rectal instruments


By • Дек 19th, 2010 • Category: Rectum

In large surgical clinics or large surgical depart­ments of regional and city hospitals, the Quenu-Miles operation may be performed synchronously by two teams of surgeors, the first team consisting of 2 or 3 operators taking care of the abdominal cavity, and the other team of two operators simultaneously mobilizing the rectum on the perineum (Fig. 159). The main advantage of the synchronous Quenu-Miles operation lies in the fact that the colon in the abdominal cavity is either not divided at all or, in the second variant of the operation, is dissected for only I or 2 minutes. This considerably reduces the danger of infection of the ab­dominal cavity and the possibility of implantation me-tastasing. Moreover, simultaneous work of two teams of surgeons facilitates the operation and reduces its du^ ration (down to 1 hour and 20 min).

The patient is placed on his back with the legs drawn apart (Fig. 155,1). The positioning of the abdominal and perineal teams is shown in Fig. 159, each team being served by a separate scrub nurse. Prior to surgery catheters are inserted into the urethers, an in­dwelling catheter is passed into the bladder, and a broad diathermy electrode is placed under the sacrum (see Fig. 155.1).

While the abdominal team opens the abdominal ca­vity and explores it, the perineal team performs presac-ral and perirectal novocain block by injecting 150 ml of 0.25 per cent novocain solution into the presacral re­gion, £0 ml laterally into each of the levator ani mus­cles, and then 100 ml anteriorly between the rectum and the prostate (or vagina) (Fig. 160.1).

As with the standard Quenu-Miles operation the ab­dominal team now dissects the mesosigmoid and pelvic floor peritoneum first on the left (Fig. 160.2) and then on the right side (Fig. 160.3)

The bowel is next tied oil with a gauze tape above the tumour (see Fig. 155.6), and the surgeon ligates the inferior mesenteric artery (see Fig. 155.7) distal to the branching-off of the left colic artery from it (see Fig. 155.8), The perinea! team then starts freeing the poste­rior and lateral rectal walls in the pelvis (see Fig. 155.9; 10; 11 and 12).

As the abdominal team frees the bowel and ligates mesenteric vessels, the perineal team inserts an alcohol-soaked and squeezed-out pack into the rectum and closes the anal orifice with a purse-string suture (see Fig. 157.1). Next, the surgeon marks out the anus with an oval incision, strips away the fat inwardly and brings together the wound margins towards the midline over the closed anus. The wound edges are then sutured with silk and a gauze roll placed between the sutures (Fig. 160.4). Next, the perineal team carefully dissects the pelvic diaphragm around the entire rectal circumference between clamps, with ligation of the vessels. The anterior rectal wall is now separated from the prostate (or vagina).

Meanwhile, the abdominal team is completing the mobilization of the rectum in the pelvis by dividing the anterolateral ligaments. At this point both teams help each other in performing maneuvers in the pelvis.

The freed rectum is pulled through to the perineum and a sterile rubber cap or a vinyl chloride bag are put on to it (Fig. 160.5).

Meanwhile the abdominal team makes an additional incision in the left iliac regon to bring out the stoma. The perineal team moves the freed capped end of the rectum containing the growth to the pelvis, while the abdominal team promptly grasps the cap top with fin­gers or a swab-holder and pulls the entire rectum through the iliac wound (Fig. 160.6).

Next, the abdominal team peritonealizes the pelvic floor, while the perineal team completely (if possible) closes the perineal wound in layers. A counter-opening is then worked laterally to the left of the wound through which a rubber drainage tube (No. 14—16 by the Charriere scale) is passed to the sacrum, into the lesser pelvic cavity (Fig. 160.7).*

Following through peritonization of the pelvic floor and mesenteric bed and suturing of the mesosig-moid of the exteriorized sigmoid to the lateral abdomi­nal wall (see Fig. 155.18), the abdominal team closes the abdominal cavity, the long externalized piece of bo­wel is divided over a clamp at a level 6 cm above the skin, and the sigmoidostomy is fixed in the iliac wound in the usual fashion, with the aid of long threads pre­viously left (Fig. 160.8).

* In the ward a water or electric pump is attached to this drainage tube.

Second variant of synchronous Quenu-Miles operation.

In obese patients having a very long sigmoid colon and also in the case of  large tumour, it is our prac­tice to perform the second variant of synchronous Quenu-Miles operation, in which, following full mobili­zation of the rectum in the pelvis and on the perineum by two teams of surgeons, the freed sigmoid colon is cut across between two stout ligatures closer to its pro­ximal end (see Fig. 155.14). The sigmoid stumps are then immediately painted with iodine and closed with rubber caps (Fig. 161.1). The freed distal sigmoid por­tion containing the tumour is next promptly removed by the perh:eal route (Fig. 161.2). The perineal wound is closed as already described, and the proximal portion of the sigmoid is brought out to the wound in the left iiiac region to serve as preternatural anus. (See fig. 155.17). After the bowel has been sutured around the wound circumference, the cap is at once removed and the bowel lumen is opened.

Abdominoperineal excision of the rectum per­formed synchronously by two teams of surgeons

First variant of synchronous Quenu-Miles ope­ration

Second variant of synchronous Quenu-Miles operation

Fig. 159. Abdominoperineal excision of the rectum per­formed synchronously by two teams of surgeons:

Position of the patient and operators during operation.

Fig. 160. First variant of synchronous Quenu-Miles ope­ration:

1. Novocain block of the perineum and pelvic floor.

2. Dissection of the mesosigmoid and pelvic floor on the left.

3. Same but to the right of the sigmoid.

4. Suture of the skin wound edges over the anus on a gauze roll.

5. Fixing the cap of the pulled-through rectum.

6 Passing a long piece of bowel with cap through the iliac wound.

7. The closed perineal wound with a side rubber drain.

8. The long piece of bowel brought out through the iliac stoma is severed between clamps.

Fig. 161. Second variant of synchronous Quenu-Miles operation:

1. Rubber caps are put on to sigmoid stumps.

2. Removal of dissected bowel with cap from the peri­neal side.

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