Normal Postoperative Appearances

M. Bittinger

Restoring Intestinal Continuity

Following surgical resection of the colon—whether due to benign or malignant disease—the continence of elimination of feces must be restored. If continuity restores the natural pathway, i. e., so that evacuation occurs transanally, an anastomosis is necessary between resected segments. Continuity can be restored using end-to-end, end-to-side, or side-to-side anastomoses (Fig. 7.1).

Ileocolic anastomosis. An ileocolic anastomosis is an anastomosis between the ileum and the colon (e.g., after a right hemicolectomy). This is generally an end-to-end (Fig. 7.2) or end-to-side anastomosis (Fig. 7.3). One can usually see a slight difference between the velvety, small intestinal mucosa and the smooth, shiny colonic mucosa. The transition is usually visible as a clear, smooth border and is only seldom slightly polypoid in appearance (Figs. 7.2, 7.3).

Colocolic anastomosis. A colocolic anastomosis is constructed between two colon segments (e.g., following resection of the sigmoid colon) and is usually an end-to-end anastomosis. A normal colocolic anastomosis appears as a smooth, whitish curvilinear scar that does not noticeably narrow the lumen (Fig. 7.4). Sometimes larger venous vessels can be seen near the anastomosis, but not intersecting it; occasionally suture remnants or metal staples (from the use of automatic sutures) can be seen on the anastomosis (Fig. 7.5).

End End Anastomosis Colon
Abb. 7.1 Schematic illustration of options for restoring continuity following intestinal resection: end-to-end anastomosis (top), side-to-side anastomosis (middle), end-to-side anastomosis (bottom).
Neoterminal Ileum

Abb. 7.2 Ileocolic end-to-end anastomosis.

The ileum folds and velvety mucosa of the neoterminal ileum can be seen; the colon has a smooth mucosal surface and distinct vascular pattern. The anastomosis appears as a smooth ring.

Abb. 7.3 Ileocolic end-to-side anastomosis. Neoterminal ileum with typical ileal mucosa at lower right; blind end of anastomosed colon at upper left. Note the difference between the vascular patterns in the ileum and colon.

Abb. 7.4 Colocolic end-to-end anastomosis, visible as a smooth, whitish, curvilinear scar. Note on either side of the anastomosis ring the prominent vessels that do not intersect it.

Endoskopische Incision Anastomose

Abb. 7.7 Anastomosis between pouch and anal canal directly above the sphincter. In the distance, near the 12-o'clock position, a longitudinal seam is visible on the pouch; the anastomosis appears as a white ring.

Abb. 7.5 Colocolic end-to-end anastomosis, shown here as a flat, white ring. Two metal staples with feces are visible at about the 1-o'clock and 11-o'clock positions; at about the 2-o'clock position is the blind end of a small diverticularlike indentation.

Abb. 7.6 Ileoanal pouch (J pouch). On the right is the opening of the neoterminal ileum, and on the left is the blind end of the ileum loop where the ileum was folded back on itself. Perpendicular to the ileum folds, the partly fibrin-covered (i. e., not recent) incision is visible between the two loops with a staple. The pouch's wide lumen functions as a reservoir for stool.

Abb. 7.7 Anastomosis between pouch and anal canal directly above the sphincter. In the distance, near the 12-o'clock position, a longitudinal seam is visible on the pouch; the anastomosis appears as a white ring.

TO X

Ileoanal Pouch Anal Anastomosis
Abb. 7.8 Ileoanal pouches. Schematic illustration of the four most commonly used types.

Ileoanal pouch. The ileoanal pouch is a special form of restoring continuity following proctocolectomy. This procedure is generally used for severe ulcerative colitis and ulcerative colitis with dysplasia. Unlike ileostomy, the patient retains anal continence. The ileoanal pouch is usually formed as a so-called J pouch: two ca. 15-cm-long ileum loops are placed next to each other, joined to form a reservoir, and anastomosed to the anal canal (Figs. 7.6, 7.7). The ileoanal pouch functions as a reservoir for stool, thus avoiding too frequent elimination. Other pouches are also commonly used, though significantly less often than the J pouch, which is technically the easiest to construct (Fig. 7.8).

Stomas

If restoration of continuity is not possible permanently (e.g., following rectal excision due to low rectal carcinoma) or temporarily (e.g., to protect a rectal anastomosis), a stoma is necessary. An ileostomy is a connection between the ileum and an opening in the skin (stoma); a colostomy refers to passage of waste through the colon to an opening in the skin. Stomas can be either endstomas or double-barreled stomas that have two openings, allowing the remaining intestinal segment distal to the stoma a means of draining (Fig. 7.9). A normal stoma is characterized by a sufficiently wide intestinal opening; there is no significant protruding (prolapse), and there are no signs of

Normal Colostomy Appearance

Abb. 7.10 Normal smooth colostomy with normal, wide opening. The oblong, yellowish structure at about the 12-o'clock position and the whitish deposits on the mucosa next to it are feces.

<1 Abb. 7.9 Colostomy. Schematic illustration of an end colostomy (left) and a double-barreled colostomy (right).

irritation to the mucosa or surrounding skin (Fig. 7.10). If the opening of the stoma is not wide enough to permit passage of the small finger, stenosis is indicated and must be treated. As the contents of the small intestine are much more aggressive than those of the large intestine, an ileostomy requires more care than a colostomy and skin irritation occurs much more frequently.

References

1. Cohen Z, Smith D, McLeod R. Reconstructive surgery for pelvic pouches. World J Surg 1998;22:242-6.

2. Liebe S. Operationsfolgezustände. In: Hahn G, Riemann J. Klinische Gastroenterologie. Stuttgart: Thieme 1996; pp. 1036-48.

3. Silverstein F, Tytgat G. Praxis der gastroenterologischen Endoskopie. Stuttgart: Thieme 1999; pp. 350-4.

4. Starlinger M. Chirurgische Therapie der Colitis ulcerosa. In: Adler G. Morbus Crohn, Colitis ulcerosa. Berlin: Springer 1993; pp. 268-84.

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