Operations on the sigmoid colon. Method of resection of the sigmoid colon Surgery for stenosis of the sigmoid colon

Resection sigmoid colon, surgery to remove the sigmoid colon may help relieve symptoms various diseases, increase the life expectancy of patients and improve their quality of life. It may be associated with complications such as infection, risk of permanent colostomy, and adverse reactions to anesthesia. Doctors do not recommend this procedure in all cases and usually provide patients with as much information as possible about it, ensuring they can make an informed decision about whether to undergo surgery or not.

During the resection of the sigmoid colon, the patient is under general anesthesia. The surgeon makes an incision to gain access to the intestine and carefully dissects and then removes the desired section of it, after which he sews the resulting ends together and closes the incision. This procedure can be performed laparoscopically through several small incisions. This method reduces the risks associated with this operation. If it is impossible to use it to gain access to abdominal cavity an open incision is required.

This disease can cause severe pain and result in cumulative damage to the patient's intestines. Treatment is initially done with more conservative methods, but if the patient develops complications such as stenosis (where the colon becomes narrowed) or rectal bleeding, the affected area of ​​the colon may need to be removed. Another potential risk of diverticulitis is the formation of fistulas, pathological passages between the colon and neighboring structures.

Resection of the sigmoid colon provides immediate relief for patients with diverticulitis.

Some patients recover completely and return to normal life. Others continue to face complications. In addition, there is a possibility of needing a colostomy. If the patient's colon is very damaged, the doctor may make a temporary opening for the digestive tract in the abdominal wall to provide rest to the colon. In some cases, this exit becomes permanent because the patient's body never recovers, and the patient has to deal with the colostomy throughout his life.

For colon cancer, sigmoid colon resection is usually part of first-line treatment. This surgery can provide the patient with a full recovery, especially if the cancer is diagnosed on early stages. If cancer is detected in advanced stages, doctors evaluate the patient's quality of life in case of sigmoid colon resection and in case of refusal. Patients may refuse invasive surgery if the surgery adds only a few weeks to their life, or if they prefer to receive palliative care instead of treatment.

Resection of the sigmoid colon (sigmoidectomy) is a radical surgical intervention that involves removing part or all of the sigmoid colon. The extent of removal is determined by the severity of the pathology, which is an indication for surgery. If the lesion of the sigmoid colon is benign and a rather limited area is involved in the pathological process, then it seems possible to save most of the organ. In this case, the operation involves excision of a small fragment of the intestinal tube.

Indications

There are a number of pathologies for the treatment of which there is a need for this surgical intervention:

• traumatic injuries (in this case, emergency surgery is necessary);
• benign neoplasms that lead to partial or complete obstruction of the intestinal lumen or are high risk malignant tumor degeneration;
• malignant neoplasms(if applicable cancer, then the operation is performed with regional lymphadenectomy to prevent relapse);
• complicated diverticulitis (diverticula are pouch-like protrusions of the intestinal wall that can appear in any part of the gastrointestinal tract, but most often occur in the large intestine);
• volvulus of the sigmoid colon, leading to intestinal obstruction;
• ulcerative lesions of the mucous membrane, which leads to severe discomfort for the patient (pain, constipation, frequent bleeding) and cannot be treated with medication.

Contraindications

Contraindications for sigmoidectomy:

• acute inflammatory process in the large intestine (the operation is performed after drug treatment inflammation); inflammation
• running forms cancer with distant metastases;
• heavy accompanying illnesses in the stage of decompensation.

