rectal instruments


By • Дек 18th, 2010 • Category: Colon

Combined resection of the entire descending colon, splenic flexure, and distal transverse colon is performed in those cases when the growth is localized in one of these portions of the colon (see the Korte chart, Fig. 170).

After such a resection intestinal continuty is restored by creating an anastomosis between the transverse and sigmoid colon. When there are signs of intestinal obs­truction, a cecostomy or colostomy in the right half of the transverse colon should be done as a preliminary to this operation.

With a stenosing tumour of the splenic flexure, the sigmoid stump may be sutured following the resection and the open end of transverbe colon exteriorized as a temporary stoma.

The patient is placed on his back; in the course of the operation the operating table is tilted to the right. Endotracheal ether-oxygen or azeotropic mixture ane­sthesia is employed.

A median incision of the abdominal cavity is made, being curved to the left above the umbilicus (6 cm from it) to run as far as the anterior axillary line (Fig. 176.1).

After opening the peritoneum the surgeon palpates the liver and transverse colon (together with its me­sentery) for metastases.

The operating table is now slightly turned to the right, and the surgeon shifts the small gut to the right side of the abdominal cavity to be held there by a large gauze square.

With the assistant now drawing the left wound angle and a triangular flap of the abdominal wall to the left with blunt retractors, the surgeon pulls the descending colon taut to the right and dissects with scissors the pe­ritoneal reflection to the left of the descending colon along its entire length, i. e. from the sigmoid to the splenic flexure (Fig. 176.2). Usually, this incision pas­ses along an avascular line of the peritoneum.

The bowel is now cautiously separated bluntly by swab dissection from the posterior abdominal wall to the right, gradually exposing the lower half of the kid­ney, musculus quadratic lumborutn, musculus psoas major, and left urether (Fig. 176.3).

The incision of the posterior parietal peritoneum to the left of the bowel is then continued upwards to the splenic flexure where, following its clamping, the colic ligament connecting the colon with the diaphragm and spleen is severed (Fig. 176.4).

The next step is division between clamps and liga-tion of the left quarter (in some cases the left third) of the gastrccolic ligament, taking care to avoid injury to the transverse mesocolon.

The descending colon and splenic flexure thus libe­rated are then taken out of the wound and rendered taut by the assistant, with the surgeon dividing bit by bit the «mesentery» (i. e. internal peritoneal leaf) of the descending colon and part of the transverse mesocolon, sacrificing the left colic artery and vein (Fig. 176.5).

Following ligation of the mesentery the surgeon se­parates the omentum from the left quarter of the trans­verse colon in an area free of vessels, and removes the freed part of omentum along its entire length.

Two clamps are then applied to both proximal and distal ends of the bowel segment to be removed. The bowel is isolated by gauze, cut off on both sides with a knife near the stiff clamps (Fig. 176.6) and removed.

The mucosa of both the stumps is painted with iodine tincture, the soft clamps are brought together, and an end-to-end anastomosis is performed between the trans­verse colon and sigmoid stumps. The technique for this anastomosis has been described earlier (see Fig. 171.5,6,7 and 8). After completing the anastomosis, careful perito-nealization of the posterior abdominal cavity wall is car­ried out (Fig. 176.7). If in the splenic flexure the perito­neum cannot be stretched over the retroperitoneal fatty tissue defect, the latter may be closed with omentum. In conclusion the assistant inserts per anum a thick soft rubber tube into the sigmoid, with the surgeon passing this tube up above the anastomosis.

The abdominal cavity is closed completely, with the cut rectus muscle carefully sutured in two layers.

Resection of descending colon and splenic flexure

Resection of descending colon and splenic flexure

Fig. 176. Resection of descending colon and splenic flexure:

1. Incision line of the anterior abdominal wall.

2. The surgeon is dissecting with scissors the perito­neal reflection along the left margin of descending colon.

3. Using a swab, the surgeon separates the descend­ing colon from the posterior abdominal wall to the right (towards the midline).

4. Division of the colicolienal ligament under forceps control.

5. Dissection of the «mesentery» (internal peritoneal leaf) of descending colon between clamps.

6. Cutting off the mobilized splenic flexure and des­cending colon between clamps.

7. Anastomosis has been established, and peritoneali-zation performed. (Schematic). A rubber tube is passed into the bowel (indicated by dotted lines).

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