INJURIES OF THE RIGHT COLON BEYOND THE CAECUM

If the wound is in the anterior wall only, you may be able to insert a large de Pezzer catheter, as for a caecostomy, as in A, Fig. 66-19.

If the wound is less than 2 cm, and its excised edges have a good blood supply, suture it in two layers and drain the paracolic gutter. Do a proximal caecostomy with a de Pezzer catheter (B).

If the wound cannot safely be sutured do a right hemicolectomy (as described below). If you are skilled, do an end to side anastomosis (D). If you are less skilled, bring the ileum and the transverse colon out of the wound (C).

An easier but less satisfactory alternative is to mobilize the peritoneum in the paracolic gutter, so as to bring the damaged part of the colon out through an appropriate incision in the abdominal wall without tension or torsion. You can then close the abdominal wound, and refect the injured colon to leave a double barrelled colostomy (E).

HEMICOLECTOMY FOR AN INJURY OF THE RIGHT COLON

Wall off the patient’s intestines with gauze or place them in a sterile plastic bag. Expose his caecum. Incise the peritoneum in his right paracolic gutter close to his colon from the tip of his caecum upwards to his right hepatic flexure (A, in Fig. 66-20). There will be little bleeding.

Divide his hepatocolic ligament and tie the small blood vessels in it.

Using finger dissection reflect his right colon medially (B). Cover the raw surface that remains with moist packs.

CAUTION! Don’t injure: (1) His right ureter. (2) The second or third parts of his duodenum (C).

Figure 66.21: WOUNDS OF THE TRANSVERSE, DESCENDING, AND SIGMOID COLON. E, a small wound, exteriorized on a loop colostomy. F, a small length of gut excised and a double colostomy made through the same wound. G, a longer length of gut excised in the descending colon and colostomies made through separate incisions. H, part of the colon resected and the rectum closed. By kind permission of Peter London.

Clamp and divide the mesentery of his colon just distal to his hepatic flexure (D). Tie the branches of his ileocolic and right colic, and some of the terminal branches of his middle colic arteries. You are not operating for malignancy, so you can conveniently tie them fairly near the gut.

Dissect his greater omentum off the proximal part of his transverse colon.

Prepare his terminal ileum at its mesenteric border, and divide its mesentery to join the incision that you have just made in his mesocolon. Doubly tie any vessels you cut in his mesentery.

Place a pair of crushing clamps obliquely across his ileum, 1 cm from its mesenteric border.

Place a pair of crushing clamps across his colon, divide it between these clamps, and remove his right colon complete with its far. shaped piece of mesentery and the piece of his terminal ileum.

Cover the end of his ileum with a saline pack until you are ready to anastomose it.

Close the end of his colon with continuous catgut on a straight or curved needle by passing the sutures over the end of the crushing clamp (E). Remove the clamp and pull the sutures tight. Use 2J0 atraumatic silk or chromic catgut (if infection is present) to place a continuous line of Halstead mattress sutures 1 cm from the suture line, taking care not to include any fat (F). Invert the first line of sutures as you pull these mattress sutures up.

END-TO-SIDE ANASTOMOSIS Bring the patient’s ileum, still held in its clamp, close to the anterior tenia of his colon (G).

If you have not previously excised his omentum, retract it upwards, and grasp the anterior taenia of his colon with Babcock forceps at the proposed site of the anastomosis.

Apply a small straight crushing clamp to the anterior tenia, so as to include a small bite of colon (H).

Arrange the clamps so that you can join the serosa of his colon and the ileum with mattress sutures of 2/0 silk (I). Leave the sutures at either end long to act as stay sutures. Cut into his colon by excising the protrusion from the crushing clamp on the anterior taenia (J).

Apply an enterostomy clamp behind each crushing clamp, remove the crushing clamps, and excise the crushed edges of both his ileum and his colon. If necessary, enlarge the opening in his colon.

Approximate the mucosal surfaces of both organs with continuous fine catgut, starting in the midline posteriorly and continuing round on either side (K). Continue the sutures roun the angles and anteriorly as Connel inverted sutures (L). Complete the anastomosis with an anterior row of mattress sutures (M). Reinforce the angles with some additional mattress sutures.

Suture the edges of the mesentery of his ileum and colon, so that his intestine cannot later herniate through it.

CAUTION! Test the patency of the stoma, it should be big enough to admit your index finger.

POSTOPERATIVE CARE Continue nasogastric suction and intravenous fluids for 3 to 5 days. Don’t remove his naogastric tube until there is clear evidence that the stoma is patent, as shown by the absence of abdominal distension after the tube has been clamped for at least 12 hours.