rectal instruments

PERINEAL AMPUTATION OF THE RECTUM


By • Дек 19th, 2010 • Category: Rectum

We employ perineal amputation of the rectum in tho­se cases when the abdominoperineal operations carry in­creased risk, i. e. in very obese patients, in persons aged between 70 and 80, and in patients with general or local contraindications to abdominoperineal interven­tions. These include noncompensated cardiovascular disea­ses, pulmonary lesions, hepatic and renal insufficiency, etc. In such we perform the operation under local anest­hesia according to A. V. Vishneusky.

A prerequisite for perineal amputation is the require­ment that the entire tumour (that is including its upper pole) could be swept around by the finger and that it is not completely fixed.

The patient is prepared along the same lines as in co-Ionic operations (see Part One) and placed on his right side with the legs flexed in the hip-joint and accomoda-ted on a special table (Fig. 167). The operation is perfor­med under general anesthesia with azeotropic mixture or with ether and oxygen or under local anesthesia accor­ding to A. V. Vishnevsky, the latter type of anesthesia being used, as already mentioned, in gravely ill or wea­kened patients with lesions of the witally important or­gans. If properly conducted, local anesthesia according to A. V. Vishnevsky ensures complete loss of sensitivity, and it is essential that exactly 150 ml of 0.25 per cent novocain solution be injected into the presacral space, 50 ml into each ischiorectal space and 50 ml into the an­terior perineum region. The technique of local A. V. Vish­neusky anesthesia is depicted in Fig. 168.

An indwelling catheter is introduced into the bladder, and the anal orifice is closed with a purse-string suture (see Fig. 157.1).

A wide incision is started along the line of anesthesia over the sacrum and coccyx and then doubled and car­ried along the anal circumference to terminate on the anterior perineum (Fig. 169.1. Schematic). The perianal skin is dissected off inwards and sutured over the anus with 4—5 stout silk stitches whose knots take in the gauze roll as shown in Fig. 169.2. The suture ends are not cut off, being left to serve later as stays to enable the rectum to be displaced and pulled out.

The next step is removal of the coccyx. To do this, the surgeon deepens the wound over the sacrococcygeal region and dissects off the skin and subcutaneous fat on both sides. Next the assistant draws apart the wound ed­ges with retractors, while the surgeon divides the lateral coccygeal ligaments on both sides with a sharp scal­pel and frees the top of the coccyx. This is now lifted with forceps and the internal (ventral) surface of the coccyx is freed with a raspatory to a height of some 5 cm. The surgeon then inserts a spatula under the coc­cyx and uses a chisel and mallet to detach it form the sacrum (Fig. 169.3).

Following removal of the coccyx, the posterior surface of the rectum is bluntly moved forward with a swab and partly peeled off from the concave surface of the sac­rum. A large gauze square is now temporarily introduced into the extensive retrorectal space thus formed (Fig. 169.4).

Next the surgeon exerts traction on the stays and de­epens the perinea! wound around rectal circumference in such a way that the bulk of the ischiorectal fat remains attached to the rectum (Fig. 169.5).

After securing hemostasis, the surgeon starts dissec­tion of the levator ani muscle (see Fig. 157,3). This is done under digital control after clamping the muscle with Billroth forceps (Fig. 169.6). When the levatores have been divided circumferentially, hemostasis is insti­tuted by ligating the muscle under the Billroth forceps.

Next, the surgeon starts separating the anterior sur­face of the rectum. In females, the vagina is detached from the rectum by a swab or scissors under the control of the index finger passed into the vagina. In males, mo­bilization of the anterior rectal wall is more difficult be­cause the prostate is taken in by the anterior semi-cir­cumference of the common rectal fascia (Denonvilliers’ aponeurosis), and the surgeon has to palpate with his left index finger the prostate and the catheter and then, keeping close to the bowel, to dissect this fascia cauti­ously with scissors and to detach the prostate (together with the catheter) from the anterior rectal wall. (This separation is facilitated by injecting novocain solution between the rectum and the prostate). Following this step it is necessary to grasp with Billroth forceps and divide the lateral rectal ligaments (Fig. 169.7). The gau­ze square introduced into the retrorectal space earlier, is now withdrawn, and the rectum drawn forwards to the left of the surgeon. In the wound depth, the posterior rectal wall and its vessels are well visualized. These ves­sels are grasped with Mikulicz clamps, divided between thorn and ligated with stout silk, preferably by stitching (Fig. 169,8), and the posterior half of rectal circumferen­ce is freed.

