rectal instruments

PLASTIC OPERATION ON THE ANTERIOR WALL OF RECTUM, VAGINA AND SPHINCTER IN WOMEN FOLLOWING OBSTETRICAL TRAUMA


By • Дек 21st, 2010 • Category: Rectum

This operation is performed in women suffering from sphincteric weakness and perineal deformity due to an obstetrical trauma or other injuries. A common sequela of such trauma is the absence, of anterior perineum, with the mucosa of the posterior vaginal wall fusing with the anterior rectal wall to form a narrow transverse band (Fig. 136). The anterior sphincteric segment is either absent or thinned out by scars.

The patient is placed in the same position as for hemorrhoidectomy. Local, inhalation, or endotracheal (with azeotropic mixture) anesthesia is employed.

Initially, each labia minora is sutured to the adjacent part of thigh so as to provide a wider entrance to the vagina. From 100 to 120 ml of 0.25 per cent novocain so­lution should be injected into the rectovaginal septum (Fig. 137,1). A transverse incision 10—11 cm long is then made along the narrow band between the vagina and anus, and each edge of the resultant wound grasped with Allis forceps and retracted upwards and downwards. The posterior vaginal wall is next dissected free from the anterior walls of the anal canal and rectum for a considerable distance by sharp dissection with scalpel under the guidance of the finger introduced into the vagina (Fig. 137,2). The thinned-out anterior wall of the rectum is truncated by excising a wedge 1.5—2 cm in length (Fig. 137,3).

The triangular defect of rectal wall is now closed with 4 or 5 catgut sutures together with the raw edges of the sphincter, without including the rectal mucosa (Fig. 137,4). When placing these sutures, a finger should be introduced into the rectal lumen so as to prevent the needle from penetrating into the rectal lumen through mucosa. The margins of the anterior portion of the leva-tor ani muscle are now approximated along the midline and widely sutured with stout catgut (4 sutures are ap­plied). In this way the rectovaginal septum of the peri­neum is strengthened.

The vaginal wall, which has been dissected off up­wards, is then also decreased in size by excising a tri­angular flap, 4—5 cm long and 3—4 cm wide at its base (Fig. 137,5).

The edges of the resulting triangular vaginal wound are united by means of interrupted catgut su­tures the needle first pierces the entire vaginal wall ex­cept for mucosa and then takes a bite of the anterior rectal wall, to emerge on the other side uf the vaginal wound (Fig. 137,6).

In tying these sutures (in all 4 or 5 such sutures are applied) from the vaginal side, the edges of the vaginal wound are approximated while the posterior vaginal wall is sutured to the anterior rectal wall. Silk sutures are laid on the skin both in the transverse and longitudinal directions, with the transverse sutures forming a skin pe­rineum. A thin rubber or polyvinyl tube is inserted for 48 hours between the sutured vaginal wall and the rec­tum (Fig. 137,7).

If there is a large ciractricial skin defect, it is advisable to mark out and dissect away a thick skin flap on the left-hand side of the wound, stretch it over the perineal wound and suture it to the opposite skin edge as shown in Fig. 137,8. The edge of vaginal mucosa and that of the rectum are then sutured to the anterior and posterior margins of the flap, respectively.

The postoperative care of the patient is the same as in rectovaginal fistula (see Fig. 86,7).

Procto-vagino-sphinctero plastic operation

Procto-vagino-sphinctero plastic operation

Fig. 136. Varieties of perineal deformity following an ob­stetrical or accidental trauma.

Fig. 137. Procto-vagino-sphinctero plastic operation.

1. 0.25 per cent novocain solution is introduced into the rectovaginal septum.

2. The posterior vaginal wall is dissected free with scalpel from the anterior rectal wall.

3. Excision of a triangular wedge from the scarchan-ged anterior rectal wall.

4. The triangular rectal defect is sutured with catgut without involving the mucosa (under the control of the surgeon’s finger introduced into the rectum).

5. A triangular flap is removed from the dilated pos­terior vaginal wall.

6. The triangular vaginal defect is closed with catgut sutures taking bites of the anterior rectal wall.

7. Appearance of the perineal wound following appli­cation of longitudinal and transverse sutures.

8. The skin defect of the anterior perineum is closed with a flap of skin taken from the left side of the wound.



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