Operative Technique Fig 23169

The patient is placed in the supine position, and a urinary catheter and nasogastric tube are inserted. Through a midline incision, the large

Figure 23.1. The continent colonic conduit. Reprinted from Keighley MRB, Williams NS (eds.). Constipation. In: Surgery of the Anus, Rectum and Colon, second edition. London: WB Saunders, 1999, pp 737-55, copyright 1999, with permission from Elsevier.

bowel is mobilized from the cecum to the proximal transverse colon. The conduit is usually performed at the hepatic flexure, and is marked using a Bab cock forceps, and distally from here a 15-cm length of bowel is measured (Fig. 23.2A). The greater omentum is removed from this segment of colon, and where necessary, excess fat is removed from the mesocolon,taking care not to damage the mesenteric vessels. This defatting allows the colon to be intussuscepted during the formation of the valve. The ascending colon is transected approximately 15 cm from the ileocecal junction as previously marked, and 15 cm distally a 2-cm colotomy is made. A Babcock forceps is then passed retrograde through the colotomy and the full thickness of the colon is grasped 5 cm from the site of tran-section. The bowel is intussuscepted through the transverse colon and stabilized using longitudinal rows of nonabsorbable sutures and staples. The valve is a minimum of 5 cm long to prevent reflux of irrigant and colonic contents through the abdominal aperture.

A Silastic Foley catheter (14 F) is inserted from the open proximal end of the colon through the valve, and secured using two non-absorbable purse-string sutures at the apex of the valve, leaving a 1-cm gap to allow intubation of the conduit. The catheter balloon is inflated and together with the valve is positioned back in the transverse colon through the colotomy, which is then closed using a continuous Maxon suture. The base of the valve is secured with circumferentially placed interrupted sutures from its external aspect to the afferent limb of the conduit to further protect against de-intussusception of the valve. The afferent limb is narrowed using a linear stapler (Fig. 23.2B), the excess bowel is trimmed off and the staple line oversewn, to form the irrigation conduit.

An end-to-side anastomosis between the ascending and distal transverse colon is performed to restore intestinal continuity. At the aperture site, skin flaps forming an inverted wine-glass shape are fashioned (Fig. 23.3A), preserving subcutaneous tissue and thus an adequate vascular supply to prevent stenosis. The catheter and conduit are then passed through the abdominal wall without tension. A small V is then excised from the conduit wall, and its entrance sutured to the lateral skin flap (base of the wine glass; Fig. 23.3B). The arms of the skin flap are then sutured to the conduit entrance,

Figure 23.2. Creation of the conduit. a: Identification and preparation of conduit site at the hepatic flexure, with formation of transverse colo-tomy 15 cm distal to transection of the ascending colon. b: Appearance of the afferent limb of the conduit after narrowing by stapling,with intus-suscepted conduit valve reinserted through the colotomy and stabilized with sutures. Reprinted from Keighley MRB,Williams NS (eds.). Constipation. In: Surgery of the Anus, Rectum and Colon, second edition. London: WB Saunders, 1999, pp 737-55, copyright 1999, with permission from Elsevier.

Figure 23.2. Creation of the conduit. a: Identification and preparation of conduit site at the hepatic flexure, with formation of transverse colo-tomy 15 cm distal to transection of the ascending colon. b: Appearance of the afferent limb of the conduit after narrowing by stapling,with intus-suscepted conduit valve reinserted through the colotomy and stabilized with sutures. Reprinted from Keighley MRB,Williams NS (eds.). Constipation. In: Surgery of the Anus, Rectum and Colon, second edition. London: WB Saunders, 1999, pp 737-55, copyright 1999, with permission from Elsevier.

Figure 23.3. a-c: Formation of the conduit entrance, showing inverted wine-glass-shaped incision of the abdominal wall, through which the conduit is delivered, and sutured to the lateral skin flap following excision of a V-shaped segment from the afferent limb. Reprinted from Keighley MRB, Williams NS (eds.).Constipation. In: Surgery of the Anus, Rectum and Colon, second edition. London: WB Saunders, 1999, pp 737-55, copyright 1999, with permission from Elsevier.

Figure 23.3. a-c: Formation of the conduit entrance, showing inverted wine-glass-shaped incision of the abdominal wall, through which the conduit is delivered, and sutured to the lateral skin flap following excision of a V-shaped segment from the afferent limb. Reprinted from Keighley MRB, Williams NS (eds.).Constipation. In: Surgery of the Anus, Rectum and Colon, second edition. London: WB Saunders, 1999, pp 737-55, copyright 1999, with permission from Elsevier.

forming a slightly recessed aperture that has an acceptable cosmetic appearance, minimizes leakage, and allows easy catheterization of the conduit (Fig. 23.3C). The abdomen is then closed and the catheter sutured to the abdominal wall to prevent dislodgement. Any coexistent anatomic abnormality of the rectum considered to significantly obstruct rectal emptying during preoperative proctographic assessment (functional rectocoele) can be repaired at the same time as conduit construction.45

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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