Right hemicolectomy with ileocolic tube drainage

RIGHT HEMICOLECTOMY WITH ILEOCOLIC TUBE DRAINAGE* WILLIAM L. WOLPSON, M.D., P.A.C.S. BROOKLYN,N. Y. ITHOUT specifying a11 the pathoIogica1 conditions or changes of the right coIon that reuuire right hemicolectom‘;;, I have seIected_ two i&strative Iesions for which.this operation had been performed. The intestina1 ends were joined by an end-to-end union and an iIeocoIostomy rubber drainage tube was inserted and so arranged that it demonstrated some usefu1 features of practica1 vaIue. If I interest readers in a singIe probIem in the Art of Surgery: nameIy, right hemicoIectomy, it may serve to focus attention on other Iatent opportunities for practica1 tria1 and research in this heId. RecentIy the exaItation and gIorification of the Science of Surgery has tended to obscure the importance of the Art of Surgery. Discussions as to the reIative importance of the divisions of Surgery, Art versus Science, are never satisfactoriIy ended. Strong and earnest advocates of each cIass are quick to emphasize and express their preference, depending entireIy on persona1 incIinations and beIiefs. BeIieving as I do that the idea1 surgeon requires excehent quaIities of head, hand, and heart, and must be a composite thereof, I hoId no brief for the pure technician, the exponent of man
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when worthy. In surgery particuIarIy, it is important not to foIIow too quickIy nebuIous fancies, specuIations, and unproved theories hastiIy accepted when garbed as science. It can be definiteIy stated that pure science cannot advance aIone from its test tube, anima1 experimentation, Iaboratories or the morgue. Such work must be transported, transIated and activated by competent and skiIIed craftsmen of the Art of Surgery into measures usefu1 for the Iiving. It continues true, that the demand of humans is that, when required, operations upon us be done by trained mechanics, not theorists; skiIIed performers, not Iaboratorians; but by competent surgeons trained in the Art of Surgery. E. Starr Judd’ in a presidentia1 address before the Western SurgicaI Association concIuded as foIIows : “Perfection of the Art of Surgery can be obtained onIy by constant practice, and onIy those who are wiIIing to spend much time and effort in the deveIopment of this sort of craftsmanship, aIong with their studies of the Science of Medicine, wiI1 have an opportunity to become the rea1 Artists of Surgery. ” SurgicaIIy, the entire coIon may be divided into a right and Ieft part. Important differences in these two haIves have made this somewhat arbitrary cIeavage of practica1 and basic use for any operative consideration directed thereto. EmbryoIogicaIIy, the right coIon was derived from the midgut, the Ieft coIon from the hindgut. The superior mesenteric artery through its branches and arches of the iIeocoIic, coIica dextra and coIica media give an adequate and a rich bIood suppIy to this part of the coIon, whereas

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the Ieft coIon suppIied in main by the inferior mesenteric artery and a Ieft branch of the colica media does not receive so generous a vascuIar series of arches of bIood (Fig. I). The entire coIon maintains its bIood vesseIs on the inner Ieaf of the mesentery. Its Iymphatic system is carried with it. The outer Ieaf may be considered an avascuIar Iayer. UsuaIIy, the contents in the right coIon are fluid and therein the number of bacteria is fewer and Iess activeIy infectious than in the Ieft haIf. Obstructions on the right side are often Iess compIete. The genera1 effects of such a bIockage are not so disturbing or toxic. LocaI intestina1 waII damage is better toIerated. AI1 the principIes that are essentia1 for the remova of the right coIon have been we11 accepted and standardized for its accompIishment. The type of anastomosis best performed for the bowe1 ends continues to be vigorousIy debated. An essentia1 requirement is a free and avascular mobiIization of the ascending colon by splitting the outer Ieaf of peritoneum near its attachment to the posterior parieta1 waI1, Iiberating the proxima1 haIf of the transverse coIon by Iifting the omenturn from its attachment to that area and severing the iIeum about 6 in. from the iIeoceca1 junction. It has been my pIan, first to start on the iIeum by sectioning that bowe1 with the actua1 cautery (Fig. 2) then doubIy cIamping the iIea1 mesentery toward the iIeoceca1 area. The second step has been to spIit the outer mesenteric Ieaf of the cecum, ascending coIon and hepatic ffexure (Figs. 3 and 4) permitting this portion of the coIon to rise high up, after which the omentum has been detached from the transverse coIon (Fig. 5). AI1 this compIeted wiII permit these parts to hang IooseIy and easiIy on its inner or vascular bIade so that the bIood vessels can be cIearIy seen, doubIy cIamped, divided and tied. Attention to the right ureter and the right spermatic vesseIs in this area must be observed.

