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THE KOMMEL-ZERENIN OPERATION: (Fixation of the rectum to the sacrum by the abdominal route)

By • Дек 26th, 2010 • Category: Rectum

This operation is intended for non-obese patients bet­ween 35 and 55 years of age and free from cardiovascu­lar diseases. The operation gives good results, the inci­dence of recurrences not ecceeding 12 per cent.

Under inhalation anesthesia, preferably using an aze-otropic mixture, and in the supine horizontal position, the abdominal cavity is opened and the patient is changed to a Trendelenburg position, being tited through 12° to the horizontal.

With the pelvic colon picked up by the surgeon’s hand and pulled upwards, the mesenteric peritoneum is incised from the promontory to the 3d sacral vertebra (Fig. 119,1) and the outer margin of the peritoneum is grasped with Billroth forceps. After the sacral fascia has been incised, the rectum is bluntly dissected off to the left of the sacrum by means of a swab, and the sacral perio­steum is exposed (Fig. 119,2). The rectum is then drawn away to the left with a retractor.

Using a curved cutting needle, 4 thick silk ligatures are then applied to the anterior sacral surface, starting from the promonotory and involving the periosteum (Fig. 119,3).

The ligatures are then handed to the assistant who draws the sigmoid colon taut upwards, while the surgeon, by threading the left end of the ligature in turn on a round needle, sutures the sigmoid posteriorly and laterally (Fig. 119,4) so as to include the peritoneal margin remaining on it.

The sutures on the pulled-up sigmoid are then tied tightly with a triple knot, beginning with the inferior (coccygeal) suture (Fig. 119,5).

Next, the right-hand margin of the peritoneal flap is sutured to the anterolateral surface of the fixed rectum with silk ligatures (Fig. 119,6).

The assistant now inserts a thick rubber tube into the rectum, the surgeon directing the tube slightly supe­rior to the promontory.

The abdominal cavity is sutured with silk interrupted sutures through all its layers, except for the skin. (Fig. 120.1).

While each of the sutures is being tied by the sur­geon, the assistant crosses the threads of the next su­ture (Fig. 120,2). The operation is completed by placing sutures on the skin.

No opium tincture should be given to the patient. The rubber tube is removed in 2 or 3 days, usually af­ter a bowel action.

Exercises of the sphincter is to be started a month or so after the operation if needed

Complete closure of the abdominal cavity

Complete closure of the abdominal cavity

Fig. 119 Kiirnmel-Zerenin operation: fixation of the rec­tum to the sacrum by the abdominal route:

1. Medial inferior laparotomy has been performed, and the peritoneum incised on the pelvic colon mesentery,

2. The colon is moved to the left with a swab on a holder; the anterior sacral surface is exposed; the middle sacral artery is visualized.

3. Four thick silk sutures have been placed on the anterior surface of the promontory involving the perios­teum.

4. Using the same sutures in turn the surgeon puts several stitches on the rectum in a posteroanterior direc­tion so as to include peritoneum margin.

5. The surgeon tightly ties the sutures, which fix the rectum to the anterior surface of the sacrum.

6. The medial edge of the peritoneal flap is sutured to the anterolateral surface of the fixed rectum.

Fig. 120 Complete closure of the abdominal cavity:

1. Thick silk sutures are applied to all layers of the abdominal wall, excepting the skin.

2. The assistant raises and then crosses the threads of the next suture thereby approximating the margins of abdominal wound and helping the surgeon to tie the su­tures.

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