rectal instruments


By • Дек 19th, 2010 • Category: Rectum

Loop («double-barrelled») sigmoidostomy is indicated in inoperable tumour of the rectum that narrows its lu­men; in cases with signs of acute or subacute intestinal obstruction due to cancer or other lesions of the distal colon; and in grave complications in the pelvis fol­lowing operations for low anterior resection or pull-through of the sigmoid.

The patient is placed in the supine position and et­her-oxygen or local anesthesia is used.

In the sigmoidostomy operation, the author uses a double incision — first a low medial laparotomy which permits the sigmoid to be readily identified and the na­ture of pathological changes to be ascertained; and, se­condly, an additional left oblique incision through which the sigmoid loop is taken to the outside (Fig. 154.1).

After opening the abdominal cavity through a me­dian incision and exploring the intestine, the surgeon notes the dimensions and disposition of the sigmoid co­lon. Next he passes his left hand into the abdominal ca­vity with the palmar side facing the parietal peritoneum and makes the left half of the abdominal wall bulge out.

An oblique incision of the abdominal wall is now made on this protruding portion of the abdominal wall by the right hand (Fig. 154.2), with the assistant drawing the wound sides apart with retractors and clamping the bleeding vessels. Having carefully opened the parietal peritoneum, the surgeon grasps its margins with Miku-licz clamps and, after taking his left hand out of the abdominal cavity, extends the second abdominal wound by scissors till it is 5—6 cm long. Aponeurosis is ex­cised in the shape of an oval.

The skin of the iliac wound is now sutured by means of fine silk to the peritoneal edges around its entire cir­cumference (Fig. 154.3), so as to prevent cicatricial con­traction of the stoma. The ends of these sutures (there arc 8 to 12 of them) are not cut off.

The sigmoid loop intended to serve as sigmoidosto­my is then taken to the outside through the oblique wound thus prepared. (Fig. 154.4). In the middle of mesosigmoid, a window 3 cm long is next made keeping close to the sigmoid wall.

The exteriorized loop of sigmoid is now sutured all around to the wound walls by means of a round needle and the threads left after the application of cutaneous-peritoneal sutures (Fig. 154.5).

After both limbs of the sigmoid colon have been an­chored to the wound edges, the surgeon passes a 8 cm long sterile rubber tube through the window previously formed in the mesosigmoid. To make it stiff a metal rod is inserted into the tube. The tube should be passed in such a way that the exteriorized bowel loop as it were sits astride it (Fig. 154.6).

After changing his gloves, the surgeon closes the medial laparotomy wound with stout silk in two rows.

A fat gauze band heavily soaked in Vishnevsky oint­ment is next laid in 3 layers around the externalized sigmoid on the skin and under the rubber tube (Fig. 154.7).

An alcohol gauze is then applied to the abdominal wound and a vaseline one to the bowel. A gauze-cotton dressing is laid on the abdomen.

Twenty four hours following the operation, the sig­moid loop is laid open by grasping the sigmoid top equidistantly with four Bilrot clamps and dissecting its wall transversely to open the lumen.

After securing hemostasis, the wound is drawn apart with retractors and a broad thick-walled rubber tube is inserted into the proximal sigmoid limb for a distance of 5—7 cm (Fig. 154.8).

The edges of the bowel wound are now sutured with catgut whose long ends are tied around the tube. A dressing is applied to the wound.

Nine to 12 days after sigmoidostomy, the exteriorized sigmoid colon is dissected transversely throughout its thickness, taking special care to secure hemostasis of the bleeding vessels. The rubber tube with rod is with­drawn. Both stoma openings will gradually shape themselves.

In very weakened patients sigmoidostomy may be performed without medial laparotomy, only from a single left incision, using the just described procedure.

Operation for loop («double-barrelled») sigmoidostomy

Operation for loop («double-barrelled») sigmoidostomy

Fig. 154. Operation for loop («double-barrelled») sigmoidostomy:

1. Two incisions used for sigmoidostomy: low lapa­rotomy and left oblique incisions.

2. The surgeon makes the abdominal wall bulge out on the left by his left hand while dissecting it with his right hand.

3. Suturing skin edges to the margins of peritoneal incision with leaving long tails following the tying of sutures.

4. The sigmoid loop is brought out through the iliac wound. A window i§ made in the middle of mesosigmoid.

5. The sigmoid loop is sutured circumferentially to the abdominal wound walls.

6. A rubber tube with metal rod is passed through the mesenteric window.

7. A fat ointment-soaked gauze strip is laid around the exteriorized sigmoid on the skin and under the rub­ber tube. The laparotomy wound is completely closed^

8. The bowel is cut between clamps. A broad rubber tube is introduced in the proximal end of the bowel.

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