rectal instruments

Perineal phase

By • Дек 19th, 2010 • Category: Rectum

This phase consists of complete removal, by the peri-neal route, of the rectum and distal sigmoid (which have been previously freed and brought down to the pelvis).

Leg rests are fixed to the table and the patient is slowly changed to the lithotomy position (see Part I, Fig. 23).

Having prepared the operative field, the surgeon lays a purse-string suture around the anal orifice, ties it, and cuts off its ends. An oval incision is then made through the skin and subcutaneous fat to surround the anus at a distance of 2.5—3 cm (Fig. 157.1). The skin and subcutaneous iat are stripped off to the depth and to the centre, the wound edges are approximated along the midline and grasped with Allis forceps on both sides (Fig. 157.2).

Under the forceps, the skin edges are sutured with interrupted silk, the forceps are removed and the stitches are tied on a gauze roll and left as stays.

In dissecting off the fat to the midline, the surgeon exposes the under surface of the levator ani muscle. This is incised laterally and posteriorly, the index fin­ger is introduced into the opening thus formed, and the entire muscle is gradually dissected on the finger (Fig. 157.3) with scissors around the full circumference of the rectum. To control hemorrhage a Billroth forceps should be applied to the muscular fibers of the levatores ani external to the finger prior to the dissection. This ma­neuver invariably involves division of the anococcygeal ligament.

After passing the fingers and half of the right hand into the retrorectal space along the anterior surface of the coccyx and sacrum, the surgeon grasps the previ­ously mobilized rectum and pulls it to the outside to­gether with a part of the sigmoid colon (Fig. 157.4).

Now the rectum is held in the pelvis only by the prostatic and bulbocavernous muscle attachments of its anterior semicircumference Carefully pulling the rectum downwards, the surgeon uses in turn scissors and a swab to separate the rectum from these organs (from the vagina in females).

Following careful hemostasis in the pelvic by means of stitching, gauze packs abundantly soaked with Vish-tievsky ointment are introduced into the extensive peri-heal and pelvic wound (Fig. 157.5).

The postoperative management of patient follows the lines described on page 42, Part I.

The exteriorized bowel is opened 24 hours after the operation, and a thick rubber tube is introduced into its lumen.

The formation of iliac stoma is completed 10 days after the operation (the bowel should protrude 4 cm above the skin level).

Appearance of the abdominal wall two days after the Quenu-Miles operation is shown in Fig. 157.6.

Variant of operation in cases with lesion of the po­sterior vaginal wall. If the posterior vaginal wall or the rectovaginal septum is affected, it is removed together with the perianai skin and anterior perineum by making two parallel incisions of the vagina almost as far as the posterior vaginal fornix (Fig. 158.1). After deepening these incisions and stripping apart the walls of dissec­ted vagina, the surgeon separates the levator ani mus­cles as described above (see Fig. 157.3) and proceeds to remove en bloc the rectum together with the poste­rior vaginal wall spread on the rectal stump. This is followed by suture of the posterior vaginal wall from the perineal wound side by means of burying sutures (Fig. 158.2) without involving the mucosa. It is more advisable to insert two layers of suture. Packs are then applied to the perineal wound.

Abdominoperineal excision. Perineal phase:

Abdominoperineal excision. Variant of operation when the posterior vaginal wall and rectovaginal septum are affected with lesion

Fig. 157. Abdominoperineal excision. Perineal phase:

1. The anal opening has been closed with pursestring suture.

2. After the perianal skin has been stripped off to the centre, its edges are brought together in the middle and grasped with forceps.

3. Dissection of the levator ani muscle under forceps control.

4. The rectal and sigmoid stumps have been exterio­rized through the perineal wound.

5. Ointment packs have been introduced into the pel­vic cavity through the perineal wound.

6. Appearance of the abdominal wall after the Quenu-Miles operation.

Fig. 158 Abdominoperineal excision. Variant of opera­tion when the posterior vaginal wall and rectovaginal septum are affected with lesion:

1. Longitudinal incisions of the posterior vaginal wall and anterior perineum.

2. Closure of the defect of the posterior vaginal wall from the perineal wound side

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