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Often the greatest diffxcuIty is encountered at the corner of the hepatic Aexure. Here, the coIon must be carefuIIy stripped

FIG. I. Anatomical

study of co1011to visualize v:tscular arches.

downward and inward and the supporting Iigament and vesseIs carefuIIy isoIated and tied. Guarding the duodenum at this point is necessary as injury to this structure is not infrequent. Now, the transverse coIon is divided between cIamps (Fig. 6) and the entire attacked intestine with a Iarge part of its mesenteric attachment is removed. FinaIIy, I have united the iIeum to the transverse coIon with an axia1, straightline, or end-to-end union (Fig. 7). I have introduced a rubber tube (No. 20 F. catheter) into the iIeum, through the stoma and into the transverse colon, to provide intestina1 drainage and maintain the patency of the stoma (Fig. 8). Separate openings as eyes in the tube are provided for both the transverse coIon and the iIeum. About 4 in. from the anastomosis, this tubing, after its introduction into the

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ileum, is fixed at its point of aperture with two rows of purse-string sutures and the distaI or free end of the catheter is

FIG. Z. IIeum sectioned with cautery after three clamps have been arranged thereon. -One crushing clamD . is placed distallv and two flexibIe rubber sheathed cIamps pIaced proximaIIy to Iine of section. When caudally pIaced iIea1 cIamp is removed, there wiII be suficient bowe1 to perform ileocolic anastomosis. 1

.,

carried under and through a smaI1 opening made into the great omentum which had been detached from the sectioned transverse coIon (Fig. 9). This aIIows that portion of the omentum to Iie Aat over the anastomosis. No suturing is required. Through a separate stab-wound into the abdomina1 waI1 or from the origina wound itseIf, the catheter may be aIIowed to have its exit. This depends upon how the catheter wiI1 best arrange itseIf without the Ieast distortion. The resuIts of every recent bowe1 anastomosis axia1, IateraI, or end-to-side, invoIve similar diffIcuIties that vary onIy in degree. These may be divided in a primary or immediate group, and a secondary or deIayed group. Under the primary, we Iist: I. Local soiIing 2. Inadequate blood suppIy

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3. Edge tension 4. Hemorrhage 5. Marginal constriction

FIG. 3. SpIitting outer Ieaf (avascuIar) of peritoneum, permits rapid and bIoodIess scissor and finger mobiIization of cecum and ascending coIon.

6. Stoma, immediate size and patency 7. Coverage 8. Infectivity g. Type of intestina1 content. In this group are errors mainIy of technica character. Secondary or delayed group: I. MarginaI gangrene 2. CIosure of stoma due to excessive cont.ractions 3. Excessive exudate narrowing the stoma 4. MarginaI abscess 5. LocaI paresis 6. LocaI retention of feca1 contents 7. BaIIooning of bIind stumps 8. BIow out of cIosed ends g. LocaI abscess IO. Kinking of segments I I. FecaI fistuIa. In this second group, many of the mentioned factors interfering after a satisfactory anastomosis has been compIeted,

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occur as a resuIt of the faiIure of feca1 contents, gas, ffuids or soIids to be properIy propeIIed forward, causing increased ten-

FIG. 4. Cecum and ascending colon roiled over. Blood vessels can be viewed, clamped, cut and tied.

