Total proctocolectomy permanent ileostomy

The colon is about 1.5 m long, about 1/4 of the small intestine. There are 4 features in the appearance of the colon, which are easy to distinguish from the small intestine: 1 Colonic band: 3 longitudinal bands of the longitudinal wall of the colon wall, from the cecum end to the sigmoid colon junction; 2 Colonic bag: due to the shorter colonic band The colon is longer, causing the intestinal wall to shrink into a saclike shape; 3 fat sag (intestinal lipid sag): is the accumulation of the visceral subperitoneal fat tissue of the colon, which is most distributed along the colonic zone and flatter at the proximal colon. The sigmoid colon is mostly pedicled; 4 the intestinal lumen is larger and the intestinal wall is thinner. The colon is divided into the cecum, ascending colon, transverse colon, and sigmoid colon. The function of the colon is mainly to absorb water and store feces. The absorption is mainly in the right colon. Because the contents are liquid, semi-liquid and soft-like, it mainly absorbs water, inorganic salts, gases, small amounts of sugar and other water-soluble substances, but cannot absorb protein and fat. If the peristalsis of the right colon is reduced, the absorption capacity is enhanced; if there is a hard stool in the transverse colon, constipation is often caused. The contents of the left colon are soft, semi-soft or solid, so only a small amount of water, salt and sugar can be absorbed. If the intestinal peristalsis in the left colon is enhanced, the absorption capacity is reduced, often with diarrhea or loose stools. The colonic mucosa can only secrete mucus, so that the mucosa is lubricated to facilitate the passage of feces. After the colon is removed, the function of absorbing water is gradually replaced by the ileum, so it does not cause permanent metabolic disorders in any part or even all of the colon. The cecum is located in the right axilla, the beginning of the ascending colon, and is connected to the end of the ileum, with a blind tubular appendix at the posterior end. The ileum that protrudes into the cecum is folded into a lip-shaped ileocecal valve, which has the function of a sphincter to prevent reflux of intestinal contents. The cecum is covered by the peritoneum, so it has certain mobility. If the range of motion is too large, a mobile cecum can be formed, which can be reversed or enter the sac. The ascending colon is a continuation of the cecum, which descends to the lower right lobe of the liver and bends to the left to form a colonic hepatic curve that migrates to the transverse colon. There is peritoneal coverage in front of and on both sides of the ascending colon, and the position is relatively fixed. However, the honeycomb tissue and the posterior wall of the abdomen are separated from the right kidney and the ureter. There is a duodenal descending slightly above the medial side of the colonic hepatic flexion. When the right colon is removed, do not damage the duodenum, especially when there is adhesion. The transverse colon begins with the colonic hepatic curvature and turns sharply to the left under the spleen, forming a spleen of the colon and connecting the descending colon downward. The transverse colon is completely covered by the peritoneum and forms the transverse mesenteric membrane, and the mesentery is attached to the posterior wall of the abdomen. The position of the spleen of the colon is higher, and the upper part is close to the tail of the pancreas and the spleen. The protection of the pancreas and spleen should be paid attention to when the colon is resected. Similarly, in the case of rupture of the spleen and massive splenectomy, the damage of the spleen of the colon should also be prevented at any time. The descending colon begins with the spleen of the colon and connects to the sigmoid colon down to the left ankle. The descending colon is roughly the same as the ascending colon and is only peritoneum on the front and sides. Since the posterior and descending colons are all outside the peritoneum, when there is a hematoma in the retroperitoneum, the extraperitoneal part of the colon should be examined to avoid serious consequences. The sigmoid colon starts from the left iliac crest and the upper edge of the third iliac crest is connected to the rectum. The mesentery of the sigmoid colon is relatively long, so it is more active and may be one of the causes of intestinal torsion. The blood supply to the right colon is from the right branch of