Preparation

Proper preparation for surgery significantly reduces the risk of complications and shortens rehabilitation time:

1. 7-10 days before the intervention, the patient is prescribed a special dietary regimen, which completely eliminates the consumption of heavy, indigestible and fermentable foods.
2. Held full examination patient. General clinical examinations are prescribed (general and biochemical analysis of blood, urine, FLG). This is carried out to identify concomitant diseases and their timely treatment. An undiagnosed general somatic disease can complicate the operation and worsen the prognosis for the patient. If the patient is constantly taking any medications, the doctor can stop them or change the dosage if necessary.
3. Examined in detail gastrointestinal tract. Colonoscopy is performed (according to indications, a biopsy is taken from the affected areas), sigmoidoscopy. In some cases, the surgeon may prescribe a survey radiography of the abdominal cavity or irrigoscopy. Indications for these studies are determined on an individual basis.
4. The day before surgery, bowel cleansing is required. Cleansing can be done in several ways: taking laxatives, cleansing enemas. More modern method It is considered to be taking osmotic solutions (Fortrans), but these solutions are quite expensive. The choice of cleansing method depends on the doctor’s prescription and the patient’s preferences. It is important that the patient adheres to the prescribed diet for the week before surgery, as this also has a cleansing effect.
5. The last meal and water intake should be 12-16 hours before surgery.
6. Several hours before the start of surgery, antibacterial drugs are administered, since bacterial contamination of the intestines is very high and there is a risk of developing infectious complications in the postoperative period.

Technique

Resection can be performed different ways:

1. Laparoscopic method. The operation is performed using special endoscopic video equipment. During the operation, only a few small incisions are made on the skin of the abdomen, which makes this method more gentle and avoids the appearance of large scars.
2. Laparotomy method (open). It involves a wide dissection of the skin and underlying tissues, therefore it is more traumatic and unaesthetic, but there are pathologies when the surgeon needs to perform extensive intervention (most often oncology), and a minimally invasive operation will be ineffective.

There are several in various ways restoration of the passage of intestinal contents:

1. Formation of intestinal anastomosis. The parts of the intestine that remain above and below the resected area are sutured.
2. Formation of a colostomy. The afferent segment of the intestine is completely sutured and the afferent end of the intestine is brought out to the anterior abdominal wall with the formation of a colostomy (Hartmann operation). This can be either an intermediate or final stage of the operation.

The type, technique and extent of surgical intervention are determined by the attending physician, taking into account the type of pathology, its volume and the degree of intestinal damage. Also, the price for providing this service will depend on the method of operation.

Stages of surgery:

1. Carrying out endotracheal anesthesia.
2. Access to the sigmoid colon. The actions at this stage depend on the chosen method of operation (laparoscopic or laparotomy). For laparotomy access, an inferomedian incision is used.
3. Revision of the abdominal cavity. In a minimally invasive operation, endoscopy is performed; in an open operation, a direct examination of the organ and adjacent tissues is performed.
4. Mobilization of the section of intestine that will be removed. At this stage, the intestinal mesentery is dissected, as well as ligation, intersection of blood vessels and nerves.
5. Resection of the affected area. The estimated volume of intervention is selected in the preoperative period, but the surgeon determines the final length of the area to be removed during the operation (during the revision). A section of intestine is removed along with the mesentery (in some cases, regional lymph nodes are additionally removed).
6. Restoring the integrity of the intestinal tube. Depending on the indications, at this stage an anastomosis is created or a colostomy is placed on the anterior abdominal wall.
7. At the final stage, drainage tubes are installed and the surgical wound is sutured.

If resection was performed for a malignant disease, then the operation is supplemented with chemotherapy and radiation treatments.

Rehabilitation period

The rate of recovery after surgery depends on the volume of intervention performed and the general condition of the body. The rehabilitation period is also affected by the patient’s compliance with the medical and protective regime.

First day postoperative period the patient is in the ward intensive care. Antibacterial, anti-inflammatory and analgesic drug therapy is carried out. Chemotherapy drugs may be administered according to indications.

Diet after resection:

• 12-24 hours after surgery, drinking water and unsweetened tea is allowed;
• It is necessary to expand the diet gradually. During the first week, the diet should consist only of liquid and pureed food;
• gradually you can include a small amount of solid foods in the menu;
• the patient will eat small portions 5-6 times a day;
• after a month, the patient can gradually return to his usual diet, but completely eliminate fatty, smoked, spicy and alcohol;
• with a properly selected diet there should be no digestive disorders.

