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ONE-STAGE ABDOJVUNOPERINEAL EXCISION OF THE RECTUM (Quenu-Miles Operation)


By • Дек 19th, 2010 • Category: Rectum

This operation is indicated when the tumour is lo­cated at a distance of up to 6 cm inclusive from the anal verge.

The operation is preceded by a bilateral catheterization of the urethers. A catheter is introduced into the bladder and a presacral block (150 ml of 025% novocain) (see p. 31) is instituted.

The patient is placed on his back with the legs ele­vated and supported on special rests (Fig. 155.1). A broad diathermy electrode wrapped with gauze is laid under the patient’s sacrum to take care of possible he­morrhage.

The patient is given ether-oxygen anesthesia or com­bined anesthesia with azeotropic mixture.

Abdominal phase A medial laparotomy is performed from the mons pubis up to a point 2 cm above the um­bilicus. A small additional incision is also made at the end of this phase to bring out the «single-barrelled» sig-moidostomy (Fig- 155.2).

After opening the abdominal cavity, the liver, retro-peritoneal space and mesocolon are carefully inspected for metastases, and the tumour is palpated in the pelvis to ascertain the degree of its spread.

The surgeon now pulls the loop of the ileum out of the abdominal cavity and injects 100 ml of 0.25 per cent novocain solution into the mesenteric root from a fine needle by means of a 10-ml syringe (Fig. 155.3) to pre­vent post-operative paresis of the small gut.

The patient is then changed to the Trendelenburg position (a 12° tilt), and the small gut is shifted from the lesser pelvis into the upper part of the abdominal cavity to be held there by two large pieces of moist

The pelvic colon is pulled upwards to the right, and the surgeon incises the mesosigmoid peritoneum with a scalpel 4 cm above the promontory and dissects it by scissors along its left surface at a distance of 5— 7 cm from the mesenteric edge of the bowel (Fig. 155.4). This incision is continued down to the pelvic floor and then turned to the right to run as far as the middle of rectouterine or rectovesical plica. By moving the inci­sion edge of the mesentery to the midline the surgeon defines the urether and the inferior mesenteric artery and its branches.

The surgeon now pulls the bowel to the left, incises the peritoneum, and makes a symmetrical incision of the mesosigmoid and pelvic peritoneum in the region of the right pelvic space (Fig. 155.5). The peritoneal leaf is also dissected down to the pelvic floor, the incision being continued anteriorly and then curved to go along the rectovesical plica to the right to meet the first in­cision.

To prevent implantation metastases, the bowel is tied off with a gauze tape in its middle portion above the growth through the opening made in the mesentery (Fig. 155.6).

The left peritoneal edge is grasped at its upper angle (i. e. above the promontory) with a long forceps and drawn aside, and the bowel-supplying arteries are di­vided in the mesentery; this maneuver in most cases can be done under direct vision without transillumination. The inferior mesenteric artery and its branches are now well seen (Fig. 155.7). In the upper angle of the mesen­teric wound, the artery and vein are dissected between two ligatures just below (distal to) the branching of the left colic artery (Fig. 155.8).

The proximal end of the dissected artery is additional­ly tied off with silk.

Two or 3 sigmoid arteries may also be ligated (Fig. 155,8).

The surgeon then turns his attention to freeing the posterior surface of the rectum. He lifts up the sigmoid colon, dissects with scissors the thin fascia lying over the aortic bifurcation and sacrum, and inserts the blade of an abdominal retractor into the space between the sacrum and the posterior rectal surface to elevate and move the rectum away from the sacrum (Fig. 155.9). The surgeon now uses long scissors to separate the rec­tum from sacrum under direct vision and penetrates in­to the retrorectal space.

Such dissection of the rectal ligaments prevents in­jury to the sacral periosteum and occurence of bleeding from sacral osteal veins (a complication endangering the patient’s life!).

By dissecting the rectum away from the sacrum, the surgeon gradually separates, either sharply or by a swab, the ligaments and fillers connecting them till the coccyx is reached. The suigeon now introduces his right hand, into the partly separated retrorectal space and by gentle movements bluntly frees the posterior semicir-cumference of the bowel down to the top of the coccyx and, laterally, almost as far as the lateral ligaments (Fig. 155.10). To stop capillary bleeding, a large gauze pack is inserted into the extensive retrorectal cavity thus formed.

Having separated the rectum from the sacrum, the surgeon elevates the rectosigmoid with his left hand and frees with scissors the lateral and anterolateral bo­wel surfaces from the fat, keeping always close to the pelvic walls (Fig 155.11), alter which the anterolateral ligaments located just over the pelvic diaphragm are ex­posed and dissected with scissors (Fig. 155.12). Middle rectal arteries often pass within these ligaments, but they as a rule do not bleed appreciably. The anterola-

teral ligaments are dissected with long scissors both under visual and digital control. It should be remem­bered that this is an extremely important step of the Quenu-Miles operation.

