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INTRAABDOMINAL EXCISION OF RECTOSIGMOID WITH ESTABLISHMENT OF TERMINAL ILIAC SIGMOIDOSTOMY (Hartmann operation)


By • Дек 19th, 2010 • Category: Rectum

This operation is resorted to relatively rare, only when the growth is located as high as 10 cm from the anal verge. The operation is indicated in thin, weakened patients showing signs of partial obstruction of the sigmoid, or else in very obese persons when the surgeon cannot take the risk of forming a primary end-to-end anastomosis following resection of the sigmoid.

It should be mentioned that the curving of the rectum in the sagittal plane makes possible to free the rectum in the pelvis to extend the bowel by 5 cm or more follow­ing its freeing in the pelvis.

Under ether-oxygen anesthesia or azeotropic mixture
anesthesia and the patient in the supine position with
his legs fixed to the table, the abdominal cavity is opened by low medial laparotomy and explored for metastases.

The patient is now turned to a Trendelenburg tilt, the small guts are moved to the upper half of the abdomen to be fixed there by large gauze squares.

The assistant now rendered the sigmoid taut and shifts it to the right, while the surgeon makes a cut with long scissors through the left surface of mesosigmoid and carries it on to the peritoneum of the left pelvic space and then, in a curving course, along the rectovesical plica (Fig. 166.1).

Having seized, in the pelvis, the external peritoneal edge with a long forceps, the surgeon deepens the pelvic wound by means of a long swab, and moves the subcu­taneous fat medially, thus exposing the left urether (see Fig. 155.4).

Now the surgeon draws the sigmoid upwards and to the left.while cutting the mesosigmoid peritoneum with scissors on the right. Now the sigmoid is pulled upwards; and to the left and is held so, while the mesosigmoid peritoneum is cut on the right, this cut being carried for­ward to the right pelvic space, from which it is curved to the left along the recto-vesical plica to meet the end of the previously made incision (Fig. 166.2). The sigmoid is then ligated with tape proximal to the tumour (Fig. 166.3).

The lyre-shaped incision of the peritoneum is now dee­pened, with the pelvic fat excised cautiously in the di­rection of the rectum both on the right and on the left of it (Fig. 162.1). External to the rectum the left and then the right urethers are then defined (see aboye, Fig. 162,2). In the mesenteric wound, 3 cm above the promontory, the lower mesenteric artery is defined and ligated between sigmoid arteries.

The surgeon then detaches the rectum anteriorly from the fundus vesicae (cervix of the uterus) by means of a wick and Cowper’s scissors, and inserts a gauze strip to control bleeding.

Having elevated the sigmoid with his left hand, the surgeon lifts up with forceps and dissects, through the previously made incisions of the mesosigmoid, the fasci-al tissue covering the sacral promontory, thus exposing the area of bifurcation of the abdominal aorta. Now the sur­geon passes an abdominal retractor through this opening into the retrorectal space, again elevates sigmoid and divides the ligaments between it and the sacrum under direct vision (Fig. 166.4). Next, he detaches with scissors and swab the fatty tissue and porous connections bet­ween the sigmoid and lateral pelvic walls (see Fig. 155.11). In this operation, the anterolateral ligaments of the rec­tum are not sacrificed, since inside them there pass mid­dle rectal arteries needed to supply the rectal stump re­maining in the pelvis.

Having thus completed the mobilization of the rectum in the pelvis, the surgeon dissects transversely the upper and middle thirds of the sigmoid (Fig. 166.5).

While pulling out the mobilized sigmoid with the left hand, the surgeon applies to the freed rectum in the pel­vis two angulated clamps whose blades compress its lu­men (Fig. 166.6); the distance between the blades should not exceed 1.5 cm.

The lesser pelvis cavity around clamps is now filled with moist gauze strips, and the bowel is dissected bet­ween the clamps with a long curved scissors so that a 1 cm length of the bowel edge is left over the distal clamp (Fig. 166.7).

The proximal portion of the rectum subject to removal along with part of the sigmoid and the tumour, is then ligated with stout silk under the clamp, the latter is withdrawn, and the free end of the rectum is wrapped up with a sterile towel.

