Colectomy, Ileorectal Anastomosis

Colectomy with ileorectal anastomosis is a surgical procedure that involves removing a diseased portion of the colon and connecting the ileum (last part of the small intestine) to the rectum. It is typically performed to treat conditions such as colon cancer, inflammatory bowel disease, or diverticulitis. This procedure aims to restore normal bowel function and improve the patient's quality of life.

Step 1: Anesthesia

The first step in this surgical procedure is administering general anesthesia to the patient. The anesthesia is used to ensure that the patient is completely unconscious and pain-free during the surgery. Once the anesthesia has taken effect, the surgeon can begin the operation.

Step 2: Incision

The surgeon makes an incision in the abdomen with a 10 or 15 blade on a #3 knife handle, usually in the midline or to the left of the midline. This incision is made to allow the surgeon to access the colon and perform the necessary surgical procedures.

Step 3: Mobilization of the Colon

The surgeon will use a variety of sized retractors such as Richardsons or a Balfour, along with cautery, Ferris Smith forceps, DeBakeys, and metzenblum scissors to dissect down, and then identify the colon and mobilize it from its attachments to the abdominal wall and surrounding structures. This allows the surgeon to access and remove the diseased portion of the colon. Allis clamps, tonsils, and Kochers are also commonly used to manipulate tissue.

Step 4: Ligation and Division

The next step is to identify the blood vessels that supply the diseased segment of the colon and ligate (tie off) them to prevent bleeding. This is commonly done by placing a tonsil clamp or right angle clamp under the vessel, using a DeBakey to place a free tie (2-0 or 3-0 Silk ties) in the jaws of the tonsil or right angle, pulling the clamp back under the vessel, and tying off the suture and cutting it short with a pair of straight Mayo scissors. The colon is then divided above and below the diseased portion, and the diseased segment is removed. A linear cutting stapler is used to do this. The surgeon will tell you what size staple load will be used. The Bovie will be used on the edges if there is any bleeding present.

Step 5: Ileorectal Anastomosis

The surgeon then brings the ileum (the last part of the small intestine) down to the rectum and creates a new connection (anastomosis) between them. A separate prep table or mayo stand should be draped and prepped with some lap or raytecs. The surgeon may use sutures or staples to create the anastomosis. The instruments used during this step include bowel clamps, staplers, and suture material. The most common type of stapler used is an EEA stapler. During this step, the surgeon or an assistant contaminates themselves by going to the smaller prep stand/mayo stand and inserting the stapler through the rectum. The person that's still sterile (usually the surgeon) will have the anvil (tip of the stapler) loaded onto a Kelley. They will fire the stapler and it will make a "donut" of tissue that is sometimes sent to pathology.

Step 6: Anastomosis Testing

Once the anastomosis has been created, it is tested to ensure that there is no leakage. This is done by filling the area with a sterile fluid and observing for any leakage. The instruments used during this step include syringes and sterile fluid.

Step 7: Closure

The final step is to close the incision in the abdomen with sutures or a skin stapler and apply a sterile dressing. 1 PDS, 2-0 silk, 3-0 silk pop offs for the anastomosis, 3-0 chromic gut, and 3-0 and 4-0 Vicryl are all commonly used. The instruments used during this step include needles, suture material, and staplers.

Tips and tricks

Be sure to have long variations of clamps for deep in the abdomen.

The Surgery Sparknotes

1. Make an incision in the abdomen
2. Mobilize the colon with retractors, scissors, and electrocautery devices
3. Ligate and divide the blood vessels with clamps, scissors, and electrocautery devices
4. Create an anastomosis with bowel clamps, staplers, and suture material
5. Test for leakage using syringes and sterile fluid
6. Close the incision with needles, suture material, and staplers