the middle colon of the superior mesenteric artery, the right colon and the ileal artery. About 25% of patients have no middle colon arteries, but are replaced by one of the right colonic arteries, and some patients have two middle colon arteries. The blood supply to the transverse colon is from the middle colon of the superior mesenteric artery. The blood in the left colon is from the left colon and sigmoid arteries of the inferior mesenteric artery. The vein is accompanied by an artery and eventually injected into the portal vein. There is no anastomosis between the left colon artery and the middle colon artery, and there are few marginal arteries. Here, the Roilan point should be noted. Lymphatic vessels are also associated with blood vessels, through the lymphatic vessels at the base of the superior and inferior mesenteric arteries to the para-aortic lymph nodes, and finally into the thoracic duct. Therefore, in the treatment of colon cancer, the entire length of the intestine and its mesentery supplied by the colonic artery must be removed. Total gastrointestinal resection for permanent ileostomy is suitable for multiple polyposis of the large intestine. Chronic ulcerative colitis is ineffective or combined with rectal cancer, and a few are used for multiple colon cancer and extensive colonic diverticulum. Treatment of diseases: rectal cancer, rectal polyps, chronic ulcerative colitis Indication Total colectomy for permanent ileostomy is applicable to: 1. Multiple polyposis of the large intestine, the rectum has been malignant; it is also suitable for rectal polyps with almost no normal mucosa and electrocautery removal of all polyps may cause severe scars and obstruction. 2. Chronic ulcerative colitis is ineffective or combined with rectal cancer. 3. A small number for multiple colon cancer and extensive colonic diverticulum. Contraindications For patients at high risk for ulcerative colitis, especially with complications such as free perforation, a second-stage surgery should be performed. Preoperative preparation 1. Before the diet, 3 to 5 days into the semi-liquid diet, 1 to 2 days before surgery into the clear stream. 2. Take oral 25% magnesium sulfate 30ml or castor oil 30ml every night for 3 days before oral administration. 3. 3 days before mechanical intestinal lavage, saline enema 1 time per night, clean enema before surgery. 4. Oral antibiotics The following options can be selected: 1 neomycin 1g, erythromycin 0.5g, 1d 8th, 14h, 18h, 22 o'clock before surgery; 2 kanamycin 1g , metronidazole 0.4g, 3d before surgery, 3 times / d. 5. Other drugs vitamin K4 ~ 8mg, 4 times / day. Note that water and electrolyte balance. If necessary, enter an appropriate amount of water and electrolyte solution intravenously 1 day before surgery. In order to avoid insufficient nutrient supply during colon preparation, the elemental diet can be used to replace semi-liquid and whole-flow foods. The elemental diet itself can cause mild diarrhea, so laxatives should be reduced or not given. If the factor diet is about 1 week, oral laxatives and intestinal lavage can be dispensed with, but antibiotics and vitamin K are still needed. 6. Whole gastrointestinal lavage method Before the operation, the Chinese food was given to the liquid food, and the whole gastrointestinal lavage was started 3 hours after the lunch. The lavage fluid is an isotonic electrolyte solution or a solution prepared by adding 1000 ml of warm water with 6 g of sodium chloride, 2.5 g of sodium hydrogencarbonate, and 0.75 g of potassium chloride, and injecting or orally through a gastric tube, and injecting 2000 to 3000 ml per hour. Until the liquid discharged from the anus is clean and free of dung. The advantage of this method is that it is fast, effective and free from hunger. The disadvantage is that it is easy to cause abdominal distension, which can cause sodium and water retention, so heart, liver and kidney dysfunction should not be applied. 7. Chronic ulcer colitis patients, due to electrolyte loss before and after surgery, so should do a variety of blood biochemical tests before surgery, such as potassium, chlorine, sodium, etc., in order to give due correction. Because the patient's condition is often poor, you should give appropriate amount of high protein, high calorie, low slag food, if necessary, give intravenous nutrition or factor diet. According to the patient's treatment, choose the appropriate operation time. 8. If necessary, insert a bilateral ureteral catheter before surgery to avoid intraoperative injury to the ureter. 