Now the surgeon closes the lumen of the remaining rectal stump over the distal clamp by means of interrup­ted silk sutures (Fig. 166.8). After 6—7 such sutures have been inserted, the angulated clamp is removed and threads of the 4—5 middle sutures are cut off, so that the assistant holds the rectal stump by the remain­ing first and last stitches.

The surgeon then buries the first suture line with long forceps and applies a second row of 5—7 Lembert sutures (Fig. 166.9), after which both angles of the bo­wel stump are also buried by Lembert sutures.

The lesser pelvic cavity is then thoroughly swabbed dry with a gauze wick. Any bleeding, even if slow ana scarce, is stopped by stitching the clamps with a fine round needle. The pelvic floor is peritonealized by sutur­ing the edges of the dissected pelvic floor peritoneum. During peritonealization, the top of the closed rectai stump should be sutured to the edges of the peritoneal leaves being united by burying it in the pelvic depth with forceps (Fig. 166.10).

Having peritonealized the pelvic floor and the bowej stump, the surgeon proceeds to suture the peritoneum on the posterior abdominal wall in the area of mesosigmoiL bed (Fig. 166.11).

Next comes the last and a very important step of thu operation, namely, formation of a terminal sigmoidosto-my.

In weakened patients showing signs of intestinal ob­struction, when the surgeon wishes to terminate the ope­ration as soon as possible, sigmoidostomy may be esta­blished in the upper corner of the laparotomy wound, although in all cases it is advisable to try to form an iliac stoma. To do this, an incision is made in the left iliac region through all layers of the abdominal wall. Aponeurosis is excised in the shape of an oval or in cruciate fashion, and the skin is sutured to the peritoneal edge around the wound circumference (see Fig. 154.3). The surgeon next lifts up the freed sigmoid together with the tumour through the medial wound and dissects it away between two stout ligatures 6—8 cm over the skin level (Fig. 166.12). The operative specimen is now taken away, and the remaining stump, which should be tied off tightly with ligature, is covered with a rubber cap (Fig. 166.13), brought out through the iliac wound and sutured all around taking special care not to pierce the bowel wall (Fig 166.14).

Operation for interaperitoneal excision of the rectosigmoid with establishment of a terminal iliac sig­moidostomy (Hartmann, operation)

Operation for interaperitoneal excision of the rectosigmoid with establishment of a terminal iliac sig­moidostomy (Hartmann, operation)

Operation for interaperitoneal excision of the rectosigmoid with establishment of a terminal iliac sig­moidostomy (Hartmann, operation)

Operation for interaperitoneal excision of the rectosigmoid with establishment of a terminal iliac sig­moidostomy (Hartmann, operation)

Fig. 166. Operation for interaperitoneal excision of the rectosigmoid with establishment of a terminal iliac sig­moidostomy (Hartmann, operation):

1. The sigmoid colon has been drawn taut to the right, and the surgeon dissects, on the left, the mesosig­moid peritoneum as far as the pelvic floor.

2. Pulling the sigmoid upwards and to the left the surgeon dissects the mesosigmoid peritoneum on the right and carries the incision along the rectovesical plica to meet the peritoneal incision.

3. The sigmoid has been ligated with tape proximal to the tumour.

4. The sigmoid is lifted up with a long abdominal re­tractor and the ligaments between sigmoid and sacrum are divided with scissors under visual control.

5. The surgeon cuts the mesosigmoid between clamps as far as the boundary between the upper and middle thirds of sigmoid.

6. Having pulled out the mobilized sigmoid with the left hand, the surgeon applies two angulated forceps to the freed rectum so that the forceps blades are spaced 1.5 cm apart.

7. The bowel has been cut off with long curved scis­sors over the distal clamps.

8. Closure of the rectal stump lumen with silk su­tures above the clamp.

9. Application of a second row of burying silk sutu­res to the stump.

10. Peritonealizing the pelvic floor defect, with the needle first piercing the right peritoneal edge, then the stump, and, finally, the left peritoneal edge.

11. Appearance of the pelvic floor following its pe-ritonealization.

12. Cutting off the freed sigmoid together with tu­mour 6—8 cm above the skin level (the sigmoid is to­welled and dissected between two ligatures over the me­dial wound).

13. A rubber cap is pulled on to the ligated sigmoid stump.

14. The sigmoid stump has been brought out through the iliac wound, closed with the cap, and is being sutu­red around with the remaining threads.



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