Resection in Nonneoplastic Conditions

Hartmann's procedure - this is one of the most commonly used emergency operations for colorectal disease. Although this was initially devised for the elective treatment of proximal rectal tumours, it is now usually used in the emergency setting to treat conditions such as perforated diverticular disease (most commonly), perforated tumour, etc. The procedure itself is defined as resection of the sigmoid colon (and a variable length of proximal rectum if required) with the fashioning of a terminal end colostomy and closure of the rectal stump. The colostomy may be reversed at a later date by forming an end-to-end colorectal anastomosis.

Terminal End Colostomy

Figure 5.6 (a) Resection in low anterior resection and total mesorectal excision (b) Resection in abdominoperineal excision.

Figure 5.6 (a) Resection in low anterior resection and total mesorectal excision (b) Resection in abdominoperineal excision.

Non-acute presenting diverticular disease is usually treated surgically by either sigmoid colectomy or left hemicolectomy depending on the extent of the disease.

Surgery in colorectal inflammatory bowel disease - the surgical management of colorectal Crohn's disease is similar to that in the small intestine (see Chapter 4); namely, surgical intervention is reserved for those in whom medical management has failed (i.e., minimal resection of the diseased segment) or who are suffering complications, e.g., obstruction, pericolic abscess, fistula, etc.

As in Crohn's disease, close liaison between surgeons and physicians is required in the management of ulcerative colitis. Emergency surgery is needed in cases of acute severe colitis and/or toxic megacolon. The procedure of choice is a subtotal colectomy and end ileostomy with the

S pouch J pouch

S pouch J pouch

Colectomy With Hartmann Pouch

proximal end of the rectum brought to the surface in the form of a mucus fistula. This spares an already sick patient the added trauma of pelvic surgery and, if ulcerative colitis is confirmed by histological examination, allows an ileoanal pouch procedure to be considered in the future. Prior to the mid-1970s, patients with refractory ulcerative colitis underwent a panproctocolectomy (removal of the colon, rectum and anus) with a permanent end ileostomy. However, in 1976 the procedure of restorative proctocolectomy was introduced and removed the need for a permanent ileostomy in suitable patients. In this procedure the entire colon and rectum are removed and the mucosa may be stripped from the upper anus above the dentate line (some surgeons prefer to leave this mucosa intact as it is thought to improve future continence). An ileal reservoir (pouch) is formed (Figure 5.7) and an ileoanal anastomosis is fashioned. A protective loop ileostomy is formed as close to the ileal pouch as possible and this can be closed at a later date (usually 2-3 months) after healing has been completed. A proportion of these patients (approximately 10%) may develop "pouchitis" - increased frequency of stool and feeling generally unwell. The exact aetiology of this is unknown but some feel it may be due to bacterial overgrowth in the pouch.

Angiodysplasia - if bleeding is severe enough to require surgical intervention, and if conservative treatment such as endoscopic coagulation has been unsuccessful, the procedure of choice will be dictated by the site of the bleeding point(s). However, if the site of bleeding cannot be discovered a total colectomy with ileorectal anastomosis (or end ileostomy, rectal mucus fistula and reversal at a later date) may be required.

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