rectal instruments


By • Дек 18th, 2010 • Category: Anus

The surgeon now closes with silk the right and left angles of the iliac wound in layers lateral to the exter­nalized sigmoid loop (Fig. 174.5). The base of sigmoi-dostomy is covered with a dressing. After 24 hours the proximal limb of the loop is opened with a scalpel, and a thick rubber tube is passed and fixed in the bowel. In 7 or 8 days the bowel is cut across over the tube with rod and a loop sigmoidostomy having two short «barrels» is formed 2—3 cm above the skin level.

This operation is undertaken 1 to 2 months following the formation of the «double-barrelled» sigmoidostomy.

Under local or general ether-oxygen or azeotropic mixture anesthesia and with the patient lying supine, 30 ml of 0.25 per cent novocain solution with adrenaline (3 drops of adrenaline per 100 ml novocain) are first injected perianally through the skin from 4 symmetrical points, using a 10 ml capacity syringe with a 4—5 cm long needle; the novocain will peel off the bowel from the surrounding soft tissues (Fig. 175.1), thus facili­tating subsequent mobilization of sigmoidostomy. The mucosa of the loop sigmoidostomy is now carefully rubbed with swabs soaked in 2 per cent iodine tincture, and an oval incision is made around the stoma (Fig. 175.2). The skin is dissected off from the sigmoidostomy around its full circumference with a knife or scissors. To avoid injury to the bowel the surgeon passes there one or two fingers of his left hand (Fig. 175.3). By pulling the bowel upwards and mobilizing it, the surgeon gains access to the abdominal cavity both on the right and on the left.

After changing his gloves, the surgeon separates with scissors the loop sigmoidostomy from parietal pe­ritoneum along the finger introduced into the abdomi­nal cavity. The stoma is then brought out from the ab­dominal cavity for a distance of 3—4 cm and draped with gauze.

The external fringe of the sigmoidostomy mucosa and the adjacent skin rim are cut off with scalpel. Next follows a wedge-shaped dissection of the spur between the afferent and efferent loops of sigmoidostomy. Having grasped the spur with two straight forceps that isolate its wedge-shaped portion (Fig. 175.4), the surgeon ex­cised the spur over the forceps with straight scissors, and passes 3 fine silk sutures through the mucosa of the spur base under the forceps. The threads are now handed to the assistant (Fig. 175.5), the forceps is opened and pulled out, and the sutures are quickly tied to secure hemostasis. The same maneuver is carried out with respect of the opposite forceps. Having obliterated the spur (Fig. 175.6), the surgeon starts suturing the bowel after its serosa has been freed (as much as this is possible) from fibrous formations. Two layers of su­tures are then placed around the entire external semicir-cumference of the bowel (Fig. 175.7), and the suture line is powdered with Streptocid. The surgeon then slightly descends the sutured bowel to the abdominal cavity and closes the iliac wound in two layers, the first row of sutures being passed through the peritone­um and aponeurosis grasping, with 2—3 bites, the se­rosa of the sutured bowel in the centre. A gauze strip is then packed under the skin sutured with widely placed sutures.

No opium tincture should be given. A purgative is ad­ministered on the third day. Bed rest is required for 10 days.

Operation for obliteration of the temporary loop sigmoidostomy

Operation for obliteration of the temporary loop sigmoidostomy

Fig. 174. Establishment of temporary loop sigmoidostomy without sigmoid resection:

5. Appearance of temporary loop sigmoidostomy just after the resection.

Fig. 175. Operation for obliteration of the temporary loop sigmoidostomy:

1. Instilling novocain solution around the anus to fa­cilitate its dissection.

2. Oval incision around the anus.

3. The loop sigmoidostomy is dissected off; a finger is introduced into the bowel lumen to avoid injury to its wall.

4. The spur is excised in wedge-shaped manner over two clamps facing each other.

5. Three sutures have been passed through the spur base over the clamp, and the suture ends handle to the assistant.

6. The spur has been excised. Sutures laid on its base can be seen.

7. Suture in two layers of the outer bowel circumfe­rence—the sigmoidostomy opening.

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