Complexities in Colorectal Surgery. Decision-Making and Management

Foreword
Preface
Acknowledgments
Contents
Contributors
Part I: Preoperative
	1: The First Encounter
		Introduction
		Prior to the Encounter
		The Initial Encounter
			A Formal Introduction
			The Physical Examination
			Conveying Pathology Results
		The Team and Teaching
			The Team’s Role
			Educational and Informational Resources for Patients
			Support Groups and Personal Resources
		Counseling and Consent
		Difficulties at the First Encounter
			Physical, Psychological, or Language Barriers
			The Internet: A Double-Edged Sword
			Navigating a Litany “To Dos”
			Difficult Questions Posed to You
			Preemptive Discussion of Potential Complications
		The Patient’s Family
		Communicating with Other Physicians
		Conclusion
		Summary Pearls
		References
	2: Perioperative Risk Assessment
		Introduction
		Risk Stratification
			Assessing a Procedure-Specific Risk
			Assessing an Anesthesia-Specific Risk
			Assessing a Patient-Specific Risk
				The Healthy Patient
					Age
					Exercise Tolerance
					Social Habits
					Medications
					Anesthetic Issues
						Preoperative Testing
				The Comorbid Patient
					Consultation
		Cardiovascular Risk Assessment and Risk Reduction
		Pulmonary Risk Assessment and Risk Reduction
		Chronic Renal Failure Risk Assessment and Risk Reduction
		Diabetes Mellitus Risk Assessment and Risk Reduction
		Hepatic Failure Risk Assessment and Risk Reduction
		Surgical Site Infection (SSI) Risk Assessment and Reduction
		Anastomotic Leak: Risk Assessment and Risk Reduction
			Risk Evaluation and Informed Consent
		Summary Pearls
		References
	3: Perioperative Nutrition Support in Colorectal Surgery
		Introduction
		Prevalence and Impact of Malnutrition
		Patient Assessment
			Albumin
			Nitrogen Balance
			Cancer Cachexia
		Initiation of Nutritional Support
		Nutritional Options: Enteral and Parenteral
		Enteral Feeding
		Early Enteral Feeding Versus NPO
		Enteral Shortcomings
			Aspiration
			Feeding Tolerance
		Enteral Complications
		Total Parenteral Nutrition
			Complications
				Catheter
				Metabolic
		How to Write TPN
			Enteral Versus Parenteral
		Perioperative Management
			Immunonutrition
			Total Parenteral Nutrition
		Postoperative Management
		Summary/Pearls
		References
Part II: The Abdomen
	4: Diverticulitis: Beyond the Basics
		Introduction
		Indications for Surgery
		Indications for Surgery: Uncomplicated Diverticulitis
			Risk of Subsequent Attacks of Diverticulitis After Recovery from Uncomplicated Diverticulitis
			Risk of Developing Complicated Diverticulitis After Recovery from an Attack of Uncomplicated Diverticulitis
			Risk of Developing Free Perforation/Risk of Requiring Emergency Surgery and Stoma After Recovery from an Episode of Uncomplicated Diverticulitis
			Smoldering Versus Discrete Attacks of Diverticulitis
			Severity of Disease and Indications for Surgery
			Other Considerations in Recommending Resection
			Risk of Recurrent Diverticulitis After Resection
			Young Patients and Diverticulitis
			Laparoscopy and Indications for Surgery
			Nonoperative Management and Non-resective Treatment
			My Recommendations for Elective Resection in the Setting of Uncomplicated Disease
		Complicated Diverticulitis
			Diverticular Fistulas
			Diverticular Stricture
			Diverticular Abscess
			Perforated Diverticulitis with Purulent or Feculent Peritonitis
			Reoperative Surgery for Diverticular Disease
				Reoperative Surgery After Hartmann Resection
					Timing
					Preoperative Preparation
					Preoperative Imaging
					Intraoperative Considerations
						Patient Positioning
						Approach to the Procedure
						Exposure and Lighting
