rectal instruments

INTRAABDOMINAL RESECTION OF RECTOSIGMOID (Low Anterior Resection)


By • Дек 19th, 2010 • Category: Colon

Intraabdominal resection of the rectosigmoid and pelvic colon is performed in cases of mobile adenocarci-nomas of the rectum and sigmoid located 9 to 24 cm from the anal verge in females and 12 to 24 cm in ma­les.

Operative technique. The patient is placed on his back and endotracheal anesthesia with ether and oxygen or azeotropic mixture is employed. Prior to the operation, both urethers and the bladder (an indwelling catheter are catheterized for 2—3 days).

The abdomen is opened by low medial laparotomy and the abdominal cavity is explored for metastases and ex-1 tent of the primary growth. The patient is then changed to the Trendelenburg position and the small gut is displa­ced to the upper half of the abdominal cavity. The bowel is next tightly ligated by a narrow tape over the tumour through the mesenteric window (see Fig. 1,55,6).

The assistant now pulls the sigmoid to the right, while the surgeon cuts the mesosigmoid with scissors on the left, carryig this cut to the left pelvic space and then on to the right to the rectovesical plica area (see Fig. 155,4). The pelvic wound is next deepened with fin­gers and swab, the left urether is exposed and drawn to the left by a retractor, and the pelvic fat is moved to the right in the direction of the rectum (Fig. 162,1). The inferior mesenteric artery is next exposed from the pro­ximal end of the mesenteric incision, being ligated bet­ween the first and second sigmoid arteries (Fig. 162,2).

After pulling the sigmoid colon to the left, the sur­geon dissects the base of mesosigmoid on the right and carries the incision down to the right pelvic space to meet the previous incision (see Fig. 155.5). By moving aside the fat with swab the right urether and the abdomi­nal aortal bifurcation are exposed (Fig. 162,3).

The rectum is now separated anteriorly from the fun-dus of the bladder (uterus) to a depth of 2.5—3 cm (see Fig. 155.13).

After pulling the rectum forwards, the surgeon tears apart with fingers the fascial plate covering the sacral promontory at the mesosigmoid base and exposes the aortal bifurcation. A long abdominal retractor is intro­duced into the retrorectal space, and the rectum is sepa-1 rated from the anterior sacral surface under direct vision by means of a long scissors and swab, taking special ca­re not to njure the sacral veins (Fig. 162,4).

Next, the surgeon introduces his right hand into the retrorectal space as shown in Fig. 162.5 and frees the posterior semicircumference of the rectum downwards to the middle of the coccyx and laterally almost as far as the lateral ligaments.

In freeing the lateral surface of the rectum from the pelvis, the surgeon must remember that a substantial por­tion of the rectum is to be left in the pelvis for subse­quent anastomosis with the sigmoid colon and that the middle rectal arteries should be left intact. For that rea­son it is not allowed to sever anterolateral rectal liga­ments within which these arteries usually run.

Having mobilized the rectum, the surgeon turns his attention to dividing the mesosigmoid, starting from its already freed root near the promontory of the sacrum. The mesosigmoid is dissected in piecemeal fashion bet­ween Billroth forceps in the direction of the middle of the sigmoid colon (Fig. 162,6).

After completing the mobilization of rectosigmoid, the surgeon applies, in the pelvis, an angulated clamp 3— 5 cm distal to the tumour to compress the bowel lumen transversely; the clamp handle is then turned in such a way that the posterior rectal surface is exposed (Fig. 162,7). At this point the surgeon should instruct one of his assistants not directly engaged in the opera­tion to clean and sterilize the rectal mucosa through the anal orifice by rubbing the rectum with gauze swabs fix­ed on a swab-holder (first with dry swabs and then with swabs soaked with 2 per cent iodine tincture).

Two clamps are then placed close to each other (Fig. 162,8)—a stiff clamp distally and a soft one pro-ximally — to that portion of the sigmoid proximal to the tumour and previously freed from mesosigmoid, and the bowel is sectioned between the clamps. The distal sig­moid portion containing the tumour is wrapped (toget­her with the stiff clamp) with gauze and pulled upwards to give good exposure of the entire posterior aspect of the rectum.

