rectal instruments


By • Дек 19th, 2010 • Category: Rectum

In the past three years, more than 100 operations for low anterior resection have been performed in the clinic headed by the author, using the КД-28 apparatus for es­tablishing anastomosis by applying a mechanical suture of tantalum staples. This apparatus is described on page 50 (Fig. 50, 51 and 52).

The apparatus serves for single-motion establishment of intestinal anastomosis in an end-to-end or end-to-side fashion The lumen between the bowels being sutured is formed with the aid of a cylindrical knife by excising the bowel walls.

The patient is placed in the same position as in the Quenu-Miles operation (see Fig. 155.1).

Until the moment the anastomosis is established, this
operation is performed exactly as the low anterior resec­
tion of the rectum just described (Fig. 162.1, 2, 3, 4, 5, 6
and 7).

Having applied an angulated forceps to the rectum inferior to the tumour, the surgeon inserts, under the forceps, closely placed purse-string sutures of stout silk. A similar suture is then laid on the sigmoid colon above (proximal to) the straight forceps applied to it (Fig. 163.1).

A soft clamp is next applied proximal to the purse-string suture.

The rectum and a portion of the sigmoid are now cut off along with the forceps but preserving the purse-string sutures (Fig. 163,2).

The opened rectal and sigmoid stumps are painted with iodine tincture from inside, and the assistant, who stands between the separated legs of the patient, passes per anum the tube of the assembled and loaded appara­tus till its head («mushroom») emerges in the rectal lumen in the pelvis.

The assistant then rotates the screw of the apparatus to propel its head for a distance of 5—7 cm as far as the promontory (Fig. 163,3). (This head is attached to a movable internal rod). The purse-string suture on the rectal stump is now tied around the rod, and the sigmoid stump is put on the protruding head of the apparatus with the aid of the forceps that stretch it (Fig. 163.4).

The purse-string suture of the sigmoid stump is tied on the rod, the threads of both purse-string sutures are cut off, and the soft clamp is removed from the sigmoid stump (Fig. 163.5).

The assistant, who stands at the patient’s perineum, then rotates the external screw anticlockwise to approach the apparatus head to its body, thereby bringing into contact the intestinal stumps to be sutured (Fig. 163.6. Schematic).

The assistant engaged in handling the apparatus pres­ses strongly its movable handle thus suturing circumfer-entially the approximated bowel ends with staples, while simultaneously cutting out an opening for the anastomo­sis by means of a circular knife.

The apparatus is now carefully withdrawn per anum, and the surgeon applies a second row of seromuscular’ sutures to the anastomotic line at the depth of the pelvis (Fig. 163,7).

The key to successful anastomosis using the КЦ-28 apparatus lies in meticulous liberation of the intestinal tnds being united from fatty attachments and tissue.

The operation is completed by reconstructing the pel­vic floor peritoneum over the anastomotic line (Fig. 163.8).

Prior to closing the abdominal cavity, the assistant introduces per anum a thick rubber tube above the anastomosis.

Low anterior resection of the sigmoid using the КЦ-28 apparatus

Low anterior resection of the sigmoid using the КЦ-28 apparatus

Fig. 163. Low anterior resection of the sigmoid using the КЦ-28 apparatus:

1. Application of a closely placed purse-string suture around the rectal circumference under the forceps and to the sigmoid colon over the forceps.

2. Opening the rectal and sigmoid stump and applica­tion of purse-string sutures to them.

3. Head (mushroom) of the apparatus has been pu­shed forward to the promontory level.

4. Sigmoid stump is being put on the apparatus head (mushroom) with the aid of Allis forceps. Schematic.

5. Purse-string suture on the stumps has been tight­ened and its end cut off.

6. Ends of the bowels to be connected have been ap­proximated on the apparatus rod. Schematic.

7. Insertion of a second row of seromuscular sutures.

8. Reconstruction of pelvic peritoneum over the anas­tomotic suture line.

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