rectal instruments


By • Дек 19th, 2010 • Category: Colon

In most cases sigmoidectomy is a single-stage opera­tion making possible full restoration of intestinal pa­tency by means of an end-to-end anastomosis. And it is only in cases of acute or chronic obstruction of the sig-moid that this has to be externalized and cut off toget­her with the tumour, with establishment of a loop sig-moidostomy. If it is twisted and necrosed, the sigmoid should be resected, its distal end closed completely, and the proximal end brought out as a terminal sigmoidostomy.

In performing the end-to-end anastomosis following resection of the sigmoid, use is made of both the exist­ing methods of intestinal anastomosis, the open and clo­sed techniques.

As a rule, we perform, after sigmoidectomy, proximal decompression, i. e., formation of cecostomy or, occasio­nally, transverse colostomy. Today in addition to we pass a thick rubber tube per rectum into the sigmoid in order to protect the anastomotic sutures, with the surgeon di­recting this tube from the abdominal side higher, above the anastomosis level.

The patient is prepared exactly as in standard colo-nic operations.

With the patient in the supine position with his legs fixed to the table and under combined anesthesia with azeotropic mixture, the abdominal cavity is ope­ned through a median incision running from the mons pubis to a point 3 cm above the umbilicus. The patient is then changed to the Trendelenburg position and the small gut drawn upwards and held there with the aid of moist gauze squares.

Drawing the sigmoid to the midline and to the right by his hand, the surgeon now makes another slightly curved incision of mesosigmoid and carries it down to the pelvis 2—3 cm below the promontory level (Fig. 171.1).

The edge of the cut peritoneum and mesosigmoid fat are then cautiously displaced with a swab upwards to moist gauze squares.

Next, the surgeon draws the sigmoid to the left and dissects the mesosigmoid peritoneum by a slightly cur­ved incision (Fig. 171.2) which is brought down to the lesser pelvis to a level corresponding to the first incision. At this stage the wound has already penetrated the en­tire mesosigmoid.

After ligating and dividing one or two sigmoid arte­ries in the fatty tissues, the surgeon severs the mesosig-moid between clamps and approaches the sigmoid wall in turn first from below (distally) and then proximally, so that the limits of the sigmoid segment to be removed are spaced 6—9 cm from the tumour on either side (Fig .171.3). In dividing the mesentery and ligating the vessels, the surgeon must avoid injury to the stem of the superior rectal artery which is defined by palpation or transillumination.

Both segments of the sigmoid — proximal and distal-where the bowel is to be severed are now freed from me­sentery for a distance of 3 cm, and two stiff clamps are applied equidistantly to the sigmoid segment to be remo­ved. Additionally, two narrow soft clamps with their bla­des covered with rubber tubing are applied to the sig­moid 2—2.5 apart from each of the stiff clamps (Fig. 171.4).

The operative field under the bowel to be removed is next surrounded with two large gauze squares, and the surgeon sections the sigmoid with a sharp scalpel in two places between the clamp jaws, so that the incision line passes just next to the stiff clamps.

Following removal of the operative specimen, the as­sistant uses soft clamps to turn both opened sigmoid stumps and then approximates them for the purpose of anastomosis.

The surgeon now opens the sigmoid lumen with a forceps and paints the mucosa of both stumps from inside with a 2 per cent iodine tincture.

Now the surgeon grasps both appositional stump walls with 4 Billroth forceps (two forceps on each edge of the cut sigmoid) and everts the posterior walls of the sig­moid stumps prior to the insertion of the first row of anastomotic sutures.



Fig. 171. Sigmoidectomy:

1. Incision of mesosigmoid peritoneum on the left: the incision is carried slightly downwards to the lesser pel­vis.

2. Incision of mesosigmoid peritoneum on the right. The sigmoid arteries are ligated.

3. Division of mesosigmoid between clamps in two-directions (proximal and distal) relative to the tumour.

4. Resection of the freed portion of sigrnoid together with tumour.

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