						Initial Dissection
						Identification and Mobilization of the Hartmann Pouch
						Performing the Anastomosis
						Alternatives
						Abdominal Wall Closure
				Reoperation for Sepsis and Anastomotic Complications After Hartmann Takedown
				Reoperation for Recurrent Diverticulitis
		Conclusion
		Summary Pearls
		References
	5: Carcinomatosis: Cytoreduction and Heated Intraperitoneal Chemotherapy (HIPEC) Versus Palliation
		Background, Basics, and Rationale
			General Aspects, Epidemiology
			Change of Paradigm
			Anatomy and Embryology
			Classification and Types of Growth of PC
			History and Rationale for Intraperitoneal Drug Therapy
			Peritoneal Cancer Index (PCI)
			Residual Tumor Classification (Completeness of Cytoreduction, CC Score)
			HIPEC: Technique, Rationale, and Drugs
			Multimodal Therapy in Peritoneal Carcinomatosis
			Second Look Concept
		Decision Making/Preoperative Work-up
			Indications and Interdisciplinary Tumor Board
			Contraindications
			Quantitative Prognostic Factors (QPIs)
			Ethical Considerations
		Intraoperative Work-up
			Cytoreductive Surgery: Logistics, Strategy, and Technique
				Oncological Planning
				Technical Planning
				Surgical Planning
					Type of Disease
					Extent and Location of Disease
					Approach to “Critical Lesions”
					Abdominal Wall Assessment
					Approach to Liver Metastasis
				HIPEC Planning
				Anesthesia Planning
				Nutritional Planning
				Stoma Planning
				Perioperative Antibiotic Prophylaxis
				Venous Thromboembolism Prophylaxis
				Mechanical Bowel Preparation
				Skin Preparation
				Operating Room
				Induction of Anesthesia and Monitoring
				Surgical Technique
				Perioperative Chemotherapy
				Early Postoperative Intraperitoneal Chemotherapy (EPIC)
			Complete CRS Not Achievable: What Now?
		Postoperative Considerations
			Morbidity and Mortality
				Complication Management and Patient Follow-Up
		Pearls and Practical Tips in Peritoneal Cytoreductive Surgery
		References
	6: Metastatic Colorectal Cancer
		Introduction
		Multidisciplinary Approach
		Evolution of Care
		Indications for Operation
			Should I Biopsy the Metastasis?
			What Should I Do with the Primary Lesion in the Patient with Extensive Disease?
			What Treatment Modality Should Come First?
			The Obstructed Patient: What Now?
		Specific Sites of Disease
			Liver
			Lung
			Peritoneal Metastases
			Ovary
			Brain
		Controversial Points
		The Patient with a “Near Obstruction”
		Role of Radiation for Rectal Cancer in Patients with Stage 4 Disease
		Technical Pearls
			Salvage Operation
		Palliative Care
		Summary Pearls
		References
	7: Enterocutaneous Fistulas
		Initial Evaluation
			Controlling Sepsis
			Managing Patient Expectations and the Importance of “Patience”
		Evaluation of the Fistula
			Defining the Anatomy
			Nutritional Support
			Postoperative Nutrition
		Rehabilitation Phase
			How to Control Fistula Output and Role of Adjunctive Medications
			Creative Ways for Wound Care
			Dealing with Medications for Underlying Disease
		Surgical Evaluation
			Spontaneous Closure or Not?
			Timing of Operation
			Reviewing the Prior Operative Notes: Does It Help?
		Techniques
			Preoperative Preparation
			Surgical Approach
			Abdominal Wall Reconstruction
			Dealing with a Stoma
		Follow-up
			Postoperative Management
			Management of Postoperative Complications
				Wound Infection
				Bleeding
				Anastomotic Leakage and Recurrent Enterocutaneous Fistula
			Who to Operate on?
		Summary Pearls
		References
	8: Enteroatmospheric Fistula
		Introduction
		History: The Evolving Concept of EAF
		Clinical Presentation and Defining Goals
		Prevention
			Problem: The Fascia Won’t Close Initially, Now What?
