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D.E. Beck
After completing the appropriate resectional procedure, sufficient proximal and distal
mobilization provides tension-free bowel ends for a secure anastomosis. Difficulty in obtaining
tension-free bowel occurs more commonly with a left-sided (e.g. colorectal) anastomosis.
Additional left colon length is obtained with the following procedures:
division of the inferior mesenteric vein at the inferior border of the pancreas.
If these manoeuvres do not provide adequate bowel length, branches of the distal middle colic
artery and veins may need to be divided. However, this may compromise the blood supply to the
remaining colonic end. If this occurs, the ischaemic bowel must be resected and additional
vessels divided to provide the required length. In some cases, the middle colic vessels will have
to be divided proximally and the blood supply of the residual colon will need to be based on the
right, or ileocolic artery. In most patients, these vessels will provide adequate blood supply to the
proximal transverse colon or hepatic flexure, which can be made to reach to the rectum with one
or two techniques.
One method is to make an opening in the ileal mesentery medial to the ileocolic artery and vein,
then bring the proximal colon through this opening to reach the pelvis. (Fig. 49). Another option
is to completely mobilize the right colon and turn it to the right (counterclockwise). This rotates
the caecal tip to the right middle abdomen (towards the liver), reverses the direction of the colon,
and provides enough length for the hepatic flexure to reach the pelvis (Fig. 50). This manoeuvre
moves the caecum to an abnormal position, so it is important to remove the appendix.
Development of appendicitis would produce confusing signs and symptoms.
These techniques were initially learned from Dr J. Byron Gathright (Ochsner Clinic) and Dr V.W.
Fazio (Cleveland Clinic).
Figure 49 (a) Opening in mesentery is created medial to the ileocolic artery and vein. (b)
Transverse colon is brought through the ileal mesenteric opening to reach the pelvis.
Gambar 49 (a) Pembukaan di mesenterium dibuat medial ke arteri ileokolika dan
vena. (b) usus melintang dibawa melalui pembukaan mesenterika ileum untuk
mencapai panggul.
Figure 50 (a) Right colon is mobilized, right colic vessels are divided, and appendix is removed.
(b) Right colon is turned (counterclockwise) to allow the hepatic flexure to reach the pelvis.
Gambar 50 (a) usus kanan digerakkan, kapal kolik kanan dibagi, dan lampiran
dihapus. (b) usus kanan diaktifkan (berlawanan arah jarum jam) untuk
memungkinkan lentur hati untuk mencapai panggul.