Bowel Flashcards
Hand sewn anastomoses by Henry: steps (5)
Hide prior staples at ends.
Posterior interrupted layer. Start w/ corners and keep them for retraction and transition to anterior part
Open the bowel
Internal layer: start 3-0 PDS, one away, one towards you. Running sutures are converted to Connel at transition points approx at 9&3 o’clock.
Second layer of interrupted Lambert sutures to complete the circle
Keep running suture on the tension
Enterotomy repair by Henry? Bites?
Generous, full thickness bites
Significance of right phrenic vein during debulking?
Leads to right hepatic vein
How to plan colon resection by Gwenael Ferron of Toulouse, France? Blood supply to colon.
Based on tumor location and blood supply areas:
Ileocolic trunk
Right colic/middle colic trunk - to 2/3 of transverse colon
IMA:
Left colic
Sigmoid
Superior rectal arteries
Small contribution from IIA (per Gray’s Anatomy p1138)
via middle and inferior rectal arteries
Transection of left colic artery: location and significance?
Does transection of left colic branch immediately at its trunk, before the division, allow for subsequent additional collateral flow between ascending and descending branch of left colic artery?
See arteriogram in Gray’s Anatomy p1140 to appreciate short distance
What is “inner arterial arc of Riolan”?
meandering course between main trunk of middle colic artery and the ascending branch of the left colic artery
when present, only prominent in cases of occlusion of SMA or IMA
Grey’s Anatomy p1139
What is marginal artery of Drummond?
anastomotic vessel running along the inner margin of the colon - gives off short terminal branches to the bowel wall
It comes from SMA branches and left colic
poorly developed in sigmoid colon and can be absent at splenic flexure or have non-functioning caliber
Grey’s Anatomy: p1138
Transection of IMA: best location to preserve colon blood supply?
Should be close to the origin which potentially would allow for collateral flow between left colic artery and superior rectal artery
If transected little bit further, connection between ascending and descending branches of left colic artery still could be preserved
Gray’s Anatomy arteriogram p1140
Role of IIA branches: middle and inferior rectal arteries in chronic conditions affecting circulation in the region?
Can cause massive dilation of marginal artery in abdominal aortic aneurysm;
Collateral supply to lower limbs in occlusion of CIAs via dilated middle rectal aa
Grey’s Anatomy p1139
Venous drainage from large intestines
Midgut - colic branches of SMV
Hindgut derivatives- distal 1/3 of transverse colon to upper anal canal - IMV
Some rectum drainage via middle rectal vv. into IIV and inferior rectal vv. into the internal pudendal vv.
Grey’s p1140
Arterial branches from ileocolic trunk? (7)
Superior division
Inferior division
Anterior caecal branch
Posterior caecal branch
Appendiceal artery
Multiple branches to jejunum and ileum
Terminal branch anastomoses with termination of ileocolic a.
Grey’s p1129
Difference in terminal blood supply between jejunum and ileum?
Jejunum:
less branches
less tiers of arterial arcades (1-3)
longer and bigger straight aa
two leaves of vessels within avascular mesenteric plane
Ileum:
only one artery within the mesentery
SMV it’s course and drainage?
Ascends in mesentery to R of SMA
joins splenic vein behind the neck of the pancreas in the trans pyloric plane to form the portal vein (lower border of L1 vertebra)
Grey’s p1130
Ileostomy catheter or rod removal ~ Ostomy type?
Loop with defunctionalized distal limb: 80% of circumference transected, no eversion on distal loop
3-5 days
Double barrel: evert with stitch 3 cm from ostomy
7-10 days
Early vs. Late ileostomy reversal: Systematic review of 6 trials by 2022:
Early: 8-17 days:
\ LOA, OR time
/ SSI, /LOA
Late: 57-278d
No difference:
morbidity, reoperation, anastomotic leak