Possible complications

Possible complications:

• bleeding due to inadequate hemostasis;
• failure of postoperative wound sutures or anastomosis;
• infectious complications (life-threatening conditions such as peritonitis and sepsis may develop);
• dynamic intestinal obstruction (intestinal paresis);
• adhesive disease;
• postoperative hernia.

A sigmoidectomy is a major surgical procedure. However, if the operation is performed correctly by qualified surgeons and the patient follows all recommendations, it is possible to achieve a good quality of life for the patient after resection.

Obstructive resection of the sigmoid colon is the name of a surgical intervention that is used to treat diseases of various etiologies. In clinical practice, the procedure is used extremely rarely.

Structure of the human intestine

Attention! Indications for the intervention are determined by the doctor. Before undergoing the procedure, you need to weigh all the benefits and potential harm. Before surgery, you need to try other methods to solve the problem.

Indications for surgery

The sigmoid colon or “sigmoid” is the last section of the large intestine that opens into the rectum. The sigmoid is also called the “high pressure zone of the colon,” where stool is pushed toward the anus. Because the pressure in this part of the intestine is significant, some patients develop diverticula, which are saccular projections of the intestinal wall.

Diverticulosis is the most common indication for partial removal of the colon. Rarely, diverticula can develop into carcinoma in the sigmoid colon. In this case, an extended resection (rectosigmoid resection) is usually performed.

Operation

Diverticulum occurs mainly in the sigmoid part of the intestine, where increased internal pressure causes the mucous membrane to bulge. Diverticula in the sigmoid do not always require surgical intervention. Only after several inflammations of the diverticulum (diverticulitis) is surgical removal of the intestinal section performed.

Diverticulitis is primarily treated with antibiotics. Only with complications of diverticulitis (perforation with peritonitis, fistula in another organ) is urgent surgical intervention recommended. If an abscess occurs, it needs to be punctured.

Inflammation of diverticula (diverticulitis)

In the acute stage of diverticulitis it is carried out CT scan. It is recommended to perform a colonoscopy before surgery and exclude concomitant diseases. For colorectal carcinoma, it is necessary to exclude secondary tumors and metastases (for example, in the liver).

Contraindications

Colectomy has no absolute contraindications, although general state The patient and indications for surgery are assessed on a case-by-case basis. A patient with severe heart disease and large polyps that are not amenable to colonoscopic removal is a classic difficult case. The physician must weigh the risks and benefits of the surgical procedure against the predicted results. A patient with severe heart failure should not undergo surgery because the risks outweigh the potential benefits.

Laparoscopic colectomy has some relative contraindications. Intra-abdominal adhesions or scar tissue from previous abdominal surgery may prevent laparoscopic surgery. Laparoscopic colectomy is made difficult by phlegmon due to perforated diverticulitis.

The surgeon should note whether the patient has bleeding or liver disease. Portal hypertension, although not considered an absolute contraindication, can lead to massive hemorrhage during surgery. As a result, the patient risks dying from severe blood loss.

Important! Removal of polyps during colectomy should be carried out taking into account contraindications. In some cases, patients died during the operation due to massive blood loss.

Types of operations on the sigmoid colon

Types of invasive intervention on the sigmoid:

• Sygotomy - an incision in the intestinal wall;
• Resection – removal of the entire sigmoid.

Preparation

Patients usually arrive at the hospital the day before surgery. Elderly patients undergo laboratory, x-ray and electrocardiographic tests.

The anesthesiologist visits patients and tells them about the type of anesthesia. During resection, combined anesthesia is often used: epidural and intubation. An enema is required in the morning an hour before the procedure. An enema is used to cleanse the intestines.

Resection of the sigmoid colon, course of the operation

Resection is performed at the location of the diverticula. In addition to the sigmoid, a small portion of the rectum (RC) is removed. The PC is removed to prevent the development of new diverticula.

Diverticulosis and carcinoma of the sigmoid colon are today treated with laparoscopic surgery. This procedure typically requires 5 to 7 intervention points using 5 to 12 mm skin incisions. One incision in the left mid-abdomen is widened during surgery, allowing the intestine to be pulled out and part of it removed.

