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ABDOMINO-ANAL RESECTION OF THE RECTUM WITH SPHINCTER PRESERVATION (Pull-through operation)


By • Дек 19th, 2010 • Category: Rectum

In this operation, the rectosigmoid (freed from the abdominal side) is drawn to the perineum through the perviously enlarged anal orifice. This operation, which is also referred to as Babcock’s operation, is indicated when the tumour is located 6—12 cm from the anal verge.

In this operation the bowel lumen in the abdominal cavity is not opened. A disadvantage of this technique is the frequently observed (in 10—20 per cent of cases) ne» crosis of the distal bowel which may lead to stricture or even to peritonitis.

Prior to the operation both urethers are catheterized, and an indwelling catheter is passed into the bladder.

The patient lies in the supine position (see Fig. 155.1) and endotracheal ether-oxygen or azeotropic mixture anesthesia is used.

Abdominal Phase. The abdominal cavity is opened by a median incision and explored to determine the tumour spread and presence of metastases.

The patient is then changed to a 12° Trendelenburg tilt, the small guts are shifted to the upper half of the abdominal cavity and held there by moist gauze squares.

With the assistant drawing the sigmoid colon to the-right, the surgeon cuts the peritoneum of mesosigmoid and of the left half of the pelvic floor with long scis­sors (see Fig. 155.4).

A gauze swab and, partly, scissors are then used to mover the fatty tissue to the midline to cisualize the let ureter, which is drawn to the left by a retractor (Fig. 164.1).

The surgeon now pulls the sigmoid to the left and> dissects the peritoneum of mesosigmoid and of the right half of the pelvic floor (see Fig. 155.5).

Next, the bowel is ligated with a tape above the tu–mour through the mesenteric window (Fig. 164,2).

This step is followed by ligation of the arteries supp­lying the rectosigmoid. This very important step invol­ves identification of the left mesenteric artery and its branches in the proximal angle of the left peritoneal in­cision 4—5 cm above the promontory. We prefer to use a transilluminator for this purpose. The procedure is as follows. The proximal portion of mesosigmoid is pulled on the glowing blad1 of the transilluminator, the opera­ting room is blacked out, and the surgeon exposes and1 divides, between two ligatures, the inferior mesenteric ar­tery and vein immediately distal to the branching — off of the left colic artery (Fig.164.3), which is to be preser­ved in any case. In these conditions, blood supply to the bowel to be pulled through is carried out by the margi­nal sigmoid artery communicating with the left colic ar­tery (Fig. 164.4). Not infrequently, the marginal artery is supplemented by the descending branch of the supe­rior mesenteric artery (shown by a double arrow in Fig. 164,4).

Following ligation of the vessels, the surgeon lifts the mesosigmoid base over the sacral promontory, incises with scissors the thin fascial plate found here, and in­troduces a long abdominal retractor into the retrorectal space through the space thus formed (see Fig. 155.9).

The posterior surface of the rectum is next separated from the sacrum under visual control as far as the coc­cyx level (Fig. 164.5), surgeon’s hand is introduced into the retrorectal space (Fig. 164.6), and the entire posterior semicircumference of the rectum is dissected bluntly by fingers as far as the coccyx top below and almost to the lateral ligaments on either side.

The lateral ligaments are carefully cut with scissors both on the right and on the left (Fig. 164.7), so that the surgeon’s fingers could freely pass along the entire late­ral surface of the pelvis as far as the pelvic diaphragm. Unless the anterolateral rectal ligaments are sectioned the pull through operation is impossible to perform from the abdominal side.

The next step involves liberation of the anterior as­pect of the rectum. To do this, the surgeon first injects 40—50 ml of 0.5 per cent novocain solution between the bladder and rectum (Fig. 164.8), followed by deep sepa­ration, with scissors and swab, of the rectum (already partially peeled off by the novocain solution) from the bladder and seminal vesicles (from uterus and vagina in females).