				An Ounce of Prevention
			Problem: So You Have an EAF (The Early Phase)
				Diagnosis
				Superficial vs. Deep
				Control of Sepsis and Resuscitation
				Early Nutrition
				Effluent Control and Skin Protection
				Intermediate Phase
				Defining Anatomy
				Nutrition
				Effluent Control and Skin Protection
				Pharmacologic Therapy
				Psychiatric Implications of EAF
				Late/Chronic Phase
				Timing of Surgery
				Optimization: Preparation for Surgery
				Staged vs. Non-staged Approaches
				Abdominal Wall Reconstruction (AWR)
				Biologic or Synthetic Mesh
		Summary Pearls
		References
	9: Technical Tips for Difficult Stomas
		Introduction
		Preoperative Assessment
		Prevention of Parastomal Hernias
		End Ostomy Creation
		Loop Ileostomy Creation
		End-Loop Stomas
		Laparoscopic Ostomy Creation
		The Obese Patient
		The Difficult Colostomy
		The Distended Colon
		The Difficult Ileostomy
		The Compromised Stoma
		Summary Pearls
		References
	10: Continent Ileostomy
		The Continent Ileostomy: Complications, Their Management, and Its Place in the Future
			The Kock Pouch
				Formation of the Ileal Pouch
				Formation of the Nipple Valve
		Complications and Their Management
			Early Complications
			Late Complications
			Management of Complications
				Early Complications
				Late Complications
					Sliding of the Nipple Valve and Its Correction
					Prolapse of Nipple Valve
					Parastomal Hernia
					Fistula Through the Nipple Valve
					Miscellaneous
					Recurrent Nipple Valve Complications
					Ileitis (Pouchitis)
					Epithelial Dysplasia and Cancer Risk
		Ileal Pouch Adenomas in Patients Operated for with Familial Adenomatous Polyposis (FAP)
			Pouch Removal
				Criteria of Selection
		Concluding Remarks
			The Continent Ileostomy: Its Place in the Future
		Summary Pearls
		References
Part III: The Pelvis
	11: Rectal Prolapse: Current Evaluation, Management, and Treatment of a Historically Recurring Disorder
		Etiology and Epidemiology of Prolapse
		Diagnosis and Evaluation
		Types of Operative Repair
			Perineal Operations
			Abdominal Operations
			Laparoscopy and Rectal Prolapse Repair
		Recurrence After Initial Repair
			Recurrence After Altemeier Procedure
			Recurrence After Abdominal Approach
		Types of Operations for Recurrence
		Our Treatment Preferences for Rectal Prolapse
			Initial Rectal Prolapse
			Perineal Proctosigmoidectomy
			Incarcerated Rectal Prolapse
			Concomitant Pelvic Prolapse
			Recurrent Rectal Prolapse
		Summary Pearls
		References
	12: Obstructive Defecation
		Evaluation
			History
			Physical Examination
			Endoscopy
			Adjunctive Tests
				Colonic Transit Study
				Balloon Expulsion
				Anorectal Manometry
				Electromyography (EMG)
			Imaging
				Defecography
				Perineal Ultrasound
		Our Recommendations
		Etiology and Treatment Options
			Non-relaxing Puborectalis
			Failure of Initial Management/Surgical Options
		Our Recommendations
		Rectoceles
			Surgical Indications
		Our Recommendations
		Internal Intussusception
			Surgical Treatment
		Our Recommendations
		Enterocele
			Surgical Treatment
		Our Recommendations
		Sigmoidocele
		Solitary Rectal Ulcer Syndrome (SRUS)
		Our Recommendations
		Persistent Symptoms
		Sacral Nerve Stimulation
		Summary Pearls
		References
	13: Fecal Incontinence
		Evaluation
			History
			Physical Examination
			Testing
		Treatment Options
			Conservative Management
			Other Therapies
				Physical Retraining (Biofeedback)
				Anal Plug
				Radiofrequency Energy (RFE)
				Injectables
				Sphincter Repair
				Artificial Bowel Sphincter
				Sacral Nerve Stimulation (SNS)
		Controversies in Fecal Incontinence Management
			Does Age Influence Choice of Treatment?
			Repeat Overlapping Sphincter Repair
			Managing Expectations of Outcome
			What Findings on Testing Influence Certain Choices?
			Is a Stoma Ever the Best Option?
			Defects in the Internal Sphincter Only or Other Types of Lateral Sphincter Defects
			How to Manage Concomitant Pelvic Floor Disorders (i.e., Rectal Prolapse, Rectocele) if Repairing the Sphincter
		Future Treatments
			Magnetic Ring
			Anal Sling
			Posterior Tibial Stimulation
		Summary Pearls
		References
	14: Local Treatment of Rectal Cancer (TEM Versus TAMIS Versus Transanal Excision)
		Introduction
		Patient Selection
		Staging the Lesion
		Why Do Lesions Recur After Local Excision?
			Location
			Impact of Lymph Nodes
			So Whom Should You Select for a Transanal Approach (for Cure)?