In a benign condition (diverticulosis), the mesentery is prepared and sutured to the intestine. In the case of carcinoma, it is separated centrally to remove the infected lymph nodes.

During the operation, the entire sigmoid and several centimeters of the PC are cut out to completely remove the so-called high pressure zone.

Descending colon(descending colon) is moved along its entire length to obtain sufficient length to connect to the PC. To do this, the left bend is disconnected from the spleen.

After resection of the rectosigmoid, the connection between the rest of the colon and rectum is restored using a stapler. At the same time, the smallest titanium staples attach the ends of the intestine to each other.

Possible complications during surgery: bleeding, damage internal organ(spleen, intestines, ureter). Such complications occur extremely rarely. Timely diagnosis and correct treatment injuries.

In very rare situations, anastomosis cannot be performed. Examples include primary perforated diverticulitis with severe peritonitis and postoperative sequelae. In these cases, it is necessary to decide on a Hartmann operation. In this case, doctors insert an artificial intestine (colostomy). Once peritonitis has healed, intestinal integrity can be restored in most cases.

Colostomy

Hartmann's operation

With this type of operation, the sigmoid is closed with a suture or stapler, and then the doctor creates an end colostomy. In this way, peritonitis and anastomotic leakage can be prevented.

Laparoscopic resection of the sigmoid colon

IN last years Laparoscopic bowel resection has become widespread in clinical practice. In this type of resection, the stomach is filled with a non-toxic gas and instruments and a camera are inserted through small incisions. The intestines are cut with special instruments (staplers optimized for the endoscopic method). Most clinics will make another small incision. After this, the intestinal suture is performed using another stapler and the path of the intestinal contents is restored.

The advantage of laparoscopic bowel resection is fewer complications (small scars). After this intervention, patients can leave the hospital and return to work earlier than usual. However, time benefits can also be achieved using the conventional method of surgery. In some clinics in Russia, patients are in the hospital for only 5 days after intestinal resection and then leave it.

Laparoscopy

The laparoscopic technique is used primarily to treat sigmoid diverticulosis and sigmoid diverticulitis in many hospitals. Some hospitals specialize in laparoscopic surgery and offer laparoscopic management of all parts of the intestine. However, very few hospitals can perform the surgery under the same conditions as open surgery. For colon cancer, laparoscopic surgery is not performed as often as standard surgery. However, the chances of recovery appear to be the same as with the conventional method.

Postoperative period

After laparoscopic surgery, patients remain in the ward. You can take the liquid that same evening. The next day you are allowed to take liquid food.

After a few days, the epidural (lumbar anesthesia), urethral and infusion catheters are removed. The incisions are usually closed at the end of the operation using suture technology, which uses a special subcutaneous thread.

After successful surgery, patients can usually return home within a week. Possible complications: bleeding, infection and general complications. If the connection between the large and small intestines does not heal well and there is stool leakage in the abdominal cavity, the operation must be repeated. In this case, the anastomosis is stitched or restored. Very rarely, an artificial bowel (stoma) is created, in most cases temporarily.

After rectosigmoid resection, the patient can continue to live a normal life. However, he will experience changes in the frequency of bowel movements. Violations can be regulated healthy eating and plenty of hydration. IN in rare cases conservative therapy is required.

Timely hydration prevents complications

After a month, problems with stool may occur. In these cases, it is useful to examine the rectum for the presence of stenosis at the level of the anastomosis.

After a laparoscopic procedure, it usually takes 2-3 weeks to recover. After laparotomy, the patient is advised to refrain from heavy loads and exercises for 4 weeks. However, he can quickly return to a normal diet. During the rehabilitation period, you need to regularly visit your family doctor.

Possible complications

In addition to the general risks during surgery and general anesthesia, in this particular case, damage to the spleen, intestines or stomach may occur. As a result of the intervention, the kidneys are rarely damaged, bladder, urethra, as well as the vessels of the abdominal cavity.

