白袍恐懼症

Colorectal resections

Arterial blood supply to the colon：手術取決於血管的blood supply 範圍

<p.s>middle and inferior rectal a.源自internal iliac a.

<COLECTOMY>

Ileocolic Resection:

 -limited resection of the terminal ileum, cecum, and appendix

 -ileocolic vessels are ligated and divided

 -curable malignancy suspected -> right hemicolectomy is indicated

 -primary anastomosis is created between the distal small bowel and the

  ascending colon

Right Hemicolectomy:

 -remove lesions or disease in the cecum, ascending colon, and for some hepatic flexure; most appropriate operation for curative intent resection of proximal colon carcinoma

-ileocolic vessels, right colic vessels, and right branches of the middle colic vessels are ligated and divided

 -Approximately 10 cm of terminal ileum usually included in the resection

 -A primary ileal-transverse colon anastomosis is almost always possible

Extended Right Colectomy:

 -curative intent resection of lesions located at the hepatic flexure or proximal transverse colon

 -A standard right colectomy is extended to include ligation of the middle colic vessels at their base

 -The right colon and proximal transverse colon are resected, and a primary  anastomosis is created between the distal ileum and distal transverse colon

  (relies on the marginal artery of Drummond)

Transverse Colectomy:

 -Lesions in the mid and distal transverse colon may be resected by ligating the middle colic vessels and resecting the transverse colon, followed by a colocolonic anastomosis. However, an extended right colectomy with an anastomosis between the terminal ileum and descending colon may be a safer anastomosis with an equivalent functional result

Left Colectomy:

 -For lesions or disease states confined to the distal transverse colon, splenic flexure, or descending colon

 -The left branches of the middle colic vessels, the left colic vessels, and the first branches of the sigmoid vessels are ligated

 -A colocolonic anastomosis usually can be performed

Extended Left Colectomy:

 -an option for removing lesions in the distal transverse colon

 -left colectomy is extended proximally to include the right branches of

  the middle colic vessels

Sigmoid Colectomy: (常做)

 -ligation and division of the sigmoid branches of the IMA

 -entire sigmoid colon should be resected to the level of the peritoneal

  reflection and an anastomosis created between the descending colon and

  upper rectum. Full mobilization of the splenic flexure often is required

  to create a tension-free anastomosis

Total and Subtotal Colectomy:

 -required for patients with fulminant colitis, attenuated FAP (AFAP), or synchronous colon carcinomas

 -the ileocolic vessels, right colic vessels, middle colic vessels, and left colic vessels are ligated and divided

 -the superior rectal vessels are preserved

-subtotal (preserve the sigmoid): the distal sigmoid vessels are left intact and an anastomosis is created between the ileum and distal sigmoid colon (subtotal colectomy with ileosigmoid anastomosis)

 -total (sigmoid is to be resected): the sigmoidal vessels are ligated and divided, and the ileum is anastomosed to the upper rectum (total abdominal colectomy with ileorectal anastomosis)

 -If an anastomosis is contraindicated, an end-ileostomy is created and the remaining sigmoid or rectum is managed either as a mucus fistula or a Hartmann pouch

<PROCTOCOLECTOMY>

Total Proctocolectomy:

 -entire colon, rectum, and anus are removed

 -the ileum is brought to the skin as a Brooke ileostomy

Restorative Proctocolectomy (Ileal Pouch Anal Anastomosis):

 -The entire colon and rectum are resected, but the anal sphincter muscles and a variable portion of the distal anal canal are preserved

 -Bowel continuity is restored by anastomosis of an ileal reservoir to the anal canal

<ANTERIOR RESECTION >(resection of the rectum from an abdominal approach to the pelvis with no need for a perineal, sacral, or other incision)

3 types:

1. High Anterior Resection(HAR):

 -resection of the distal sigmoid colon and upper rectum

 -appropriate operation for benign lesions and disease at the rectosigmoid junction such as diverticulitis

2. Low Anterior Resection(LAR):

 -remove lesions in the upper and midrectum( lesions located in the upper two-thirds of the rectum)

3. Extended Low Anterior Resection:

 -remove lesions located in the distal rectum, but several centimeters above the sphincter

 -the risk of an anastomotic leak and subsequent sepsis is higher when an anastomosis is created in the distal rectum or anal canal, creation of a temporary ileostomy should be considered in this setting

 -creation of a colon J-pouch improves function during 1st postoperative year

Hartmann's Procedure and Mucus Fistula

治療obstructing tumor in sigmoid colon者，因為colon obstruction 漲大，若直接anastomosis會造成stool leak，導致severe peritonitis。

colon or rectal resection without an anastomosis in which a colostomy or ileostomy is created and the distal colon or rectum is left as a blind pouch. The term typically is used when the left or sigmoid colon is resected and the closed off rectum is left in the pelvis.

If the distal colon is long enough to reach the abdominal wall, a mucus fistula can be created by opening the defunctioned bowel and suturing it to the skin (alleviate mucus production out of the intestine that is not used)

<上圖>Low anterior resection for tumors in the upper two thirds of the rectum. A, Temporary colostomy; B, subsequent colorectal anastomosis; C, restoration of GI tract continuity.

Abdominoperineal Resection

removal of the entire rectum, anal canal, and anus with construction of a permanent colostomy from the descending or sigmoid colon

Primary wound closure usually is successful but the large perineal defect, especially if radiation has been used, may require a vascularized flap closure

in some patients

 圖片來源(還有colonoscopy清除polyp的方式)

http://www.hopkins-gi.org/GDL_Disease.aspx?CurrentUDV=31&GDL_Cat_ID=AF793A59-B736-42CB-9E1F-E79D2B9FC358&GDL_Disease_ID=FB4F2BE3-FC13-44E4-BB69-2CCE936A6CD5