Bleeding is controlled by inserting a gauze strip into the space thus formed. It should be remembered that the more carefully the rectum is freed in the pelvis during-this phase, the easier it will be to perform the perineal phase.

After freeing the rectum in the pelvis, the surgeon spreads the mesosigmoid on a gauze square and defines the boundary of preserved circulation. This is done through a meticulous examination, by the surgeon and his assistant, of the bowel surface for pulsation of small arteries.

The border between the viable bowel and that devoid of blood supply is marked by two black silk liga­tures applied to the serosa.

Should there be the slightest doubt as to whether this border has been defined correctly, use must be made of an electric thermometer whose sensitive end is buried in the mesosigmoid near the bowel wall. That place where the temperature is reduced by 0.2—0.3° С or more will be the limit of disturbed circulation.

Having applied the marker ligature, the surgeon pro­ceeds to dissect the mesosigmoid between clamps (Fig. 164,9) as far as the sigmoid wall where the liga­tures are located.

Now the surgeon has to ascertain whether the remain-» ing length of viable sigmoid colon will be sufficient to be pulled through to the pelvis as far as the anal orifice level without tension. To do this, the surgeon grasps the sigmoid at the marker ligatures with the thumb and in­dex fingers of his right hand, lifts it over the wound,-and stretches it over a sterile towel below the right in­guinal ligament up the centre of the Scarpa’s triangle, with the surgeon’s left hand helping in this maneuver by holding the sigmoid at its base (Fig. 164.10).

If the viable bowel reaches by its marker ligatures the middle of the Scarpa’s triangle without being stret­ched, the pull-through operation is feasible.

The successful pull through of the sigmoid is made easier by preliminary division of both sigmoid arteries and incision of the parietal peritoneum along the exter­nal margin of the descending colon.

It is our opinion that during this maneuver the left colic artery must not be severed, and I deem it necessary to emphasize once more that in this pull-through opera­tion no traction should be applied to the bowel. Should there be the slightest doubt as to the blood supply to the bowel being pulled through or even light traction has to be applied to it, the sigmoid pull-through operation must be abandoned, and either the Quenu-Miles operation or else the pull-through operation of the transverse colon (if it is large enough) performed instead.

Having after all decided to carry out the sigmoid pullthrough operation, the surgeon elevates the bowel and peritonealizes the posterior parietal peritoneum with closely placed silk sutures closing the entire bed of the sigmoid (Fig. 164.11). The freed sigmoid is then moved to the lesser pelvis, and the abdominal cavity is closed with a large moist towel. One of the assistants now ta­kes care of the abdominal wound, while the surgeon and the other assistant turn their attention to the perineum.

Abdomino-anal resection of the rectum with sphincter preservation (Pull-through operation)

Abdomino-anal resection of the rectum with sphincter preservation (Pull-through operation)

Abdomino-anal resection of the rectum with sphincter preservation (Pull-through operation)

Abdomino-anal resection of the rectum with sphincter preservation (Pull-through operation)

Fig. 164. Abdomino-anal resection of the rectum with sphincter preservation (Pull-through operation):

1. Incision of the pelvic floor peritoneum on the left.

2. The bowel is ligated with gauze tape proximal to the tumour

3. The lower mesenteric artery is exposed and ligated on the transilluminator blade.

4. Schematic representation of blood supply to the sigmoid following ligation of the inferior mesenteric ar­tery and sigmoid arteries.

5. Freeing the retrorectal space under visual control.

6. The entire rectal circumference is freed bluntly by the surgeon’s hand.

7. Dissection of right lateral boundaries in the pelvis.

8. Separation of the rectum from the urinary bladder.

9. Separation of the mesentery of the sigmoid with preservation of left colon artery; 2 black indentificating ligatures are established on the sigmoid.

10. Freed sigmoid is drawn on through the abdominal wound up to the level of Scarp triangle.

11. Peritonisation of back wall of the abdomen.



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