		Operative Approaches
			“Traditional” Local Excision
			Minimally Invasive Options
				Transanal Endoscopic Microsurgery (TEM)
				Transanal Minimally Invasive Surgery (TAMIS)
		The Role of Radiation Therapy
		Summary Pearls
		Take-Home Points
		References
	15: Recurrent Rectal Cancer
		Introduction
		Presentation
		Preoperative Evaluation and Staging
			Preoperative Planning
			Physical Examination
			Carcinoembryonic Antigen
			Radiologic Imaging
				Local Disease
					Computed Tomography (CT)
					Magnetic Resonance Imaging (MRI)
					FDG-PET
					Distant Disease
				Imaging Summary Recommendations
			Histology
			Classification and Patterns of Recurrence
			Defining Resectability
		Multimodal Therapy
			Role of Neoadjuvant Therapy
			Intraoperative Radiation Therapy (IORT)
			Surgical Technique
				Preoperative Regimen
				Rectal Washout
				Resection
				Types of Procedures
				Sacral Resections
				Pelvic Floor Reconstruction
				Postoperative Complications
					Stoma
		Oncologic Outcomes of Multimodal Therapy
		Palliative Management
			Radiation
			Self-expanding Metallic Stents (SEMS)
				Surgery: Fecal Diversion vs. Palliative Resection
		Multidisciplinary Approach
		Centers of Excellence
		Summary Pearls
		References
	16: The Approach to the Rectal Cancer Patient with a Suspected Complete Clinical Response: Selection of Patients to the Watch and Wait Strategy
		Introduction
		Indications for Neoadjuvant Therapy
		Types of Neoadjuvant Therapy
		Assessing Tumor Response: Why?
		Assessing Tumor Response: When and How?
		Local Excision of the Tumor Site
			Radiological Imaging
		Carcinoembryonic Antigen (CEA)
		Summary Pearls: Final Decision Management
			Additional Therapy
		References
	17: Ileal Pouch Complications
		Introduction
		Factors Associated with Pouch Failure
		Pelvis Sepsis
		Evaluation of Pouch Dysfunction
			Gastrografin Enema
			MRI Pelvis
			CT Enterography
			Tests of Anorectal Physiology
		Surgical Decision-Making
		Intraoperative Challenges During Ileoanal Pouch Creation and Anastomosis
			Problems with Reach of the Pouch
			Ischemia of the Pouch
			Problems with Stoma Creation
			Problems with the Anastomosis and Stapler Misfire
		Management of Surgical Complications Related to the Pouch
			Early Complications
				Anastomotic Disruption and Pelvic Abscess
				Postoperative Bleeding from the Pouch
			Late Complications
				Pouch-Vaginal Fistula (PVF)
					Investigations
					Treatment Options for PVF
						Local Procedures
							Advancement Flap Repair
							Fibrin Glue, Fistula Plug, Biologic Mesh Repair, and Gracilis Muscle Interposition
							Failure of Flap Repair
							Perineal Pouch Advancement
							Redo IPAA
							Loop Ileostomy
				Pouch-Perineal Fistula (PPF)
				Pouch Sinus
		Crohn’s Disease of the Pouch
		Incontinence
		Outlet Dysfunction
		Pouchitis and Cuffitis
		Pouch Prolapse
		Leak from the Tip of the “J”
		J-Pouch to K-Pouch (Continent Ileostomy) Conversion
		Pouch Failure: Permanent Diversion with Pouch In Situ or Pouch Excision?