Damage to these structures may be permanent and require further surgery. However, complications occur in very rare situations. An incision in the abdomen can lead to hernias, requiring new surgery. In some situations, surgery can lead to disability for the patient.

Sigmoid colon surgery (resection) involves the removal of this part of the colon due to the development of inflammatory processes in the mucous membrane or tumor-like formations. Usually such an operation is carried out as planned, but there are also emergency cases(for example, when mechanical injury abdomen). The intervention is considered quite complex, especially when it comes to a malignant tumor.

Location

The length of the sigmoid colon is 54-55 cm. This is approximately one-eighth of the entire intestine. It is located on the border of the abdominal cavity and the pelvis, and more specifically, in the left iliac fossa. Next to it is the uterus (in women) or the bladder (in men). The proximity of these organs makes resection technically difficult, because the surgeon must act professionally and extremely carefully.

This is interesting! The shape of the sigmoid colon resembles the Greek letter "sigma" (almost like the English letter S, but less curved), that’s why it’s called that.

This arrangement of the intestine makes it easy to palpate for preliminary diagnosis of diseases. You need to place 4 fingers of one hand on the left iliac region, bending them slightly. Then the patient must take a breath, and the doctor at this time forms a skin fold with his fingers. The patient exhales and the doctor gently presses on the abdomen to reach the posterior wall of the peritoneum. If you slide your fingers over it, you can feel the sigmoid colon.

By palpation, several indicators can be determined at once: the thickness of the intestine, its approximate consistency (thick or liquid), surface texture, and the intensity of peristalsis. The patient also reports pain when pressing and rolling.

In its normal state, the sigmoid colon is dense, does not rumble and has a thickness of approximately 2.5 cm. It can be mobile. If the doctor feels a tumor, excessive density, or the patient complains of pain even with light pressure, use additional methods diagnostics The patient is sent to donate stool and blood for analysis, he is prescribed sigmoidoscopy and (or) radiography and (or) irrigoscopy. Women are additionally sent to a gynecologist, because many female diseases have symptoms similar to pathologies of the sigmoid colon.

Indications for resection

What problems can arise with this part of the intestine? What could happen to require surgery? Is it really impossible to be cured conservatively? It is possible, but only if it is sigmoiditis - inflammation of the sigmoid colon. This disease is characterized by severe pain syndrome, bowel dysfunction and general deterioration in health (weakness, heat, sometimes fever).

But sigmoiditis is not the case when the patient requires resection. Inflammation is treated with antibiotics and diet therapy (table No. 4). In rare situations, it is necessary to perform plastic surgery of the vessels that supply the large intestine. Surgery is necessary for more severe pathologies.

The sigmoid colon accounts for almost 70% of colon cancer cases. Therefore, this organ is often subject to complete resection.

How is resection done?

If the operation is planned, the patient is first admitted to the hospital for all necessary examinations. On the eve of the intervention, he will have to adhere to a special diet, which includes only liquid and pureed foods in small quantities. This will avoid straining the intestines. Doctors also prescribe a “medicated diet” that excludes drugs that affect blood clotting.

In the morning, on the day of surgery, the patient will receive a cleansing enema. He is then taken to the operating room, where he is given general anesthesia. The resection technique will depend on the type of pathology.

Classic laparoscopic resection

One of the most popular methods of operating on the sigmoid colon without malignant tumors. It is characterized by minimal trauma and low blood loss, quick recovery and absence of pain in the suture area. Everything that happens inside the abdominal cavity is displayed on the screen, so the entire operating team can monitor the progress of the operation.

Open resection

Or laparotomy. Performed for cancerous tumors. The doctor can not only completely visualize the intra-abdominal space, but also prevent the spread of metastases directly during the intervention by quickly separating the affected area of ​​the intestine. The operation is complex and requires a long, difficult recovery. After this, temporary drainage and colostomy must be installed.

