mobilizing colons

[Tori's dad]

So, I have seen a lot of videos of cases where the hepatic or splenic flexure of the colon is mobilized in order to facilitate the procedure. I have not, however, seen anyone put the colon back to its original location because most of the videos end when the major part of the procedure is done. What is the procedure for reattaching the colon, or is there one?

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[tussy]

Are you kidding???

In case you are actually serious - no, you don't reattach the colon. Mobilizing the colon just releases the congenital adhesions that maintain it in its retroperitoneal position (mostly at the flexures). Usually it is mobilized in order to resect it or in order to get the ends to reach together after a resection (eg - mobilizing the splenic flexure to get the descending colon to reach to the upper rectum after an anterior resection).

 

[Winged Scapula]

Don't worry...nature takes care of reattaching it to *something* post-operatively.

 

[Castro Viejo]

So, I have seen a lot of videos of cases where the hepatic or splenic flexure of the colon is mobilized in order to facilitate the procedure. I have not, however, seen anyone put the colon back to its original location because most of the videos end when the major part of the procedure is done. What is the procedure for reattaching the colon, or is there one?

As others have already posted, there's generally no need to fix the colon to its anatomical position.

What is important, and what you may not have seen in the videos, is closure of the defect in the colon mesentery that's left after you've resected a portion of it and performed the anastomosis. Leaving that mesentery open is just asking for something (usually small bowel) to herniate through and possibly cause a mechanical obstruction (internal hernia).

Out of curiosity, did you see stapled anastomoses or hand-sewn anastomoses in the videos? A nice hand-sewn one is always way more impressive looking.

 

[Blade28]

What is important, and what you may not have seen in the videos, is closure of the defect in the colon mesentery that's left after you've resected a portion of it and performed the anastomosis. Leaving that mesentery open is just asking for something (usually small bowel) to herniate through and possibly cause a mechanical obstruction (internal hernia).

Good point. Gotta avoid those internal hernias!

 

[Tori's dad]

All the procedures I saw, (websurg.com), were done using staples, however, I did get the chance to watch one of the faculty at MCW do a gastric bypass and he is a big believer in sewn anastamoses. Very cool to watch.

 

[Castro Viejo]

All the procedures I saw, (websurg.com), were done using staples, however, I did get the chance to watch one of the faculty at MCW do a gastric bypass and he is a big believer in sewn anastamoses. Very cool to watch.

They're doing gastric bypass surgery open at MCW? Or is this a hand sewn anastomosis done laparoscopically? That's pretty impressive and a little ballsy.

 

[Castro Viejo]

On a related note, I can mobilize a colon using a "hands-free" method.

Must... Resist... Talking... About... Tired's... Homosexual... Tendencies...

 

[tussy]

What is important, and what you may not have seen in the videos, is closure of the defect in the colon mesentery that's left after you've resected a portion of it and performed the anastomosis. Leaving that mesentery open is just asking for something (usually small bowel) to herniate through and possibly cause a mechanical obstruction (internal hernia).

Actually there is no evidence for closing the mesenteric defect and you risk devascularizing your anastomosis (by picking up a vessel with your stitch when you close the defect) and many people, including me, no longer close the defect - especially if large (less likely to incarcerate).

 

[Tori's dad]

The gastric bypass procedure done by the surgeon I watched was done laparoscopically. He did both the jejuno-jejunostomy and the gastro-jejunostomy with suture. Staples are frowned upon.

 

[Castro Viejo]

Actually there is no evidence for closing the mesenteric defect and you risk devascularizing your anastomosis (by picking up a vessel with your stitch when you close the defect) and many people, including me, no longer close the defect - especially if large (less likely to incarcerate).

While I'll agree with you on the evidence, I've been trained to always close the mesentery. It's a bit of voo-doo on our part (and who among us hasn't been taught some kind of voo-doo in the OR?), but I've never hit a vessel stitching the mesentery together. And just a few weeks ago I took someone to the OR with strangulated small bowel where the entire small bowel and its mesentery had herniated through a mesenteric defect (the patient had had a colon resection some time in the past).

I'd be too uncomfortable if I left the defect open, to be honest.

 

[tussy]

I've taken patients to the OR for a SBO and found an internal hernia thru a mesenteric defect as well, and in those cases, when i've tracked down the original OR dictation, i found that they had actually closed the defect. One theory is that by closing the defect you just make it smaller and therefore more likely to incarcerate! I must say if the defect is huge i leave it alone, if it's a small defect and it looks like SB could incarcerate then i take the effort to close it.


what do others here do with the mesenteric defect??

 

[njbmd]

Don't worry...nature takes care of reattaching it to *something* post-operatively.

ROFLMAO

 

[jbean]

A nice way to close the mesenteric defect without risking blood supply is as follows:

When using kellys and ties to divide the mesentery, do not cut the ties - leave them long after you have tied them.

After the colon is removed, simply tie your ties from one side of the mesentery together to the ties on the other side. You do not have to take any more stitches or risk getting a vessel. You also use the strongest area (that which you tied off) to hold the mesentery together instead of relying on weak fatty tissue and peritoneum.

We tend to close the defect on open procedures and leave it alone on laparoscopic colon resections.