With low-lying tumours (not higher than 5 cm from the anal verge), the just described mobilization of the rectum may prove to be sufficient, for it ensures a 5— 1 cm increase of its length. In such cases the distal rec­tal end with the tumour .should be cut off (8—9 cm from the anal verge), and the edges of intestinal stump be su-tured to the sacral wound skin (Fig. 169.9).

In most cases, however, the peritoneum has to be dis­sected along the lateral or anterior semicircutnference of the rectum as well. Pulling the rectum to the right to­ward himself the surgeon dissects the pulled-through por­tion of peritoneum of the pouch of Douglas by means of long scissors (Fig. 169.10).

The peritoneal wound edges are then grasped with Mikulicz clamps, the surgeon’s index finger is passed in­to the pouch of Douglas, and the peritoneum is cut on the surgeon’s finger around the entire rectal circumferen­ce, so that the rectum is left attached to the sacrum only by its posterior surface.

In order to pull the bowel still further to the outside from the lesser pelvis, its mesentery should be ligated and divided. With the assistant exerting traction on the bo­wel to the left of the surgeon, this grasps the mesente-ric vessels with Billroth forceps under visual control, and then divides and ligates them with silk. In this way, pulling the stay sutures, the surgeon can divide conside­rable portions of mesosigmoid and externalize the rec­tum, and the tumour (Fig. 169.11). The externalized bo­wel is then ligated with stout silk 8—10 cm above the tumour and cut off with scissors just below the ligature.

The peritoneal edges of the pouch of Douglas are su­tured with 4—5 fine stitches to the serosa of the pulled-through bowel around its entire circumference (Fig. 169.12).

The remainders of the levator ani muscle are sutured with each other in the left corner of the wound. The li­gated bowel sturnp is then drawn to the right wound corner to the former site of the now removed coccyx.

Following careful hemostasis, the lesser pelvic cavity is loosely packed with a gauze strip soaked in Vishnev-sky ointment.

The skin of the perineal wound and of the buttocks is sutured, together with subcutaneous fat, by means of stout silk stitches, so that the end of the gauze pack is brought to the outside 3—4 cm to the left of the bowel stump (169.13).

The bowel is now again dissected transversely just above the ligature, its edges are grasped with forceps, its cavity is painted with a 3 per cent iodine tincture, and the stump is sutured all around to the skin wound edges with 5—6 stitches (see Fig. 169.9).

A cotton-gauze dressing is applied to the operative wound. The indwelling catheter is left inside for 3 or 4  days. The patient is given opium tincture for 5 days: the ointment pack is removed from the wouiiv in 4— 5 days.

Local anesthesia according to A. V. Vishnevsky in perineal amputation of the rectum

Fig. 167. The patient is lying on his right side; the legs are flexed in the hip-joints and accomodated on an ad­ditional table.

Fig. 168. Local anesthesia according to A. V. Vishnevsky in perineal amputation of the rectum.

Perineal amputation of the rectum for cancer

Perineal amputation of the rectum for cancer

Perineal amputation of the rectum for cancer

Fig. 169. Perineal amputation of the rectum for cancer:

1. Schematic representation of the incision line.

2. The skin over the anal orifice has been closed with 4 stout sutures taking a gauze roll into the ties.

3. Separating the ligament-freed coccyx by chisel and mallet (the wound has been widely drawn apart with retractors).

4. A large gauze square has been introduced through the wide wound into the stripped-off retrorectal space to secure hemostasis following removal of the coccyx.

5. Applying traction on the stay sutures, the surgeon dissects off the rectum along with the ischiorectal fat surrounding it.

6. The surgeon’s index finger has been introduced un­der the levator ani muscle, and this is dissected with Cowper’s scissors over the finger.

7. Division of lateral rectal ligaments at the prostate level.

8. Ligation and dissection of vessels, and transverse separation of fatty tissue of the posterior half of bowel circumference.

9. The sigmoid stump has been sutured circumferen­tially with 5—6 sutures to the skin wound margins.

10. Opening the peritoneum of the pouch of Douglas; the peritoneal edges are grasped with Mikulicz clamps.

11. Pulling of the freed rectum and a considerable portion of the sigmoid through the perineal wound.

12. The sigmoid has been ligated and cut off, and the peritoneal edges of the pouch of Douglas are sutured to serosa surface of the sigmoid in the wound depth.

13. The skin wound of the perineum has been closed, and a pack brought out to the left of the ligated bowel stump.



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