Operation according to Hartmann or Mikulicz

Performed for weak or elderly patients with volvulus. There is only one principle: the dead section of the intestine is removed, then the stumps are partially sutured and removed in the form of a temporary colostomy into the peritoneal cavity (outside). After a few months, the colostomy is closed (a colostomy is performed).

Possible complications after resection

Like any operation, resection of the sigmoid intestine involves complications. No one is safe from them, although, of course, the medical team tries to minimize the risks. The patient himself must also strive for this and follow all the doctor’s instructions.

The most common complications include intestinal bleeding. Older people suffer more from them due to worn out tissues. Although, the human factor can also play a role in this: if imperfect sutures are applied. Also, due to damage to the left ureter, the patient may experience pain when urinating or urinary retention. Infectious complications (especially after laparotomy) cannot be excluded. And if a person lies for a long time and his legs are not bandaged, then thrombophlebitis develops.

Features of nutrition after resection

The main function of the sigmoid colon in the body is to suck moisture from stool and give it a solid consistency. When a person loses this part of the intestine, the result is that the stool will be liquid and almost uncontrollable. Moreover, it will come out through a colostomy - the removal of the intestinal stump through the abdominal cavity. This causes some inconvenience, so a person must radically change his diet after surgery.

The diet immediately after resection is quite strict. For the first 2 days, use a minimum of water (just wet your lips), then you can drink fruit drinks or compotes. Broths are gradually introduced, and then ground food. All this time, the patient will get used to the colostomy and learn to care for it.

During the late period of rehabilitation, you will also have to eat on a limited basis. The patient is prescribed a diet with a minimum content of toxins. And that means no fried, very fatty, smoked, or hot and spicy. It is not recommended to consume coarse plant foods, legumes, baked goods, soda and whole milk to prevent gas formation.

A) Indications for resection of the sigmoid colon:
- Planned: benign pathological formations in the area of ​​the sigmoid colon, when laparoscopic access is not feasible due to adhesions and previous surgery. In case of malignant processes, it is performed exclusively for palliative purposes.
- Alternative operations: Left hemicolectomy - usually necessary for malignant tumors of the sigmoid colon. The exception is the presence of distant metastases in the liver - in these cases, resection of the sigmoid colon is performed.

b) Preoperative preparation:
- Preoperative studies: endoscopy with biopsy, X-ray contrast study; exclusion of distant metastases of malignant tumors: ultrasonography, CT scan.
- Patient preparation: orthograde lavage of the intestine, central venous catheterization, perioperative antibiotic therapy, bladder catheterization.

V) Specific risks, informed consent of the patient:
- Damage to the left ureter (1% of cases)
- Spleen injury (1% of cases)
- Anastomotic leakage (less than 10% of cases)

G) Anesthesia. General anesthesia (intubation).

d) Patient position. Lying on your back, modified Lloyd-Davis lithotomy position.

e) Online access during resection of the sigmoid colon. Median laparotomy below the umbilicus. A Pfannenstiel incision or a left pararectal Lennander incision is also possible. The best choice is the laparoscopic approach.

and) Operation stages:
- Volume of resection
- Reconstruction
- Access
- Inserting a retractor into the wound
- Mobilization of the sigmoid colon
- Circular dissection of the sigmoid colon
- Skeletonization of the mesentery of the sigmoid colon
- Removal of the drug
- Posterior wall anastomosis
- Anastomosis of the anterior wall
- Closure of the defect in the mesentery

h) Anatomical features, serious risks, surgical techniques:
- The sigmoid colon is located near the left ureter, left testicular/ovarian artery and vein, and the lower pole of the spleen.
- The anastomosis must be tension-free; mobilization of the left flexure of the colon is possible.
Warning: Avoid damaging the lower pole of the spleen by traction on the colon during mobilization.

And) Measures for specific complications:
- Anastomotic leakage: if the surgical site is well drained, expectant management with parenteral nutrition is used until the fistula spontaneously closes. If there is any sign of peritonitis, perform an urgent relaparotomy and create a diverting stoma or remove the anastomosis, close the rectum as a cecum and create an end stoma of the descending colon (Hartmann procedure).
- Anastomotic stricture: develops only if the anastomosis is under tension. If possible, perform endoscopic dilatation or repeat surgery will be required.