FIG. 5. Great omentum is detached from transverse colon on right side to iiberate it and help mobilize hepatic fiexure.

sion on the suture Iines, thus permitting the infective materia1 to press on to freshIy

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coaptated bowe1 edges and thereby damaging the stoma and its component parts. AIthough a cIassification into such groups may not be sharpIy defined and exact, it wilI serve to a better understanding of some of the hazards inherent in a11 anastomoses and of measures to decrease them. The diffrcuhies which not infrequently confront the surgeon in carrying out operations on the Iarge and smaI1 intestine are to a considerabIe degree overcome by his famiIiarity with the estabIished princrpIes of intestina1 surgery; his ability to empIoy technica methods of proved vaIue and to utiIize the various mechanica devices which, in the deveIopment of surgery of the gastrointestina1 tract, have been empIoyed to meet specia1 conditions arising during operation. Of the mechanica devices the rubber tube, I beIieve, deserves more genera1 and favorabIe recognition than is at present accorded it. Its usefuIness in certain intestina1 operations has been very e\-ident, and the resuIts of such operations so gratifying, that it seems appropriate to

FIG. 6. Transverse colon sectioned with cautery after three clamps have been placed. One crushing ciamp proximaiiy and two flexibie rubber sheathed clamps distaIiy to Iine of section. When rubber covered ciamp nearest cut end is removed, there will be ampIe bowel to perform iieocoiic union.

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record these two instances of right hemicoIectomy wherein it has been empIoyed. ExactIy how, when, and where rubber

FIG. 7. End-to-end

anastomosis of iIeum to transverse coIon. Insets, to show how iIea1 end may be widened by spIit on antimesenteric border to approximate same circumference as cut end of transverse coIon.

tubing first made its introduction to intestina1 surgery, and the subsequent steps thereafter wiI1 ngt serve any particuIar purpose in this paper. In 1910, BaIfour2 reported its vaIue in resections of the Ieft colon, especiaIIy at the rectosigmoid, a procedure that became generaIIy known as the BaIfour tube resection. He, however, gave credit to his predecessors, Rutherford Morison, Lockhart Mummery, and other EngIish surgeons. It has been the frequent and better experience of many surgeons that tube drainage is a highIy desirabIe and essentia1 part of the technique in many resections with union on the Ieft coIon. To utiIize a piece of rubber tubing through the stoma and to carry it through the anus to the externa1 surface provides a ready exit for feca1 contents. It aIso controIs the patency

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of the stoma and furnishes a scaffoIding for pIastic exudate to form upon. As a spIint, it maintains the position of the segments of intestine at rest and free from anguIation. LittIe mention has been made of the use of rubber tubing for similar purposes on the right coIon. OccasionaIIy as a direct enterostomy tube it has been set into the iIeum about 7 in. above the iIeocoIic union. More often, it has been empIoyed as tube drainage for the open ends of the coIon or iIeum. HorsIey,3 after specuIativeIy considering the advisabiIity of a rubber tube drainage through the stoma of a direct iIeocoIostomy union, empIoyed this method in a case. He, however, introduced the tube through the coIon, stoma and then into the iIeum. Unlike the step procedures required for the Ieft coIon, as a genera1 measure resections of the right coIon are accompIished in one stage. The restoration of the continuity of the intestina1 tract may be performed in many ways. Probably the most popuIar union of iIeotransversostomy continues to be the IateraI one. Next in the order of frequency is the end-to-side operation and finaIIy the axia1 or end-to-end anastomosis. There seems to be a tendency IateIy, however, to reverse this order. John F. Erdmann4 has Iong been a user of the Iine type of anastomosis. The objectors to the IateraI anastomosis have maintained that a finished procedure Ieaving two bIind stumps and three suture Iines carries a serious defect. There are too frequentIy recorded instances of earIy and Iate bIow outs of the bIind ends. Longitudina1 incision of the transverse coIon and iIeum interferes with a Iarge area of neuromuscuIar activity thereby subjecting the IocaI area to excessive paresis, IocaI contractions and greater interference to the onward propuIsion of feca1 contents. End-to-side anastomosis carries one-haIf of these objections whereas axia1 or end-toend anastomosis reduces to a minimum a11 of the fauIts of theoretica or practica1 consideration.

