Procedure :The Retroileal Transmesenteric Colorectal Anastomosis

The first technique to take down a well-vascularized colon into the pelvis is the transmesenteric lowering of the colon (Fig. 28.1). Typically, it requires a complete division of the root of the transverse mesocolon along the pancreas up to the hepatic flexure with division, if present, of the main trunk of the middle colic artery. The remnant colon is also free from its omental attachments and then brought through an avascular window of the mesentery, usually in the terminal part of the ileum, on the right of the superior mesenteric artery. This operative technique requires keeping a certain length of transverse colon to perform the pelvic anastomosis. Thus, the right colic artery needs to be preserved for adequate blood supply.

This procedure was first described in 1961 by Andre Toupet [17,18]. At the beginning, the aim of this transmesenteric passage was to perform a

Fig. 28.1 Colorectal anastomosis with transmesenteric passage of the transverse colon and closure of the peritoneal defect

One wound infection. Functional outcome was considered good by the authors but not detailed. Hogan and Joyce described a case report of redo surgery using this retro-ileal anastomosis for chronic anastomotic leakage after previous segmental left colectomy [21]. Recently, Sileri and colleagues reported their experience of 10 patients, with two of them operated on by laparoscopy [22]. Indications were the following: two left colon cancers, two left colon cancers with associated diverticular disease, two iterative resections for metachronous left colorectal cancer, two synchronous colon cancers and two patients with extensive diverticular disease. Functional outcome assessment revealed that only two patients routinely used loperamide-based medication. There was no complication related to the surgical procedure, especially the occurrence of small bowel obstruction. Indeed, this point is of importance, as this technique is associated with a theoretical risk of internal hernia through the mesenteric window, and the lowered transverse colon needs to be fixed all around the ileal mesenteric defect with interrupted sutures. Conversely, a too narrow peritoneal opening could lead to colonic obstruction or create an obstacle to venous return.

Tension-free anastomosis between the transverse colon and the sigmoid colon following a left segmental colectomy, with passing the colon on the left of the superior mesenteric artery. The transmesenteric route of the transverse colon was then taken up in 1976, with an opening of the meso created in the right mesocolon, between the right colic artery and the ileocolic artery [19].

In the literature, studies reporting this retro-ileal tunnel are few. In 1978, Turnbull gave the results of 11 patients [20]. There were six patients with complicated, extensive diverticulitis, four patients with colon cancer located to the splenic flexure and one patient with radiation stricture of the descending colon. They all had a resection of the left colon and the distal part of the transverse colon. Postoperative mortality was nil.

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