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Side-to-Side Ileotransverse Colostomy, the Anastomosis of Choice
Side.-to.-Side Ileotransverse Colostomy, the Anastomosis of Choice WALTER G. MADDOCK, M.D., F.A.C.S. Professor of Surgery, Northwestern University Medical School; Chairman, Department of Surgery, Chicago Wesley Memorial Hospital, Chicago, Illinois
THE thesis of this article is that anastomosis between the ileum and the colon after right colectomy is best accomplished by a side-to-side connection. This is an exception to my decided preference for end-to-end anastomoses for other intestinal continuities. The reason for electing side-to-side anastomosis between the ileum and the transverse colon is that in my clinical experience restoration of bowel function and passage of intestinal contents seems to be quicker through this connection than through others. There appears to be a good anatomical background for the better union, illustrated diagrammatically in Figure 1, in that the transverse colon is suspended across the upper abdomen from the transverse mesocolon, while the terminal ileum is somewhat fixed below by its relatively short mesentery attached posteriorly at about the level of the promontory of the sacrum. Consequently, to draw the transverse colon down and particularly the ileum up first requires fixation holding the bowel segments together (Fig. 1, A, C) and then an anastomotic opening between the attached sides without tension (Fig. 1, B). This condition does not prevail with either an endto-end or end-to-side connection, since in both the anastomotic sutures are also the fixation sutures. The weight of the ileum tends to pull downward and I have observed a resulting angulation at the anastomotic site repeatedly at the finish of the intestinal work (Fig. 2, A, B). This always obstructs the opening between the ileum and the colon to some degree. Such should be avoided if possible, and can be by the side-to-side anastomosis (Fig. 2, C) which lies easily and much more in line. Choice here follows the excellent surgical precept that "if it isn't easy, it isn't right." If there is difficulty, if something does not look right and easy, do something to make it right, easy and natural. The procedure as planned may be wrong; inability to see and work easily in the field may call for enlarging of the incision or more relaxation from anesthetic agents or adjusting of retractors; there may be too much tension between tissues
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WALTER
G.
MADDOCK
Fig. 1. Diagram emphasizing preference for side-to-side ileotransverse colostomy because of attachment of colon superiorly and ileum inferiorly. A, Closed end of transverse colon turned down and sutured to side of ileum. B, Side-to-side ileocolostomy without tension. C, Closed end of ileum, not more than 2 em. beyond anastomosis, turned up and sutured to side of colon. D, Edge of distal ileal mesentery sutured to proximal ileal mesentery.
Fig. 2. Diagrams of ileocolostomies showing more angulation and consequent narrowing of anastomotic opening with A, end-to-end and B, end-to-side connections than with C, side-to-side continuity.
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93
to be approximated; structures may lie in awkward relation at the end of the intra-abdominal work; and an easy postoperative course may hinge upon correcting these defects, or providing proper drainage or a simple gastrostomy first to keep the stomach empty of air, thus preventing distention, and later to serve for nutritious tube feedings for the patient not eating enough. The short blind end of the ileum 2 or 3 em. beyond the anastomosis is no problem. The fecal stream easily passes into the colon with little or no pressure against the ileal end, hence no distention. It is only with long blind loops, more than 10 or 12 em. in length, with peristalsis working toward the end that ballooning with ulceration and possible fistula formation occurs. 251 E. Chicago Avenue Chicago 11, illinois
THE thesis of this article is that anastomosis between the ileum and the colon after right colectomy is best accomplished by a side-to-side connection. This is an exception to my decided preference for end-to-end anastomoses for other intestinal continuities. The reason for electing side-to-side anastomosis between the ileum and the transverse colon is that in my clinical experience restoration of bowel function and passage of intestinal contents seems to be quicker through this connection than through others. There appears to be a good anatomical background for the better union, illustrated diagrammatically in Figure 1, in that the transverse colon is suspended across the upper abdomen from the transverse mesocolon, while the terminal ileum is somewhat fixed below by its relatively short mesentery attached posteriorly at about the level of the promontory of the sacrum. Consequently, to draw the transverse colon down and particularly the ileum up first requires fixation holding the bowel segments together (Fig. 1, A, C) and then an anastomotic opening between the attached sides without tension (Fig. 1, B). This condition does not prevail with either an endto-end or end-to-side connection, since in both the anastomotic sutures are also the fixation sutures. The weight of the ileum tends to pull downward and I have observed a resulting angulation at the anastomotic site repeatedly at the finish of the intestinal work (Fig. 2, A, B). This always obstructs the opening between the ileum and the colon to some degree. Such should be avoided if possible, and can be by the side-to-side anastomosis (Fig. 2, C) which lies easily and much more in line. Choice here follows the excellent surgical precept that "if it isn't easy, it isn't right." If there is difficulty, if something does not look right and easy, do something to make it right, easy and natural. The procedure as planned may be wrong; inability to see and work easily in the field may call for enlarging of the incision or more relaxation from anesthetic agents or adjusting of retractors; there may be too much tension between tissues
91
92
WALTER
G.
MADDOCK
Fig. 1. Diagram emphasizing preference for side-to-side ileotransverse colostomy because of attachment of colon superiorly and ileum inferiorly. A, Closed end of transverse colon turned down and sutured to side of ileum. B, Side-to-side ileocolostomy without tension. C, Closed end of ileum, not more than 2 em. beyond anastomosis, turned up and sutured to side of colon. D, Edge of distal ileal mesentery sutured to proximal ileal mesentery.
Fig. 2. Diagrams of ileocolostomies showing more angulation and consequent narrowing of anastomotic opening with A, end-to-end and B, end-to-side connections than with C, side-to-side continuity.
Side-to-Side Ileotransverse Colostomy
93
to be approximated; structures may lie in awkward relation at the end of the intra-abdominal work; and an easy postoperative course may hinge upon correcting these defects, or providing proper drainage or a simple gastrostomy first to keep the stomach empty of air, thus preventing distention, and later to serve for nutritious tube feedings for the patient not eating enough. The short blind end of the ileum 2 or 3 em. beyond the anastomosis is no problem. The fecal stream easily passes into the colon with little or no pressure against the ileal end, hence no distention. It is only with long blind loops, more than 10 or 12 em. in length, with peristalsis working toward the end that ballooning with ulceration and possible fistula formation occurs. 251 E. Chicago Avenue Chicago 11, illinois