The next step is the freeing of the anterior rectal surface by separating it from the fundus vesicae and seminal vesicles (or uterus). The bladder is retracted forward by means of an abdominal retractor and 30— 50 ml of 0.25 per cent novocain solution with two drops of adrenaline solution are introduced into the space between the fundus vesicae and the rectum.

The bladder is then separated from the rectum both bluntly (by a swab) and sharply (by scissors) (Fig. 155.13), and, to secure hemostasis, a gauze band is laid between the peeled off fundus vesicae, on one side, and the anterior rectal wall, on the other. The abdominal retractor is then removed.

The rectum is thus freed on all sides, as far as the pelvic diaphragm.

The surgeon now lifts up the sigmoid and dissects the mesosigmoid between two Billroth forceps approxi­mately to the middle of the bowel length. The sigmoid is dissected between two stout ligatures (Fig. 155.14), its ends are painted with iodine tincture and rubber caps are pulled on to them tightly. If required, the caps are tied with silk threads.

The proximal stump is wrapped with gauze and tem­porarily left as it is, while the distal portion of the sig­moid is brought down to the lesser pelvic cavity. Using a long needleholder, the surgeon carefully sutures the edges of pelvic floor peritoneum over the descended sigmoid (Fig. 155.15). In this way a new pelvic floor is formed located much higher (more proximal) than the natural one.

During peritonization, care must be taken not to anchor the buried sigmoid by the suture.

The peritoneum of the posterior abdominal wall and sacral promontory are then closed with closely placed sutures, after which the surgeon changes his gown and gloves and proceeds to establish a terminal sigmoido-stomy on the proximal sigmoid stump by making an additional lett incision of the abdominal wall. Incision in the left iliac region and peritonization of the wound edges are carried out as shown in Fig. 154.2 and 3. The proximal sigmoid stump is brought to the outside by taking hold of the rubber cap with a swab holder (Fig- 155.16). The exteriorized bowel is sutured circumferentially to the edges of the iliac wound (Fig. 155.17). A balsamic-ointment gauze band is then laid around the sigmoid.

This phase is completed by joining the mesosigmoid with the peritoneum of the lateral abdominal wall by means of 2 or 3 silk sutures so as to close the gap and rule out the possibility of a small gut loop penetrating there (Fig. 155.IS),

When the iliac sigmoidostomy is established, the sur­geon changes his gloves and completely closes the me­dial laparotomy wound. The sigmoidostomy should pro­trude 7—8 cm over the skin level. The cap is removed from the stump after 24 hours and the stoma is left open.

In the Quenu-Miles operation, the surgeon not infre­quently encounters a rather long sigmoid loop If this is so the bowel is ligated and divided above the sacral promontory level and caps are put on the stumps. The distal sigmoid is then descended to the pelvis as indi­cated above, while its long proximal part is brought to the outside through the iliac incision at the end of the operation. The sigmoid base is sutured circumferentially to the peritoneum, as shown in Fig. 155.17; the sigmoid is clamped at a distance of 7 cm above the skin level by means of two straight forceps (Fig. 156) and divided between them. The remaining proximal forceps is opened in 24 hours.

Abdominoperineal excision of the rectum. Abdominal phase

Abdominoperineal excision of the rectum. Abdominal phase

Abdominoperineal excision of the rectum. Abdominal phase

Abdominoperineal excision of the rectum. Abdominal phase

The long proximal sigmoid stump has been brought to the outside through the iliac wound and is cut off 7 cm above the skin level

Fig. 155. Abdominoperineal excision of the rectum. Abdo­minal phase:

1. Position of patient for Quenu-Miles operation with diathermy electrode placed under the sacrum. The indifferent electrode is shown separately.

2. Incisions of the abdominal wall in the Quenu-Miles operation.

3. Novocain block of the root of the small gut me­sentery.

4. Dissection of mesosigmoid and of peritoneum of the left pelvic space.

5. Dissection of peritoneum along the right pelvic space.

6. The bowel has been tied up with gauze tape pro­ximal to the tumour.

7. The mesosigmoid has been rendered taut. The me­senteric artery and its branches (the left colic artery and sigmoid arteries) (I, II) are visualized.

8. The inferior mesenteric and sigmoid arteries have been ligated and dissected inferior to the branching-off of the left colic artery.

9. The rectum is elevated with a long abdominaL fet-ractor and the ligaments between the rectum and sacrum are dissected by scissors under direct vision.

10. Peeling off the rectum by the hand.

11. Separation of fat and porous attachments between the rectum and pelvic wall.

12. Dissection of anterolateral ligaments of the rec­tum in the pelvis.

13. Separation of the anterior rectal wall from the bladder.

14. Dissection of the sigmoid colon over the tumour between two stout ligatures.

15. Suture of the pelvic peritoneum over the buried stump.

16. Bringing the sigmoid stump out through the iliac wound for establishment of sigmoidostomy.

17. Suturing the exteriorized sigmoid stump to the abdominal wound edges.

18. Suturing the exteriorized sigmoid to the lateral abdominal wall from the abdominal side.

Fig. 156. The long proximal sigmoid stump has been brought to the outside through the iliac wound and is cut off 7 cm above the skin level.



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