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rqevertheIess, certain diffkukies wiII occ asionaIIy arise even under the most fav orabIe conditions and effort, which

cramps centered to the right Iower quadr 2nt. She had no nausea or vomiting, but feIt distinctIy chiIIy.

FIG. 8. Introduction of rubber tube with two eyes, into iIeum, through iIeocolic stoma and into transverse coIon.

FIG. 9. Tube carried through omentum which will protect iIeaI aperture and help cIose it. Inset, rubber tube withdrawn through stab incision in abdomina1 waI1.

may be partIy overcome by the use of an iIeocoIic tube, such as I have described, to conduct a Iarge part of the intestina1 contents to an externa1 surface. This tube, as described and pictured when withdrawn from the intestine, Ieaves an opening in the iIeum which usuaIIy cIoses spontaneousIy and promptIy. CASE I. B. R., a femaIe, aged forty-three years, was admitted to the IsraeI-Zion HospitaI, July I, 1930, with a temperature of IOO’F. Marital History. The patient had been married seven years and had four chiIdren. The Iast pregnancy occurred two years ago. Past History. She recaIIed that five weeks after her Iast deIivery, she deveIoped miId Iower abdomina1 pains. The patient described interthe pain as “pin and needIe-Iike,” mittent, Iasting an hour at times. She was very indefinite as to its exact Iocation. OccasionaIIy the pain radiated to both Banks. It was never Iimited to the right Iower quadrant. No history of persistent nausea, belching, vomiting, cramps or diarrhea couId be obtained. Present Illness. Eight hours before hospitaIization, patient compIained of severe abdomina1

Physical Examination. Patient is an obese femaIe moderateIy III. The heart was not enlarged; the Iungs were noted to have &es due to chronic asthma. Abdomen was onIy sIightIy distended. In the right Iower quadrant was a wide area of IocaI tenderness with definite resistance of the underIying muscIes. Rebound tenderness was marked. It was estimated that the most tender spot was over McBurney’s point. Vaginal Examination. No peIvic pathoIogy. UrinaIysis (faint trace of aIbumin), and bIood examinations (tota white bIood ceI1 count 12,500; 76 per cent poIymorphonucIears). The Preoperative Diagnosis. Acute appendicitis. Operation and Operative Findings. Through a right gridiron or McBurney incision, the cecum was found to be invoIved by a mass formation the size of a fist. The tumefaction occupied most of the outer and Iower haIf of the cecum. The pathoIogica1 diagnosis was indeterminate; carcinoma of the cecum received the most consideration. The specimen when incised postoperativeIy showed a caIIoused uIcer of the outer side of the

