rectal instruments

PERINEAL PHASE


By • Дек 19th, 2010 • Category: Anus

The perineum is first carefully painted with iodine two times, and an alcohol — soaked squeezed — of gauze pack is passed high into the rectum and left in the rectal ampula.

The assistant now grasps the edges of the anal ori­fice with Allis forceps at 4 equidistant points and draws them apart so as to expose the anal mucosa up to the pectinate line, with the surgeon making a shallow circu­lar incision with scalpel or scissors at the level of this line. (Fig. 165.1).

Having grasped the edges of this incision with a small Billroth forceps on the right, the surgeon in turn uses scissors and a small gauze swab to carefully strip the rectal mucosa free from the sphincter around its enti­re circumference grasping, step by step, the mucosal ed­ges with Billroth forceps. The walls of the cuff thus for­med are united longitudinally and picked up with Bill­roth forceps to close the rectal lumen (Fig. 165.2).

The anal wound edges are now pulled apart, along with the sphincter, by means of Farabef retractors, with the surgeon drawing the mucosal cylinder towards himself and laterally and dissecting it off upwards with scissors for a distance of 2.5—3 cm (Fig. 165.3).

At this level the surgeon separates, by means of Cowper’s scissors and finger, the muscular and connecti­ve tissue coats outwards around the full circumference of the rectum thus gaining access to the perirectal fatty tis­sue of the pelvis.

The Farabef’s retractors are now replaced by broader blunt retractors, the surgeon draws the bowel towards himself with Billroth forceps and dissects away not only the rectal mucosa but all its walls as well.

With the assistant drawing the anal wound down­wards together with the sphincter (Fig. 165.4), the sur­geon lift up the mobilized rectal wall and dissects poste­riorly the anococcygeal ligament and the adjacent porti­ons of the levator ani muscle (pelvic diaphragm).

After handing the Billroth forceps that holds the bo­wel to the assistant, the surgeon inserts the left index finger into the wound and dissects the levator ani muscle around the rectal circumference.

The levator fibers are next severed following applica­tion of clamps to stop muscular bleeding (Fig. 165.5).

Having divided the levator ani fibers, the surgeon passes his fingers into the lesser pelvic cavity where the rectum has been previously freed all around except for the anterior wall adjacent to the vagina.

The assistant now enlarges the anal wound upwards and laterally, while the surgeon draws the bowel toward himself and downwards and cautiously separates by scis­sors and, mainly, by finger dissection the anterior rectal wall from the vagina (prostate), the surgeon’s left finger being in the vaginal cavity to avoid injury to the vagi­na (Fig. 165.6).

Having freed the anterior rectal wall along its enti­re length, the surgeon pulls the now fully mobilized rec-tosigmoid through the forceps-widened anal orifice as far as the level of the marker sutures (Fig.165.7).

The assistant standing at the abdominal wound now helps pull through and place the sigmoid properly in the pelvis. A counter opening is next made 3—4 cm to the right and behind the anus, and a rubber tube is passed through this opening to be left there for 3—5 days.

The sphincter is now sutured, above the anal mucosa, with 5—6 catgut stitches to the serosa of the adjacent sigmoid around its entire circumeference above the mai-ker sutures.

The needle should pierce the sphincter transversely (along the course of its fibers) and the bowel serosa lon­gitudinally (Fig. 165.8).

The rectum is then cut off at the skin level and the sigmoid is sutured circurnferentially to the anal mucosa (Fig. 165.9).

A balsamic-oil pack is then introduced into the coun-teropening near the previously inserted rubber tube.

A vaseline or Vishnevsky ointment dressing is applied to the perineum.

The surgeon now changes his gown and gloves and turns his attention to the abdominal wound, completing peritonization of the pelvis using the mesosigmoid for this purpose. The anterior abdominal wall is then comp­letely closed.

Pull-through operation

Pull-through operation

Fig. 165. Pull-through operation:

1. Circular incision of the anal mucosa over the pec­tinate line.

2. The dissected mucosal cuff is grasped with Bill­roth forceps that close the bowel lumen.

3. The mucosa! cylinder has been dissected free for 2,5 cm, and the anal canal (with sphincter) is dilated with blunt retractors.

4. Dissection of the anococcygeal ligament behind the bowel.

5. Scissors dissection of levator fibers around the rectum on the left index finger.

6. The surgeon’s index finger is passed into the va­gina, and the posterior vaginal wall is separated by scis­sors from the anterior rectal wall.

7. The exteriorized rectosigmoid is pulled through the distended anal orifice.

8. The bowel stump has been tied with stout thread, the sphincter is sutured with fine silk along the fibers, and the bowel serosa is sutured longitudinally by the same threads using a round needle.

9. The sigmoid has been sutured to the anal mucosa. circurnferentially.



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