		Cancer of the Pouch
		Redo Pouch Surgery
			Operative Technique
		Summary Pearls
		References
	18: The Failed Anastomosis
		The Healing Anastomosis
		The Anatomical Perspective
			Mucosa
			Submucosa
			Muscularis Propria
			Serosa
		The Physiologic Perspective
			Inflammatory Phase
			Proliferative Phase
			Remodeling
		Failed Anastomotic Healing
			Tissue Perfusion
				Macrovascular Anatomy
					Griffiths’ Point
					Sudeck’s Point
					Rectal Stump
				Microvascular Anatomy
					Arterial Oxygen Tension
			Summary Pearl
		Risk Factors
			Patient-Related
			Poor Nutritional Status
			Immunosuppression
				Steroids
				Infliximab, AZA, 6-MP
			Crohn’s Disease
			Radiation
		Diverticulitis and Emergency Surgery
			Peritonitis
			“Loaded Colon”
			Hemodynamic Instability
			Location
		Obesity and Male Gender
		Operative Risk Factors
			Blood Loss, Transfusions, and Operative Time
			Intraoperative Complications
			Total Mesorectal Excision (TME)
			Tension and Splenic Flexure Mobilization
			Drains
			Laparoscopy
			Omental Wrapping
			Simultaneous Liver Resection
		Proximal Diversion
		Mechanical Bowel Preparation (MBP)
		Prevention
			Intraoperative Anastomotic Assessment
			Laser Fluorescence Angiography
			Intraoperative Air Leak Test
			Intraoperative Endoscopic Assessment
			Intraoperative Dye Test
			Intraluminal Devices
				Transanal Decompression Devices
				Intraluminal Barriers
				Compression Anastomosis
			Extraluminal Devices
		Managing the Failed Anastomosis
			Anastomotic Leaks
				Clinical Manifestations
				Making a Timely Diagnosis
		Determining the Appropriate Intervention
			Identification and Location
			Symptomatic Versus Asymptomatic
				Postoperative Sepsis
				Presence of Diverting Ostomy
				Diversion, Resection, and Revision
		Suture Repair
		Management Unique to the Crohn’s Patient
		Management After the Acute Setting
			Endoscopic Vacuum-Assisted Closure (Endoluminal VAC) or Endo-Sponge™
			Fibrin Glue
			Covered Stents
			Transanal Repair
			Redo Surgery
		Anastomotic Stenosis
		Pathophysiology
			Symptoms and Clinical Course
			Treatment
				Balloon Dilation
				Stents
				Complete Obstruction
				Surgical Revision
		Anastomotic Stenosis Summary
		References
	19: Pelvic Bleeding
		Introduction
		Risk Factors for Major Bleeding
		Prevention
		Controlling Bleeding
		Summary Pearls
		References
Part IV: Anorectal Disease
	20: Hemorrhoidal Disease: Postoperative Complications
		The Hemorrhoidal Consult
			Dietary and Bowel Habits
			Colonoscopy
			Antiplatelet Agents and Anticoagulants
			“Every pain in the bottom is not a hemorrhoid” – How to deal with patients and referring providers when this is not hemorrhoids and they are convinced it is
		Lifestyle Modification
			Surgical Decision-Making: How to Decide on What Surgery to Do (Open, Closed, Energy, PPH, THD)
			Transanal Hemorrhoidal Dearterialization (THD)
			Hemorrhoidal Crisis: What Do You Decide to Do at the Time?
		Postoperative Regimen
			Bowel Management and Avoiding Constipation
			Pain Control with Narcotics, NSAIDS
			Sitz Baths: Do They Work?
			Preoperative Counseling and Postoperative Instructions
				Banding
				Stapled Hemorrhoidopexy
				Excisional Hemorrhoidectomy
		Complications of Hemorrhoidectomy: What Are They, How Often Do They Occur, and How to Approach and Manage Them?
			Urinary Retention
			Hemorrhage
				Whitehead Deformity
			Fecal Incontinence
			Anal Stricture
			Chronic Open Wounds
			Wet Anus and Pruritus Ani
			Chronic Pain
			Skin Tags (They Want It Flat!)
			Recurrent Hemorrhoids
		Banding Complications
			Pain
			Bleeding
			Vasovagal Symptoms and Syncope
			Sepsis
			Recurrence
		Stapled Hemorrhoidopexy (PPH)
			Indications: When Should We Be Using This Procedure?
