include either the lymphatic drainage area of the
superior mesenteric vessels or that of the inferior mesenteric vessels. While this would
approach the ideal, experience has shown that approximately four types of resections are
commonly performed: right colectomy, left colectomy, anterior resection of the rectosigmoid,
and abdominoperineal resection. For years lesions of the cecum, ascending colon, and
hepatic flexure have been resected by a right colectomy with ligation of the ileocolic, right
colic, and all or part of the middle colic vessels (A). Lesions in the cecal area may be
associated with involved lymph glands along the ileocolic vessels. As a result, a segment of
the terminal ileum is commonly resected along with the right colon. Lesions in the region of
the splenic flexure are in the one area where left colectomy by a sleeve resection may be
performed. Extensive resections can be carried out with good assurance of an adequate
blood supply, since the marginal vessels are divided nearer their points of origin. In addition
to the marginal vessels, the left colic artery near its point of origin and the inferior mesenteric
vein are ligated even before manipulation of the tumor is carried out to minimize the venous
spread of cancer cells. End-to-end anastomosis without tension can be accomplished by
freeing the right colon of its peritoneal attachments and derotating the cecum back to its
embryologic position on the left side. The blood supply is sustained through the middle colic
vessels and the sigmoidal vessels. Although the veins tend to parallel the arteries, this is not
the case with the inferior mesenteric vein. This vein courses to the left before it dips beneath
the body of the pancreas to join the splenic vein (B).
Lesions of the lower descending colon, sigmoid, and rectosigmoid may be removed by an
anterior resection. The inferior mesenteric artery is ligated at its point of origin from the aorta
(C) or just distal to the origin of the left colic artery. The upper segment for anastomosis will
receive its blood supply through the marginal arteries of Drummond from the middle colic
artery. The viability of the rectosigmoid is more uncertain following the ligation of the inferior
mesenteric artery. Accordingly, the resection is carried low enough to ensure a good blood
supply from the middle and inferior hemorrhoidal vessels. This level is usually so low that the
Los TERRYbles BooK TeaM
anastomosis must be carried out in the pelvis anterior to the sacrum. Here again the principle
of mobilizing the flexures as well as the right colon may be required to ensure an anastomosis
without tension.
The most extensive resection involves lesions of the low rectosigmoid, rectum, and anus.
High ligation of the inferior mesenteric vessels and ligation of the middle and inferior
hemorrhoidal vessels, along with wide excision of the rectum and anus, are required. Since
the lymphatic drainage to the anus and lower rectum may drain laterally even to the inguinal
region, wide lateral excision of low-lying rectal and anal neoplasms is mandatory.
In order to minimize the possibilities of tumor spread, the lesion should be covered with gauze
as early in the procedure as possible. Further isolation should be provided by ligation of the
colon above as well as below the tumor with gauze or umbilical tapes. Likewise, early ligation
of the vascular supply should be performed before manipulation of the tumor is carried out.
Since bowel anastomosis must be performed in the absence of tension, it is imperative that
considerable mobilization of the colon, especially of the splenic flexure, be carried out if
continuity is to be restored following extensive resection of the left colon. The presence of
pulsating vessels adjacent to the mesenteric margin, which has been cleared preparatory to
the anastomosis, should be assured. Injection of 1% procaine into the adjacent mesentery will
sometimes enhance arterial pulsation. Occasionally, pulsations are not apparent since the
middle colic artery is compressed as a result of the small bowel's being introduced into a
plastic bag and displaced to the right and outside of the abdominal wall. The Doppler
apparatus may be used to verify the adequacy of the blood supply.
The large intestine bears an important relation to a number of vital structures. Thus, in
operations on the right half of the colon, the right ureter and its accompanying vessels are
encountered behind the mesocolon. The duodenum lies posterior to the mesentery of the
hepatic flexure and is always exposed in mobilizing this portion of the bowel. The spleen is
easily injured in mobilizing the splenic flexure. The left ureter and its accompanying spermatic
or ovarian vessels are always encountered in operations on the sigmoid and descending
colon. In an abdominoperineal resection of the rectum, both ureters are potentially in danger
of injury. The surgeon must not only be aware of these structures, but must positively identify
them before dividing the vessels in the mesentery of the colon.
The anatomic arrangement of the colon that permits mobilization of low-lying segments
sometimes tempts the surgeon to reconstruct the normal continuity of the fecal current
without adequate extirpation of the lymphatic drainage zones. Extensive block excision of the
usual lymphatic drainage areas, combined with excision of a liberal segment of normal-
appearing bowel on either side of a malignant lesion, is mandatory. Primary anastomosis of
the large intestine requires viable intestine, the absence of tension, especially when the bowel
becomes distended postoperatively, and a bowel wall of near-normal consistency. Although
the danger from sepsis has decreased substantially in recent years, the fact remains that the
surgical problems concerned with the large intestine are often complex and require more
seasoned judgment and experience than does almost any other field in general surgery.