The posterior surface of the sigmoid stump is then su­tured With long interrupted silk stitches, just above (pro­ximal to) the soft clamp, to the posterior rectal surface along the line distal to the transverse clamp applied to the bowel (Fig. 162,9). These long sutures (there are 5 or 6 of them) are not tightened, each of them being ta­ken in the Peans’s forceps. The soft clamp fixed on the open sigmoid stump is pulled down to the pelvis and the posterior (stitched) sigmoid surface is brought close to the posterior surface of the rectum distal to its trans­verse clamp.

The sutures of the posterior anastomotic surface are now in turn tied and cut off except for the two marginal ones which are left in place to serve as stays.

The surgeon next cuts the rectum transversely just under the clamp applied to it, i. e. proximal to the poste­rior suture line of the anastomosis (Fig. 162.9 and 10).

The resected portion of the colon is now removed along with the tumour, and the edges of the now opened rectal stump are grasped with Billroth forceps and pain­ted from the inside with 2 per cent iodine.

The next step is the formation of the anastomosis. With the assistant pulling aside the stay sutures the sur­geon applies a second posterior row of fine silk sutures of the anastomosis including all the layers of rectosig-moid (Fig. 162.11). In all 6 to 8 such sutures are applied and tied from the rectal lumen side.

After cutting off the threads of the posterior row of sutures, the surgeon applies the anterior row of sutures, also through all rectosigmoid layers (Fig. 162.12). Hav­ing applied the anterior row of sutures and tied the threads, the surgeon proceeds to insert, anteriorly, the second row of Lembert sutures, after burying the first suture line with forceps (Fig. 162.13).

The operation is completed by suturing the peritoneal edges of the pelvic floor to the anastomotic line around its entire circumference so that the whole anastomosis is disposed retroperitoneally, just over the newly formed pelvic floor (Fig. 162.14). The mesosigmoid bed on the posterior abdominal wall is peritonealized by suturing the internal peritoneal margin to the remaining mesente­ry of the pulled — through sigmoid colon.

The nonsterile assistant now passes per anum into the rectum a thick rubber tube with an additional side open­ing, with the surgeon moving this tube in the pelvis 10— 12 cm above the anastomosis. The assistant then anchors the tube to perineal skin (near the anus) with a catgut stitch. The tube is removed in 2—4 days (after the first bowel action).

In those cases when the surgeon is in doubt as to the ruggedness of the anastomosis or fears suppuration of the sutures, he may drain the perirectal space from the perineal side prior to closing the pelvic peritoneum. To do this, the patient is turned to the lithotomy position, the surgeon makes an incision lateral to the anus, dis­sects the levator ani muscles and inserts an ointment-soaked gauze strip or two thin rubber tubes into the pre­viously cleared perirectal space. The drams are remov­ed five day after the operation.

Operation for low anterior resection of the sigmoid colon

Operation for low anterior resection of the sigmoid colon

Operation for low anterior resection of the sigmoid colon

Operation for low anterior resection of the sigmoid colon

Fig. 162. Operation for low anterior resection of the sigmoid colon:

1. Exposure of the pelvic fat following incision of pe­ritoneum of the left pelvic space.

2. Ligation of the inferior mesenteric artery between the first and second sigmoid arteries.

3. Dissection of pelvic fat inwardly, following dissec­tion of peritoneum of the right pelvic space.

4. The bowel is lifted up with a long abdominal ret­ractor, and the ligaments between it and the sacrum are dissected with scissors under visual control.

5. The surgeon frees bluntly the posterior rectal cir­cumference with his right hand.

6. Dissection the mesosigmoid as far as the middle portion of the sigmoid.

7. An angulated forceps is applied to the freed rectum in the pelvis to expose its posterior surface.

8. Two clamps are applied to the proximal mesente­ry-freed portion of the sigmoid, and this is dissected between the clamps.

9. Application of long interrupted sutures to the pos­terior surface of sigmoid stump and posterior surface of rectum distal to its transverse forceps. The sutures are held in Billroth forceps.

10. After tying the posterior sutures of the anastomo­sis, the surgeon cuts off the rectum just above (proxi­mal) the angulated forceps.

11. Applying the posterior row of anastomotic sutu-les to include all layers of sigmoid and rectal walls.

12. Applying the anterior row of anastomotic sutu­res through all layers of the bowels being connected.

13. Applying the second row of burying Lembert su­tures of the anastomosis.

14. The peritoneal edges of the pelvic floor have been sutured to the anterior semicircumference of the anasto­mosis; the mesosigmoid bed has been peritonealized.



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