rectal instruments

OPERATIONS FOR MALFORMATIONS OF THE RECTUM AND ANUS IN CHILDREN. Author — professor I. K. Murashov


By • Дек 21st, 2010 • Category: Anus

Malformations of the rectum and anus are met with rather rarely — 1 case per 5,000—10,000 neonates.

As a result of faulty embryonic development of the rectum and anus, a number of pathological forms of mal­formation arise, of which the following are of practical importance: atresia ani, atresia ani et recti, atresia recti, atresia ani urethralis et vesicaiis, atresia ani vaginalis et vestibularis, and atresia ani perinealis et scrotalis.

Atresia ani: the anus is closed by a thin transparent membrane (Fig. 139,1).

Atresia ani et recti: there is no anus, the rectum lying either in the pelvis or in the abdominal cavity (Fig. 139.2 and 139,3).

Atresia recti. the anus is present, but the rectum has failed to open and is situated in the pelvis (Fig. 139,4).

Atresia ani urethralis et vesicaiis: there is no anus, while the rectum terminates in a fistula which opens either into the urethra or in to the blader (Fig. 139,5 and 139,6).

Atresia ani vaginalis et vestibularis: there is no anus, while the rectum terminates in a fistula opening either

into the vagina cr into its vestibule (Fig. 139,7 and 139,8).

Atresia ani perinealis et scrotalis: there is no anus, while the rectum terminates with a fistula opening either into the perineal skin or into the scrotal skin (Fig. 139,9 and 139,10).

The only treatment lor atresias is a surgical one, by means of proctoplasty.

After operation, a plaster bandage should be applied to both knee-joints drawn apart, with the knees flexed at right angles and suspended on the upper bar of the frame. This bandage provides conditions of rest for the operative wound, while the supine position reduces the tension of sutures placed on the rectum (Fig. 140). The wound must be left open and dry throughout the period of healing.

The bandage should be applied for about a fortnight.

With respect to neonatals, the same principle of fixa­tion and rest applies, but soft bandages are applies for a period of 7 to 10 days.

Atresia ani. The operation is performed according to the vital signs within the first one or two days after birth.

No preparation for the operation is required. The pa­tient is placed in the supine position with a bolster be­neath his sacrum. The thighs are drawn up on the abdo­men. No anesthesia is needed. The membrane closing the rectal lumen is dissected either longitudinally or in a cruciform manner (Fig. 141,1) and then excised in its en­tirely along the edges of the anal orifice (Fig. 141,2).

Atresia ani et recti. The operation is performed one or two days after birth.

1st variant. The blind end of the rectum is in the pelvis. Under local anesthesia (with 0.25 per cent novo-cain solution), and in the supine position with a bolster beneath the sacrum and the thighs flexed on the abdo­men, a longitudinal perineal incisions, 3—4 cm in length, is made, the cellular tissue is bluntly dissected away, and the blind end of the rectum is mobilized (it is of a dark-green, meconium colour.

Two silk holders are then applied to the rectum, of which one serves to help further mobilization. (Fig. 142,1).

ATRESIA ANI URETHRALIS ET VESICALIS

The operation is performed according to the vital signs within the first 1 or 2 days of the child’s life.

No preparation for the operation is required. The pa­tient is placed in the supine position with the thighs fle­xed on the abdomen and a bolster beneath the sacrum.

First variant. Perineal proctoplasty. The rectal fistula is situated in the membranous part of the urethra. Under local anesthesia with a 0,25 per cent novocain solution, a longitudinal incision is made through the perineum, and the blind end of the rectum and the fistulous tract are bluntly separated (Fig. 144,1). Both the rectum and fistulous tract are of a darkgreen (meconium) colour. The separated fistula is ligated with two silk ligatures keeping close to the rectum (so that the urethra is not narrowed) and severed (Fig. 144,2). The rectum is addi­tionally mobilized and pulled through on to the peri­neum. The remainder of the fistula is excised through making an additional circular incision, and the rectum is opened (Fig. 144,3). The rectum is then fixed to the mus­cles deep within the pelvis. The opening thus formed in the rectum is sutured to the perineal skin with 4 silk stit­ches and some catgut sutures (Fig. 144,4). The wound is painted with iodine and left open. A soft bandage is ap­plied on the knee-joints for 7 to 10 days.

Second variant. Abdominoperineal proctoplasty.

The operation is performed in atresia ani urethralis with fistula localization in the prostatic portion of the urethra and in atresia ani vesicalis.