To) Postoperative care:
- Medical care: remove the nasogastric tube on days 1-3 and drains on days 7-8.
- Resumption of nutrition: allow sips of liquid from the 3-4th day, solid food- after the first postoperative stool, approximately from the 7th day.
- Intestinal function: treatment with a prokinetic agent from the 4th-5th day. A mild oral laxative may be prescribed during the first weeks after bowel function returns.
- Physiotherapy: breathing exercises.
- Period of incapacity: 2-3 weeks.

l) Stages and techniques of resection of the sigmoid colon (sigmoid colon):
1. Volume of resection
2. Reconstruction
3. Access
4. Inserting a retractor into the wound
5. Mobilization of the sigmoid colon
6. Circular dissection of the sigmoid colon
7. Skeletonization of the mesentery
8. Removal of the drug
9. Anastomosis of the posterior wall
10. Anastomosis of the anterior wall
11. Closure of the defect in the mesentery

1. Resection volume. Tubular resection of the sigmoid colon (that is, exclusively resection of the colon without complete removal of its mesentery) is indicated for inflammatory processes and diverticula. The extent of resection is determined by the degree of pathological changes in the intestinal wall. The dissection is carried out close to the bowel wall.

2. Reconstruction. Restoring bowel continuity by anastomosis between the descending colon and rectum is usually straightforward. Mobilization of the splenic flexure is necessary only with extensive resection.

3. Access. Access is through an inferior midline laparotomy, which can be extended around the umbilicus. In women, a Pfannenstiel incision can be performed for cosmetic reasons.

4. Inserting a retractor into the wound. After opening the abdominal cavity, a retractor with a ratchet is inserted. The Golyer frame has proven to be very useful for this purpose. After examining the small intestine, it is covered with a damp towel, along with the greater omentum, moved to the upper abdominal cavity, where it is held by the long blade of a medium-sized Golyer retractor.

5. Mobilization of the sigmoid colon. Small intestine and big oil seal move cranially under the medium-sized blade of the Golyer retractor. In the operating field on the left is the sigmoid colon with the root of its mesentery, on the right is the barely visible cecum and the ureter, visible through the thin peritoneum. Dissection begins with separation of the left-sided attachments of the sigmoid colon. The sigmoid colon is released from its retroperitoneal attachments close to the bowel wall along the linea alba using forceps and scissors and moved medially with gentle traction using two Duval forceps.

6. Circumferential dissection of the sigmoid colon. Complete mobilization of the sigmoid colon allows the posterior surface of the mesentery to be exposed. The extent of resection is determined by the degree of inflammatory changes. The resection margins are marked with rubber loops. The ureter should always be clearly defined within the retroperitoneal space. It is easiest to detect where it crosses the iliac vessels. The more lateral ovarian/testicular vessel must also be identified and protected.

7. Skeletonization of the mesentery of the sigmoid colon. After complete mobilization of the sigmoid colon, the mesentery is divided in portions between Overholt clamps, close to the bowel wall. Here, too, care must be taken not to damage the ureter. The vessels are ligated with 3-0 PGA. Dissection continues proximally to the descending colon and distally to the proximal rectum. To avoid tension on the anastomosis, it is necessary to completely mobilize the descending colon. Mobilization of the splenic flexure is usually not required.

8. Removing the drug. After complete mobilization and skeletonization, the intestine is resected between crushing clamps on the side of the preparation and elastic intestinal clamps on the side of the remaining sections of the intestine. The surgical site is covered with towels moistened with an antiseptic solution.

9. Posterior wall anastomosis. An end-to-end anastomosis is performed using a manual or hardware suture. The manual method requires that the proximal and distal ends be stabilized with stay sutures. Single sutures of 3-0 PGA are used. The anastomosis is created with a single-row suture, with an oblique direction of the stitch in the intestinal wall (more serous membrane, less mucous membrane), the gaps between the sutures should be 0.5 cm.