9. Patients with ileostomy should have special psychological preparations. It is best to visit patients who have recovered from this operation and see their demonstrations. Patients should be given a permanent ileostomy device and encouraged to read information about this and participate in some activities of the gang. Surgical procedure 1. A median incision or a median incision in the left side, starting from 3 cm or more above the umbilicus, and releasing the pubis. 2. After laparotomy, first turn the omentum up, close to the transverse colon and cut off the blood vessels connected to it, try to preserve the omentum; if it is a case of cancer, the omentum should be removed together with the transverse colon, instead of Plus reservation. 3. Free right colon. 10-15 cm away from the ileocecal valve, cut the end of the ileum and its mesentery, cut the cecum, ascending colon and the outside of the hepatic flexor, push the colon to the midline, cut the mesentery as close as possible to the intestinal wall, so as to cover the posterior abdominal wall The face is revealed, and other steps are seen in the right hemicolectomy. 4. Free transverse colon and left colon. The transverse colon is also separated from the transverse mesenteric membrane, the spleen colon ligament is severed and the blood vessels are ligated to free the splenic sac. The peritoneum is cut off after the descending colon and the outside of the sigmoid colon, and the colon is released to the midline as the left hemicolectomy. 5. Remove all colons. Depending on the situation, the left and right ureters can be freed and protected with a rubber sheet to prevent damage when the tissue is removed in the retroperitoneal and pelvic spaces. If there is no malignant lesion, the left mesenteric membrane is cut near the intestinal wall and the blood vessels are ligated. If there is a malignant lesion in the rectum or left colon, the inferior mesenteric artery should be severed and ligated close to the abdominal aorta, and all mesenteric membranes in the left colon should be removed. A long right angle pliers is placed in the lower part of the rectum, and a long right angle pliers is placed at the proximal end to prevent contamination when the intestine is cut. Finally, the entire colon is removed. The rectal stump is closed with a thick thread. Sharp and blunt dissection of the remaining rectum, the lower the separation, the better, so that after the perineal resection of the rectum to reduce bleeding. 6. Ileum permanent ostomy (1) The mesentery is cut from the vicinity of the intestinal wall at the end of the ileum to the mesenteric root for about 8 to 10 cm, and separated from the intestinal wall by several centimeters. If Crohn's disease, a biopsy should be done. Use two toothed vascular clamps to clamp the ileum from which the mesentery has been removed, and remove a ileum between the two clamps for pathological examination. If there is a lesion at the edge of the ileal examination, the section should be cut again. (2) In the right lower abdomen, about 6 cm below the horizontal plane of the umbilicus, and about 3 cm from the midline, cut a piece of round skin, the diameter of which is about 2/3 of the diameter of the ileum. (3) Through the circular hole, the rectus sheath, the rectus abdominis muscle and the peritoneum are cut, so that the proximal end of the ileum can be pulled out. Pull the ileum about 8 ~ 10cm, use the lobes to clamp the intestinal wall in the intestinal cavity to fix a little, then pull the mucosa outward to cover the lower half of the ileum. The edge of the mucosa that will be turned over will be sutured to the skin with intermittent sutures, one of which should pass through the skin, mucous membranes and mesentery, and then ligated so that the valgus mucosa is sufficiently fixed. In order to prevent the occurrence of sputum in the membrane and the withdrawal of the ileum, the mesentery near the proximal ileum should be sutured to the lateral abdominal cavity. Finally, a transparent ostomy bag (one piece or two pieces) can be placed at the ileostomy. 