Large Intestine: Sigmoidectomy for Diverticulitis

General Considerations

IMA Ligation

  • High Ligation: Ligate Proximally, Losing the Left Colic Artery
    • Colostomy Perfusion Per: Marginal Artery (Middle Colic)
    • Preferred if Suspicion of Malignancy
  • Low Ligation: Ligate Distally, Sparing the Left Colic Artery
    • Lower Leak Risk, Otherwise Similar
    • Preferred if No Suspicion of Malignancy

Rectosigmoid Junction Landmarks

  • Where Taenia Coli Splay or Coalesce – Best Indicator
  • Sacral Promontory
  • Peritoneal Reflection
  • Distance from Anal Verge

IMA 1

Elective Sigmoidectomy

Preoperative Considerations

  • Mechanical Bowel Prep and IV/PO ABX Decrease SSI by > 50%
  • Strongly Recommended to Undergo Cystoscopy with Ureteral Stent – Inflammation Causes a High Risk of Ureter Adhesion to Surrounding Tissues
    • Does Not Decrease Rate of Injury
    • Makes Injury Easier to Identify

Procedure

  • Access the Abdomen
    • Laparoscopic Generally Preferred
  • Mobilize the Sigmoid Colon
    • Medial-to-Lateral Approach
      • First Incise the Peritoneum Over Sacral Promontory & Extend to the Base of the IMA
      • Identify & Protect the Ureter
      • Ligate the IMA
      • Incise the White Line of Toldt
    • Lateral-to-Medial Approach
      • First Incise the White Line of Toldt
      • Identify & Protect the Ureter
      • Incise the Peritoneum & Create a Window
      • Identify & Ligate the IMA
  • Mobilize the Splenic Flexure
  • Transect the Proximal & Distal Margins
    • Proximal: Soft Pliable Bowel Free of Disease
    • Distal: Rectosigmoid Junction
  • Remove the Specimen
  • Create Colorectal Anastomosis (Hand-Sewn or Stapled)
  • Close Abdomen

Hartmann’s Procedure

Basic Procedure

  • Sigmoid Resection
  • Closed Anal Stump
  • End Colostomy

Procedure

  • Access the Abdomen (Open or Laparoscopic)
  • Incise the White Line of Toldt
  • Identify & Protect the Ureter
  • Splenic Flexure Typically Not Mobilized
    • Fresh Plane Will Facilitate Second Surgery
    • Consider Mobilization if Needed
  • Transect the Proximal & Distal Margins
    • Proximal: Where Colon is Not Thickened or Inflamed
    • Distal: Rectosigmoid Junction
      • Avoid Presacral Mobilization (Will Complicate Second Operation)
  • Identify & Ligate the IMA
  • Remove the Specimen
  • Create Ostomy & Deliver the Colon
    • *Consider Loop Transverse Colostomy if Obese & End Colostomy Unable to Reach the Abdominal Wall
  • Close the Abdomen
  • Mature the Ostomy

Hartmann’s Procedure 2

Anastomosis & Ostomy

Anastomosis & Anastomotic Leak

Colostomy

References

  1. Gray H. Anatomy of the Human Body (1918). Public Domain.
  2. Terrone DG, Lepanto L, Billiard JS, Olivié D, Murphy-Lavallée J, Vandenbroucke F, Tang A. A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review. Insights Imaging. 2011 Dec;2(6):631-638. (License: CC BY-2.0)