rectal instruments

OPERATION FOR THE FORMATION OF AN ARTIFICIAL RECTAL SPHINCTER FROM THE GRACILIS MUSCLE


By • Дек 21st, 2010 • Category: Rectum

This operation is indicated in rectal incontinence due to congenital malformations and also in rectal inconti­nence of a neurological origin and following amputation for a tumour.

The patient is placed in the same position as for hemorrhoidectomy and endotracheal anesthesia with azeotropic mixture is used.

1. The perineum and the left thigh are prepared with iodine, after which the thigh is drawn aside by the as­sistant or nurse and the knee is slightly flexed. As the thigh is drawn aside a small lump appears on its inner surface due to tension of adducting muscles. This lump is used as a guide for exposing the gracilis muscle when a straight incision is made just under this lump (Fig. 138,1) starting several centimeters below the in­guinal fold and terminating in the pes anserinus region. (If incisions are made over this lump, then the sartorius muscle would be freed, whereas it is only the gracilis muscle which is required for plastic repair of the sphinc­ter).

2. If the incision is made correctly, then the gracilis muscle is immediately brought into view (Fig. 138,2), and after several vessels have been severed, can be readily freed, together with its tendon, from the pes anserinus, up to the place where the vascular-nervous bundle (branch of the A. prophunda femoris) and the anterior branch of the obturator nerve pass into it. This bundle must be injured or the operation would not be success­ful. In isolating the muscle all its attachments with the surrounding tissues should be checked by tapping it with knife handle to see whether there is contraction of the muscle.

After isolation, the muscle is carefully wrapped up in a moist pack (Fig. 138,3), following the end of the muscle

is grasped with a swab holder introduced through the left incision into the subcutaneous canal and brought out to the anal opening (Fig.’ 138.5).

The femoral wound is then completely closed. (Fig. 138,6). Next, two canals are bluntly developed with finger above and below the incisions made around the anus, so that these canals skirt the sphincter thus free­ing the rectum around its entire circumference (Fig. 138,7).

The muscle is now passed through the canal around the rectum, taking special care not to pull the muscle from its former bed lest the vascular-nervous bundle be •njured. The muscle end, its tendon, should be sutured to itself with silk after it has been drawn through the en­tire thickness of the sphincter (Fig. 138,8). In doing this, the rectum should not be tightened very strongly by the muscle, for the idea of this operation lies not in the me­chanical narrowing of the rectum, but rather in restoring its continence due to muscle contraction.

If careful hemostasis is instituted, no drainage of the operating field is needed, although it occasionally may be found necessary to leave two drains of fat-soaked gauze (one on each side) for 48 hours. The perineal wounds are closed with interrupted catgut sutures.

After the operation, the patient is given opium tinctu­re for 7 days, and a puigative on the 8th day. The first evacuation of the bowels is with the patient lying on his side. The affected thigh is placed in a Brown splint for 10 days. Beginning with the 15—20 th day, muscle training is started aimed at controlling the function of the newly formed sphincter. For this purpose the patient is placed on his back with his legs flexed in the knee joints, and the knees slightly drawn apart and held so by someone. In this position the patient is to try to ad-duct his legs. This causes the adductors to strain so that the gracilis muscle (which is an adductor) contracts and compresses the rectum

After a 2-week course of such training the patient be­gins to contract the sphincter without outside assistance, by mere adduction of his left leg.

Operation for sphincter formation from the gracilis muscle by Faermans method

Operation for sphincter formation from the gracilis muscle by Faermans method

Fig. 138 Operation for sphincter formation from the gra­cilis muscle by Faermans method:

1. Incision is made to expose the gracilis muscle.

2. The gracilis muscle is being freed.

3. The freed gracilis muscle wrapped in moist gauze.

4. A subcutaneous canal is bluntly developed by a swab holder, leading from the thigh toward the anus.

5. The muscle is brought to the anal orifice by means of the swab holder.

6. The femoral wound is completely closed.

7. A canal is formed around the distal rectum by ma­king two parallel skin incisions.

8. The muscle has been passed into the canal thus formed and its free end sutured to the muscle belly.



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