rectal instruments


By • Дек 18th, 2010 • Category: Colon

The transverse colon is in most cases resected for a cancer localized in its second and third quarters. With the tumour located in marginal regions of the transverse colon, i. e. in the neighbourhood of the hepatic or sple­nic flexure, a more extensive resection is indicated, i. e. right hemicolectomy or concurrent removal of the des­cending colon. Resection of the transverse colon may be also resorted to in cases with gastric-transverse colon fistulas and for some other non-malignant lesions.

The patient is prepared as for radical operations on the colon.

Under endotracheal anesthesia with ether and oxygen or with azeotropic mixture and with the patient lying su­pine with a flat bolster under his loins, a transverse in­cision is made of the abdominal wall 1—2 cm above the palpable tumour or 5 cm above the umbilicus, with trans­verse division of both rectus muscles (Fig. 177.1). After opening the abdominal cavity, the extent of the growth and the presence or absence of metastases in the liver and lymph nodes are ascertained by palpation. The gas-trocolic ligament is next cautiously dissected between two Billroth forceps keeping close to the stomach. The surgeon then introduces his fore finger into the lesser omentum cavity to control the division and ligation bet­ween the forceps of the gastrocolic ligament (Fig. 177.2), so as to free on both sides the entire portion of the trans­verse colon to be removed. During this maneuver care must be exercised to avoid injury to the transverse meso-colon.

The greater omentum is elevated and freed in its en­tirety from the transverse colon by scissors in an avas-cular area (Fig. 177.3). The omentum is then cut across between forceps in the right and left corners of the wound and removed completely.

With the assistant pulling the transverse colon toge­ther with the tumour upwards, the surgeon now applies two clamps on both sides of the transverse colon seg­ment to be removed. One of these clamps (close to the tumour) is hard (Ochsner clamp), and the other, 2 cm from the first one, soft (preferably covered with rubber) (Fig. 177.4).

Now a transilluminator is used to define the course of the middle colic artery and the condition of the mar­ginal artery and of the marginal intestinal arcades. In dissecting off a wedge-shaped portion of the mesentery, it is advisable to preserve, as far as possible, the integri­ty of the middle colic artery and ligate only those of its, branches coursing to the centre, as well the marginal ar­tery of the transverse colon.

After removal of the operative specimen the soft clamps are approximated, and the surgeon starts perfor­ming an end-to-end anastomosis, after painting the mu-cosa of both the stumps with iodine tincture (see also Fig. 171,5,6,7 and 8).

The next step is insertion of posterior seromuscular sutures 1—1,5 cm from the cut bowel edge (Fig. 177.5), followed by inserting first the posterior and then the an­terior row of interrupted sutures of the anastomosis to include all layers of the bowel (Fig. 177.6). The soft clamps are now removed and a second anterior row of interrupted seromuscular sutures is applied. Finally, the window of the transverse mesocolon in carefully sutured (Fig. 177.7). The remainder of the gastrocolic ligament which is now attached only to the stomach is sutured with 4—5 fine sutures to the upper edge of the trans7 verse colon, and an antibiotic solution is instilled into the abdominal cavity.

In closing the abdominal cavity, it is necessary to ca­refully suture with stout silk both the anterior and pos­terior sheaths of the rectus muscle (together with musj cular tissue). I believe that this operation should be in­variably followed by cecostomy (see p .198, Fig. 153).

Resection of transverse colon

Resection of transverse colon

Fig. 177. Resection of transverse colon:

1. Transverse incision of the anterior abdominal wall 5 cm above the umbilicus or 1—2 cm above the palpable tumour.

2. The gastrocolic ligament is dissected on the finger by scissors between Billroth forceps.

3. The greater omentum is separated from the trans­verse colon by scissors in a vessel-free area.

4. Following division of its mesentery, two pairs of clamps are applied to the transverse colon. The sup­plying vessels are visualized.

5. The posterior row of interrupted silk sutures of the end-to-end anastomosis has been placed.

6. A continuous circular (posterior and anterior) silk suture is applied by means of a curved needle.

7. The anterior seromuscular anastomotic suture has been completed; sutures have also been placed on the rnesenteric window.

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