			Chronic Pain
			Recurrence
			Sphincter Damage
			Too Low Stapler Placement: Post-PPH Syndrome
			Bleeding
		Preventing Complications
			Technical Tips: Excisional Hemorrhoidectomy
			Patient Selection
			Fluid Restriction (Urinary Retention)
		Summary Pearls
		References
	21: Fistula-in-Ano
		Background
		Pathophysiology
		Evaluation and Workup
			History
			Physical Examination
			Imaging Studies
				Fistulography
				CT Scan
				Endoanal Ultrasound
				MRI
		Treatment
			General Principles
			Operative Management
				Lay-Open Technique (Fistulotomy)
				Setons
				Anorectal Advancement Flap
				Fibrin Glue
				Anal Fistula Plug
				LIFT Procedure
				Fistulectomy
				Dermal Flaps
			Results
				My Approach
			Complications
				Incontinence
		Recurrence
			Special Considerations
				Extrasphincteric Fistula
				Crohn’s Disease
				Fistula-in-Ano in the HIV-Positive Patient
		Rectourethral Fistulas
		Summary Pearls
		References
	22: Anal Intraepithelial Neoplasia (AIN)/High-Grade Squamous Intraepithelial Lesion (HSIL)
		Introduction and Controversy
		Defining AIN/HSIL
		Lack of Adoption
		HSIL and Anal Cancer: The Problem
		Treatment
			High-Resolution Anoscopy (HRA): Initial Examination and Technique
			Dealing with Recurrence
			Coding
			Follow-Up
			Topical Agents
			Infrared Coagulation
			Vaccination
			Special Situations: The HIV (+) Patient
			Anal Cytology and Screening/ Surveillance Intervals
		Final Thoughts
		Summary Pearls
		References
	23: Chronic Anal Pain
		Introduction
		Acute Anal Pain
			Thrombosed External Hemorrhoid (Fig.  23.1)
			Anal Fissure (Fig.  23.3)
			Anorectal Abscess/Fistula (Fig.  23.4)
		Acute or Chronic Anal Pain
			Anal Crohn’s Disease (Fissures, Fistulae) (Fig.  23.5)
			Hidradenitis Suppurativa (Fig.  23.6)
			Pruritus Ani (Fig.  23.7)
			Retrorectal Tumors
			Bicycle Seat Issues
			Prostatitis
			Constipation
			Gynecological Sources
			Proctitis/Pouchitis
				Radiation
			Anorectal Stricture
			Anal Cancer
			Foreign Bodies
			Rectal Prolapse
			Neurogenic Pain
			Infectious Causes of Anal Pain (Table  23.2)
				Gonorrhea
				Herpes Simplex, Genitalis, and Zoster
				Syphilis
				H . ducreyi (Chancroid)
				Chlamydia (LGV)
			Chronic Anal Pain
				Levator Spasm
					Epidemiology
					Management
				Coccygodynia
				Pudendal Neuralgia
		Summary Pearls
		References
	24: Complex Pilonidal Disease and Acute and Chronic Perineal Wounds: Point – Counterpoint
		Surgical Management of Complex or Recurrent Pilonidal Sinus
			Pilonidal Cystectomy Combined with Fasciocutaneous Advancement Flap
				My Approach (Dr. Orangio)
					A Case of Recurring Draining Sinuses
			Healing by Secondary Intention (Dr. Abcarian)
				My Approach (Dr. Abcarian)
			Point: Counterpoint
				Dr. Abcarian and Dr. Orangio
		Management of the Perineal Wound
			Disease Process
				Low Rectal Cancer and Anal Canal Cancer
				Inflammatory Bowel Disease (IBD)
		Management of the Nonhealing Chronic Perineal Wounds
			Disease Process
			Nonoperative Treatment
			Operative Management
		Summary Pearls
		References
Part V: Special Situations
	25: Considerations in the Elderly
		Introduction
		Evaluation for Surgery: Determination of Cardiovascular and Physiologic Risk Stratification
			Preoperative Risk Assessment
				Pulmonary Disease
				Diabetes Mellitus
				Renal Failure
				Hematologic Disorders
		Anorectal Problems
			Fecal Incontinence (FI)
			Rectal Prolapse
				Sacral Nerve Stimulation (SNS)
		Abdominal Problems
			Diverticulitis
			Proctectomy for Malignancy
				Volvulus
			Colonic Pseudo-obstruction (Ogilvie’s Syndrome)
		Psychosocial Aspects
		Controversies in Surgery in the Elderly
		Laparoscopic Surgery in the Elderly
		Summary Pearls
		References
	26: The Morbidly Obese Patient
		Introduction
		Defining Obesity and Limitations of BMI
		Abdominal Obesity: Not All Obesity Is the Same
		Preoperative Evaluation
			Systems-Based Evaluation and Prevention Tips
		Laparoscopic Colectomy in the Obese Patient
			Lesion Localization
			The Value of Your Assistant
			Patient Setup, Port Placement, and Exposure
			Dissection Techniques
			Specimen Extraction and Ideal Wound Placement
		The Role of Hand-Assisted Laparoscopic Colectomy in the Obese Patient
		Technical Considerations
			Pelvic Dissection
			Ileal Pouch-Anal Anastomosis (IPAA) in the Obese Patient
			Rectal Cancer in the Obese Patient
			Anorectal Surgery in the Obese Patient
			Anorectal Fistulas
			Sphincteroplasty