One-stage proctoplasty with a transrectal incision made downwards and to the left of the abdomen. The abdo­minal cavity is opened and the rectum and sigmoid are mobilized, after which the fistulous tract which connects the bladder or urethra with the rectum (Fig. 145,1) is freed in the rectum. Two ligatures are applied and the

fistula is divided (Fig. 145,2). If the rectum is overfilled with meconium and gases, these should be evacuated af­ter opening the rectum, then the rectum is closed.

A longitudinal incision is now made through the pe­rineum, and a tunnel is bluntly developed into the abdo­minal cavity by means of a swab holder. The rectum is pulled through this tunnel to the perineum, where it is fixed, as indicated above (see Fig. 142,2). The perineal wound is left open without dressing, while the abdomi­nal wound is completely closed.

A soft bandage is applied to the knee joints for 7— 10 days.

In two-stage proctoplasty, the fistula is first placed on the transverse colon within the first days of child’s life. The second stage is performed when the child is 3— 5 years old and is identical to the first one. The fistula is closed 3 months after proctoplasty. A plaster bandage is applied to the knee joints for a fortnight.

Atresia ani vaginalis et vestibularis

The operation is performed when the child is 6 months of age or older.

The preoperative preparation consists of purgative ene­mas with the aid of a metal catheter inserted through the fistula. In both cases the operations are done by the peri­neal route using ether-oxygen anesthesia and the prone position with the thighs flexed on the abdomen and a bolster beneath the sacrum.

Atresia ani vaginalis is operated on by making a longitudinal incision through the perineum and bluntly separating the rectum and the fistulous opening into the vagina (Fig. 146,1). The vaginal wall is then additional­ly sutured from the perineal side (Fig. 146,2), the rectum is mobilized and pulled through to the perineum. The remnant of fistula on the rectum is excised and the rectum is fixed to the skin (Fig. 146,3). The perineal wound is left open without dressing. A plas­ter bandage is applied on the knee joints for a fortnight.

Atresia ani vestibularis is operated by making an incision around the fistula and extending it downwards to the perineum. Silk holders are applied to the fistula and the rectum is widely mobilized on the perineum, af­ter which it is fixed to the muscles in the pelvic dephts. The freed fistulous tract is cut off together with an area of rectum (Fig 147,2) and the rims of the rectal opening thus formed are sutured into the perineal wound.

Sutures are then applied to the perineal skin up to the entrance to vagina (Fig. 147,3). The perineal wound is left open without dressing, and a plaster bandage is applied to the knee points for a fortnight.

When a vaginal or vestibular fistula is present a more or less formed anal orifice may be observed. In this case it is recommended to make an oval incision of the perineum over the anal opening with separation and division of the fistula. The wound on the vaginal wall and that on the rectum are sutured separately.

Atresia perinealis et scrotalis. The operation is per­formed according to the vital signs within 1 or 2 days after birth. The patient is placed in the supine position with the thighs flexed on tie abdomen and a bolster be­neath the sacrum. Under local anesthesia with a 0.25 no-vocain solution, an incision is made around the fistula and is extended downwards to the perineum (Fig. 148,1). Holders are then applied to the fistula, which is dissec­ted away and the rectum is mobilized (Fig. 148,2). The mobilized rectum is fixed to muscles deep within the pel­vis, the fistula is cut off together with a portion of rec­tum and the opening thus formed is sutured into the perineal wound as stated above (see Fig. 147.3). Sutures are then applied to perineal skin.

The wound is left open, and a soft bandage is applied to the knee joints for 7—10 days.

Schematic representations of anal and rectal atresias. The names for individual formas of atresia are given in the text

Application of a plaster bandage after perineal operation in children. (Schematic)

Operation for atresia ani

Operation for rectourethral atresia

Operation for rectovesical atresia

Operation for rectoperineal atresia

Fig. 139 Schematic representations of anal and rectal atresias. The names for individual formas of atresia are given in the text.

Fig. 140 Application of a plaster bandage after perineal operation in children. (Schematic).

Fig. 141. Operation for atresia ani. (See text).

Fig. 144. Operation for rectourethral atresia. (See text),

Fig. 145. Operation for rectovesical atresia. (See text).

Fig. 146. Operation for reetovaginal atresia. (See text)

Fig. 147. Operation for rectovestibular atresia (see text).

Fig. 148. Operation for rectoperineal atresia (see text).



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