rectal instruments


By • Дек 18th, 2010 • Category: Rectum

Total colectomy: stage one

The patient is prepared as in any operation for can­cer. Under endotracheal anesthesia with ether and oxy­gen or with azeotropic mixture and with the patient ly­ing first in the horizontal supine position and then til­ted to the left and still later to the right, the abdominal wall is incised from the mons pubis up to a point 4 cm above the umbilicus (Fig. 183.1). An additional incision is made in the left iliac region at the end of the opera­tion. When the abdominal cavity has been opened, the colon is palpated for malignant tumour due to the poly-posis.

The distal portion of the ileum (previously freed from ileac mesentery for a distance of 8—10 cm from the Bau-hin’s valve) is compressed with four clamps, of whicb one (the proximal) is soft (Fig. 183.2).

The ileum is then divided in two places so that its central segment 5 cm long is removed (the incision line is shown in Fig. 183.2 by dotted lines). The distal stump is carefully closed in I layer near the Bauhin’s valve and is buried into the cecal wall by interrupted silk sutures (Fig. 183.3). The proximal end of the ileac stump is clo­sed completely in 2 layers and wrapped with a gauze square together with the soft clamp.

The operating table is now tilted to the right, the distal half of sigmoid colon is mobilized to the promon­tory level and the rectum is draped with gauze in the pelvis. Only sigmoid arteries and arcades are ligated. The sigmoid colon is resected between two pairs of clamps (Fig. 183.4).

The proximal sigmoid stump to be used for the for­mation of iliac sigmoidostomy is painted with iodine and tightly ligated transversely with a stout silk ligature un­der a soft clamp. The clamp is now removed and a rub­ber cup put on to the stump, which is then wrapped with gauze and left in place for a while.

Attention is now directed to the rectal stump (which has previously been isolated in the pelvis with gauze) which is likewise painted with iodine, opened with Allis forceps and those polyps remaining on the mucosa are excised with scissors (Fig. 183,5). The free distal portion of the ilcum whose end has been previously closed comp­letely) is now approximated to the open rectal stump by taking hold of the soft clamp attached to it. To avoid twisting of the ileac mesentery, the closed end of the ileum should be disposed on the right, i. e. closer to the

The posterior wall of the rectal stump is now pulled forwards by two Allis forceps and the first row of sutu­res of the anastomosis is applied between the end of rec­tum and the side of ileum (Fig. 183,6). The ileac wall is next transected and a second (internal) row of conti­nuous seromuscular catgut sutures is inserted (Fig. 183.7).

After completing the second row of sutures (Fig. 183.8), the free (previously closed) end to the ileum is sutured with several silk stitches to the right rectal wall (Fig. 183.9).

The window formed after establishing the anastomosis between the free margin of ileac mesentery and posterior pelvic wall should be closed with. 3—4 silk sutures to prevent a loop of small gut penetrating into the gap.

After completing the anastomosis the surgeon turns his attention to the closed proximal stump of sigmoid to establish a terminal (non-functioning) sigmoidostomy.

It will be seen from Fig. 183.10 and 11 that this sigmoidostomy is formed in the same way as in the Quenu-Miles operation and is described in detail on p. 212 (Fig. 155.16 and 17).

The abdominal cavity is irrigated with antibiotics (colimycin) and is closed completely. A gauze strip soa­ked in balsamic ointment is packed tightly around thestoma base.

Operation for total colectomy in multiple polyposis

Operation for total colectomy in multiple polyposis

Operation for total colectomy in multiple polyposis

Fig. 183, Operation for total colectomy in multiple polyposis:

1. Incisions of skin during the first stage of opera­tion.

2. Dissection and removal of a portion of the ileum.

3. Burying the closed ileac stump in the cecum.

4. Resection of the sigmoid colon

5. The rectal stump is opened and polyps arc cut off.

6. Inserting posterior seso-serous sutures in anasto­mosing the rectal end with the ileac side.

7. A second (internal) row of sutures of ileorectal anastomosis.

8. Suturing the anterior wall of anastomosis with in­terrupted sutures.

9. Suturing the closed end of the ileum to the right rectal wall.

10. Uniting skin edges with the peritoneal incision margins without cutting off the suture ends.

11. Suturing the stump of exteriorized sigmoid to the peritoneal wound edges.

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