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ceca1 waI1. It had raised smooth edges. A rounded opening about $$ in. in diameter Ied into a large pocket within the ceca1 waI1. PuruIent fluid was in the retention cavity. The ceca1 waI1 was tremendousIy thickened by inflammatory tissue. The operation performed was an ileotransversostomy with iIeocoIic tube drainage carried through a separate stab incision in the abdomina waI1. The drainage tube was removed ten days after the operation. The patient Ieft the institution in three weeks with both abdomina1 wounds heaIed. Pathological Report. (Dr. Max A. GoIzieher.) DiverticuIar uIcer and abscess of the waI1 of the cecum. The waI1 of the intestine is considerabIy thickened. This thickening is most conspicuous in the outer Iayers. The whoIe waI1 shows diffuse inflammatory infiItration of subacute type. In the center of the waI1 at about equa1 distance from the mucosa and the serosa there is a round cavity which is fiIIed with feca1 matter. The waI1 of this cavity is compIeteIy necrotic and the necrotic tissue is surrounded by an area of intense Ieucocytic infiItration. Some sections show remnants of viabIe tissue in the waI1 of this cavity and these remnants include aIso shreds of intestina1 mucosa. We are dealing with an intestina1 intramuraI diverticuIum with inffammation of the intestina waI1, partIy of Ionger standing and partIy of an acute gangrenous type. CASE II. A. R., a femaIe, aged sixty-two, admitted to the Jewish HospitaI, July 9, 1930. Past History. EssentiaIIy negative. Present History. ApparentIy there was no previous compIaint referabIe to her present iIIness unti1 four weeks ago. Since then the patient has been compIaining of abdomina1 pains, especiaIIy on the right side. One week ago, she sought attention at the out-patient department for pain in the right upper quadrant. She remarked that she was Iosing weight and that IateIy she confined herseIf to a ffuid diet. Yesterday an attempt to administer castor oi1 preIiminary to a radiographic study caused vioIent abdomina1 cramps and vomiting. She couId pass no ffatus or stoo1 and hospitaIization was advised. Physical Examination. A medium sized, somewhat emaciated femaIe, acuteIy III, groaning with pain. Abdomen, sIightIy distended, no visibIe peristaItic waves or distended intestina1 Ioop were noted. The abdomina1 waIIs were soft and flabby, the skin thin and Iax. In the right Iower quad-

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rant a distended and very sensitive cecum couId be distinctly feIt. OnIy on deep and firm pressure was any tenderness in the right upper quadrant eIicited. Preoperative Diagnosis. PartiaI intestina1 obstruction due to carcinoma of the right coIon. Operation and Operative Findings. JuIy I I, 1930. Through a right rectus incision, an annuIar constricting neopIastic mass near the hepatic fIexure was demonstrated. GIands in the contiguous mesentery were enIarged and seemed to be invoIved. The ascending coIon and cecum beIow the growth were moderateIy widened. A right hemicolectomy with an end-to-end iIeotransversostomy was done. It was suppIemented with an ileocolic rubber drainage tube, the end of which was brought out at the Iower angIe of the wound. Notes. Two days of treatment preIiminary to operation were extremely heIpfu1. CoIonic irrigations and warm abdomina1 stupes heIped to reIieve the obstruction. Gastric Iavages reIieved the vomiting and heIped in part to decompress the gastrointestina1 tract. Intravenous gIucose soIution, hypodermocIysis of simiIar soIution heIped to restore the ffuid baIance. Postoperative Course. SeveraI weeks after operation, a peIvic abscess that deveIoped in the post cul-de-sac required a post-coIpotomy. The patient was discharged four weeks Iater. Pathological Report. (Dr. Max Lederer). Microscopic specimen 35 cm. of coIon and 45 cm. of iIeum. About 15 cm. beIow the iIeoceca1 vaIve, there is a marked induration of the waI1 invoIving the entire circumference of the gut. On section the inner aspect of this mass is marked by an uIceration with heaped margins and roughened eroding base. The Iumen is aImost compIeteIy occIuded by this mass. The Iymph nodes on the serous coat opposite this area are firm. Examination shows the wall of the gut to be the seat of an unrestrained growth of intestina1 gIands which invade the entire muscuIar coat, extending to the serosa. The Iesion is an adenocarcinoma of the coIon. There is no microscopic infdtration of the sectioned Iymph node by malignant ceIIs. REFERENCES I. JUDD, E. S. The art of surgery. .Surg. Gynec. Obst., 5 r : 479. 1930. 2. BALFOUR,D. C. The utility of rubber tube in intes-

tinal surgery. Suq. Gy&. Obst., 31: 184, xgzo. 3. HORSLEY,J. S. Resection of the caecum and ascending co&. Ann. Surg., 69: 25, IgIg. 4. ERDMANN,J. F., and CLARK, H. E. Tumors of the caecum. Ann. Surg., 85. 722, 1927.