			Hemorrhoidectomy
		Summary Pearls
		References
	27: The Pediatric Patient
		Introduction
		Anorectal Disease
			Perianal Abscess and Fistula-in-Ano
			Hemorrhoids
			Anal Fissure
			Rectal Prolapse
		Constipation
			Evaluation
			Treatment
			Surgery: Sphincter Procedures, Antegrade Continence Enema, and Stoma
		Incontinence
			Functional Retentive Overflow Incontinence
			Functional Non-retentive Fecal Soiling
			Anorectal Malformations
			Spinal Pathology
			Sphincter Damage
		Inflammatory Bowel Disease (IBD)
			Anorectal Crohn’s Disease
			Crohn’s Colitis
			Ileocolic Crohn’s Disease
			Chronic Ulcerative Colitis
			Ulcerative Colitis Emergencies
		Polyposis Syndromes
		Summary Pearls
			Examination
			Preoperatively and Intraoperatively
			Postoperatively
		Conclusion
		References
	28: Functional Problems Following Colorectal Surgery
		Introduction
		Scope of the Problem
			Colectomy
			Proctectomy
				Rectal Cancer
				Ulcerative Colitis and Familial Cancer Syndromes
				Anorectal Procedures
				Prolapse Surgery
		Management
			Diarrhea
			Fecal Incontinence
			Constipation/Obstructed Defecation
		Summary Pearls
		References
	29: Short Bowel Syndrome
		Introduction
		Pathophysiology
			Small Intestinal Resection
			Loss of the Ileocecal Valve
			Loss of the Colon
		Etiology-Specific Considerations
			Crohn’s Disease
			Mesenteric Ischemia
			Radiation Enteritis
		Clinical Manifestations
		Diagnosis and Assessment
		Medical Management
			Parenteral Nutrition
				Complications Associated with Long-Term Parenteral Nutrition
			Enteral Nutrition and Oral Diet
			Pharmacologic Agents
			Growth Factors
		Surgical Management
			Restoration of Intestinal Continuity
			Procedures to Slow Intestinal Transit
			Procedures to Lengthen Residual Bowel
			Other Non-transplant Procedures
			Small Bowel Transplantation
		Future Directions
		Outcomes
		Summary Pearls
		References
	30: The Intraoperative Consult
		Initial Mindset
		Initial Evaluation
			Positioning
			Initial Survey
			Examination
			Exposure/Operative Procedure
		Common Intraoperative Consults
			Extensive Adhesions
			Injury to Large or Small Bowel
			Injury to Rectum
			Mass
			Colonic Inflammation
			Cancer and Polyps
			Endometriosis
			Meckel’s Diverticulum
			Presacral Bleeding
			Ischemic Bowel
			Vaginal Delivery Complications
			Endoscopic Complications
			Patients with Inflammatory Bowel Disease
		Intraoperative Conditions
			Laparoscopic Approach Desired
			Not Marked for a Stoma
		Damage Control: How Do You Bail?
		Communication with Family
		Legal Issues and Documentation
		Summary Pearls
		References
	31: Laparoscopic Complications
		Introduction
		Tips to Avoiding Complications at the Beginning
			Positioning
			Dealing with the Small Bowel
			Trocar- and Instrument-Related Injuries
		Unique Complications: Right Colectomy
			Exposure
			Identifying the Correct Dissection Plane
			Identifying/Handling the Duodenum
			Major Vascular Pedicle Ligation
			The Right Ureter
		Unique Complication: Sigmoidectomy
			Exposure/Mobilization of the Left Kidney
				Identifying the Ureter
				Splenic Flexure
		Redo Operation and Conversion
		Summary Pearls
		References
	32: Laparoscopy, Robotics, and Endoscopy
		Laparoscopy: Introducing Technology in Colorectal Surgery
			Hand-Assisted Laparoscopic Surgery (HALS)
		Future Direction: Robotic Technology
		Single-Incision Laparoscopy Surgery
		Evolving Endoscopic Techniques
			Endoscopic Mucosal Resection (EMR)
			Endoscopic Submucosal Dissection (ESD)
			Combining Laparoscopy and Endoscopy
		The Cost of New Technology
		Summary Pearls, Patient Selection, and Personal Preferences
		Conclusion
		References
	33: Technical Aspects
		Introduction
		Intestinal Anastomosis
			Stapled Versus Hand Sewn and Single Versus Double Layer
			Right-Sided and Small Bowel Resections
			Left-Sided and Rectal Resection
			The Mechanical Stapler
			The Anastomotic Donut and Leak Testing
			Gaining Enough Length
			Size Mismatch
		Miscellaneous Technical Challenges
			Difficult Crohn’s Disease Mesentery
		Laparoscopy
			Serosal and Thermal Injuries
			The Misplaced Needle
			Colon and Rectal Injuries
		Summary Pearls
		References
	34: Colon and Rectal Trauma
		Historical Aspects of Colon and Rectal Trauma
		Colon Trauma
			“Catatonia” and Early Decision Making
			In the Operating Room
			Prepped Versus Unprepped Bowel
			Timing of Injury and Operative Decisions
			Operative Management: Repair, Resect, or Divert?
