rectal instruments


By • Дек 19th, 2010 • Category: Colon

This operation is employed in those cases when the surgeon fears to perform a primary resection with im­mediate anastomosis, i. e. in cases with partial obstruc­tion when there is discrepancy in the caliber of the two parts of segments of bowel to be united. The Mikulicz-Grekov operation is also indicated in emaciated patients, in very old individuals, in persons with lesions of the cardiovascular system, and in some other cases.

With the patient in the supine position and under azeotropic mixture anesthesia or local anesthesia accor­ding to A. V Vishnevsky, a left oblique incision of the abdominal wall is made, somewhat longer than that used in ordinary sigmoidostomy (Fig. 173.1). The infe­rior iliac vessels have to be divided between clamps in the corner of the wound.

Following dissection of the peritoneum, the sigmoid colon is brought out along with the tumour, and the surgeon palpates with fingers of his left hand the meso-sigmoid root and abdominal aorta to see whether there are metastases to the lymph nodes.

The next step involves division of the mesosigmoid between clamps and its removal within the limits of the part of sigmoid intended for resection (Fig. 173.2).

Straight soft forceps are now applied to the proxi­mal and distal limits of the part of sigmoid to be re­sected (Fig. 173.3), and the both clamped portions of the sigmoid are approximated so that the bowel being removed forms a «double-barrelled» loop and its mesen-teric taenia is disposed in the direction of the patient’s umbilicus. To achieve this the handles of the soft for­ceps must be turned towards the surgeon (Fig. 173.4). Now the assistant pulls the forceps somewhat upwards, and the afferent and efferent portions of sigmoid are united under the forceps with 4—5 fine seromuscular su­tures (see Fig. 173.4) placed close to the free taenia of the bowel.

The abdominal wall wound is now closed in layers to the right and to the left of the exteriorized sigmoid loop, and the edge of parietal peritoneum is sutured to the skin wound edge all around the bowel circumferen­ce, as depicted in Fig. 154.3, with leaving long tails to be used for suturing the exteriorized sigmoid loop cir-cumferentially to the skin wound edges (see Fig. 154.4 and 5). A fat ointment gauze square is now laid under the forceps on the closed wound of abdominal wall, and the bowel loop is cut off by a diathermy knife over the forceps (Fig. 173.5). These are removed in 24 hours and a thick rubber tube is cautiously passed into the afferent loop of the double-barrelled sigmoidostomy.

Resection of the exteriorized sigmoid with establishment of temporary loop sigmoidostomy

Fig. 173. Resection of the exteriorized sigmoid with establishment of temporary loop sigmoidostomy:

1. A left oblique incision of the abdominal cavity.

2. Wedge-shaped excision of mesosigmoid within the limits of sigmoid segment to be removed.

3. Two clamps are applied to the sigmoid segment subject to removal.

4. The clamps have been brought together, and the sigmoid loop is disposed over them in double-barrelled fashion; both loc°p limbs are sutured under the clamps.

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