7. The peritoneum after suturing. After the colon resection, the retroperitoneal exposure surface should be covered as much as possible, but the surrounding tissue should not be pulled too tightly. If the incision of the posterior peritoneal edge is not completely sutured, the exposed surface may be partially covered and secured to the posterior abdominal wall with sutures. Some people do not advocate suturing the peritoneum to reveal the face. 8. Close the belly. Finally, the omentum is covered by the small intestine. If the omental blood circulation is damaged, the part of the omentum should be removed. The abdominal wall incision was sutured layer by layer, and double catheter drainage was performed on both sides of the peritoneal cavity, and the drainage tube was respectively pulled out on both sides of the lower abdominal wall. complication 1. Abdominal abscess and intestinal obstruction are common complications after surgery, and should be observed repeatedly for a long time. 2. The complications of ileostomy are like colostomy, complications such as stoma prolapse, stenosis, ischemic necrosis and retraction. Therefore, these complications should be guarded during and after surgery. 3. After urinary retention of Miles, all patients had varying degrees of urinary retention, especially after pelvic posterior visceral resection or extensive resection of the pelvic lateral iliac lymph nodes. The reasons are: 1 damage to the bladder nerve supply: manifested as detrusor relaxation, bladder neck contraction and bladder swelling feeling disappeared. Bladder pressure measurement found that when filling the bladder, the pressure increased, the bladder capacity increased, and there was often no bladder swelling and the feeling of hot and cold. In most cases, when the catheter is indwelled, the bladder is not inflated, and the urinary tract infection is strictly controlled, the detrusor muscle tension can be partially restored. After 2 to 3 weeks, if the urine is urinating, the abdominal wall muscle can be contracted and pubic. Pressurized by hand, the bladder may be emptied satisfactorily, forming a so-called autonomous neurogenic bladder: the final residual urine gradually decreases to within 60 ml. 2 posterior shift of the bladder: after rectal resection, a large cavity is left in front of the humerus in the posterior part of the pelvis. In the supine position, the bladder is tilted backwards and toward the anterior humerus due to lack of support, so that the bladder and urethra The angle is more pronounced than normal. When the patient leaves the bed, dysuria can sometimes improve, so the patient should be encouraged to urinate in the proposition or standing up. 3 The bottom of the bladder and its nerve supply damage: This can cause the urinary muscle to temporarily lose the contractile force. If it is mild injury, such as indwelling the catheter for 7 to 14 days after surgery, the bladder contraction force will often return to normal. 4. Complications of perineal wounds (1) Perineal wounds: Early bleeding is caused by incomplete hemostasis or ligature detachment during surgery. Cases of anterior venous plexus injury are more likely to occur. If there is more bleeding, the blood transfusion can not be corrected, and surgery should stop bleeding. Under general anesthesia, take the low bladder lithotomy position, remove all the sutures, rinse the wound with hot saline (50 °C) to remove the blood clots, and control the bleeding point by electrocoagulation or suture method, and add drainage. If bleeding is still difficult to control, you can use a long gauze or iodoform gauze to fill the anterior chamber to stop bleeding. Gradually removed 5 to 7 days after surgery. (2) delayed healing of the perineal wound: common causes are wound infection, residue of foreign bodies such as ligature, and the external port of the drainage is too small. Therefore, the perineal surgery should use an electric knife to stop bleeding as much as possible to reduce the retention of foreign bodies. If there is still a deep perineal sinus in the first month after surgery, the external orifice should be enlarged for detailed examination to remove foreign bodies such as necrotic tissue and ligature, and the unsound wound should be scraped. 5. Acute intestinal obstruction is often caused by: 1 unsealed stoma and the gap formed by the abdominal wall, causing internal hemorrhoids. This complication can be avoided if an extraperitoneal colostomy is used. 2 The small intestine adheres to the colon or pelvic peritoneum of the stoma. If the small intestine is well arranged during surgery and the omentum is covered well, this complication can often be reduced. 3 The pelvic floor peritoneal suture was split and the small intestine was prolapsed. This complication is rare, and this complication can be avoided if the pelvic floor peritoneum is carefully sutured.