			Level 1 and Prospective Evidence in Colorectal Trauma
		Rectal Trauma
			Anatomy Is Destiny
			Diagnosis
			Management Options: Intraperitoneal Rectum
			Management Options: Extraperitoneal Rectum
			Combined Anorectal Injuries
			The Massive Perineal Wound
			Complications
			Outcomes
		Damage Control Laparotomy
		The Postoperative Checklist
		Colonoscopic Trauma
		Rectal Foreign Bodies
			Overview
			Clinical Presentation and Diagnosis
			Treatment
			Special Considerations
				Sharp Versus Blunt Objects
				Body Packing
		Summary Pearls
		References
	35: When Vascular Surgery Calls
		Background
		The Physiology of Aortic Reconstruction
			Open Aortic Surgery
			Endovascular Aortic Surgery
			Colon Ischemia After Aortic-Based Surgery
			Simultaneous Colon Mass and AAA
			SMV or Portal Vein Thrombosis After Total Abdominal Colectomy (Laparoscopic or Open)
			The Patient with Colorectal Cancer and Peripheral Vascular Disease
			Prevention of Venous Thromboembolism
			Intraoperative Iliac Vein Injuries
		Summary Pearls
		References
Part VI: Beyond the Operating Room
	36: Facing Our Failures
		Facing Our Failures
		Historical Context: Professionalism and Accountability
			Antiquity Through the Middle Ages
			Middle Nineteenth Century
			Late Nineteenth Century
			Early Twentieth Century
			Middle Twentieth Century
		Assessing Safety and Quality: Highlights
			Public Perception and Influence
			VA-NSQIP
			Institute of Medicine Report
			ACS-NSQIP
			Role of M&M Conferences
			Terminology
		Understanding the Impact of Failure
			Psychological Impact
			Stress and Health
			Fallibility, Vulnerability, and Transparency
		Failures, Organizational Culture, and Accountability
			Response to Systems Errors
			Just Culture
			Core Competencies
			Safety and Teamwork
			Individual Accountability
		Recommendations When Failure Occurs
			Immediate Steps
			Long-Term Recommendations
		Summary Pearls
		References
	37: Teaching and Training for Laparoscopic Colorectal Resection
		Introduction
		Barriers
		Who to Teach, and Why?
			Colorectal Residents (Fellows)
			General Surgery Residents
			Attending Surgeons
		Effective Training Methods
			Introduction
			Preoperative Preparation
			Intraoperative Training
			Assessment
			Laparoscopic Courses, Training Attending Surgeons
		Summary Pearls
		References
	38: The Surgeon Investigator: Balancing Research and Clinical Practice
		Introduction
		Getting Started
			Training
		Negotiation
		Managing Expectations
		How to Establish a Research Career While Starting Your Practice
			Transitioning to Independence
		Mentorship
			Setting Priorities and Managing Your Time
			Publishing
		Obtaining Funding
		Summary Pearls
		References
	39: Medicolegal and Ethical Dilemmas
		Introduction
		Malpractice
			Common Malpractice Claims
			Informed Consent
		Ethics
			Treating Yourself, a Family Member, or Friend
			Refusing Treatment
		Advanced Directives
		Conflicts of Interest (COI)
		Summary Pearls
		References
	40: Economic Issues Impacting Surgical Care Delivery
		Introduction
		Diagnosis-Related Groups (DRGs)
		Impact of Bundled Care and Episode of Care Methodologies
		A Concept of Warranty Cost
		Summary Pearls
		References
	41: Defining Competence and the Role of the Board
		Summary Pearls
		References
	42: Knowing When to Say “When”
		Introduction
		Soft Factors
		Hard Factors
			Age as a Factor
			Other External Forces
			Competency
			Technical Skills
		Transition
		Preparation
		The End Game
		References
Index