Atlas of General Surgical Techniques (Courtney M. Townsend Jr., B. Mark Evers)

Connell sutures; anterior anastomosis

FIGURE 64–9

Lembert sutures

FIGURE 64–10

7 4 4 S E C T I O N I X • C O L O N

The “bubble test” is performed to test the integrity of the colorectal anastomosis. The pelvis is filled with saline, and a rigid proctoscope is inserted into the rectum distal to the anastomosis. The lumen is gently distended by pumping air into the rectum, and absence of bubbles indicates an intact anastomotic line (Figure 64-15).

Scope

Testing the integrity of low rectal anastomosis with saline in the pelvis and insufflation of air from a sigmoidoscope

FIGURE 64–15

3. CLOSING

The peritoneal cavity is irrigated with saline, and hemostasis is obtained. The midline fascia is closed in one layer with two running absorbable sutures of loop 0 polydioxanone (PDS) beginning at the cranial and caudal end of the incision. The skin is reapproximated with staples.

No intraperitoneal drains are indicated.

The nasogastric tube is removed before the patient emerges from anesthesia.

STEP 4: POSTOPERATIVE CARE

Clear liquids are started on postoperative day 1, and diet is advanced as tolerated.

Postoperative antibiotics are not necessary.

The urinary catheter is left in place for 3 or 4 days to decrease the risk of urinary retention after pelvic dissection.

STEP 5: PEARLS AND PITFALLS

The mesorectal dissection should be performed sharply under direct vision and not bluntly with the hand.

The colorectal anastomosis must be tension free, and this may require division of the sigmoid artery at its origin and mobilization of the splenic flexure of the colon.

In T3 and T4 rectal cancers, preservation of the pelvic autonomic nerves may not be possible.

In most patients, the 29-mm circular stapler works well. Using the maximum-size circular stapler may create radial tension, leading to anastomotic leak.

If the anastomosis fails the “bubble test,” the anastomotic defect must be identified and repaired primarily. A protection loop ileostomy may be indicated for difficult or low anastomosis ( 5 cm) and for patients who underwent preoperative chemoradiation treatment.

7 4 6 S E C T I O N I X • C O L O N

SELECTED REFERENCES

1. Havenga K, Grossmann I, DeRuiter M, Wiggers T: Definition of total mesorectal excision, including the perineal phase: Technical considerations. Dig Dis 2007;25:44-50.

2. Fry RD, Mahmoud N, Maron D, et al: Colon and rectum. In Townsend CM Jr, Sabiston DC (eds): Sabiston Textbook of Surgery, 18th ed. Philadelphia, Elsevier Saunders, 2008, pp 1348-1432.

CH A P T E R65

MILES ABDOMINOPERINEAL

RESECTION WITH TOTAL

MESORECTAL EXCISION

Tien C. Ko

STEP 1: SURGICAL ANATOMY

For the total mesorectal excision, please see the discussion on pelvic autonomic nerves in Chapter 64.

The seminal vesicles, prostate, and urethra are located ventral to Denonvillier’s fascia cranially and the superficial transverse perineal muscle caudally.

STEP 2: PREOPERATIVE CONSIDERATIONS

Miles abdominoperineal resection with total mesorectal excision is indicated for rectal cancer near the levator ani muscle or persistent or recurrent squamous cell cancer of the anus after chemoradiation treatment.

Preoperative chemoradiation treatment is indicated for T3, T4 lesions or those tumors with enlarged pelvic lymph nodes on pelvic computed tomography (CT) scan or endorectal ultrasound.

Appropriate bowel preparation such as GOLYTELY or four bisacodyl (Dulcolax) tablets followed by HalfLytely should be administered the day before surgery. Preoperatively, a single dose of broadspectrum antibiotic (such as ertapenem) is administered.

The permanent colostomy site is marked by an enterostomal nurse preoperatively to ensure the best placement of the colostomy.

747

7 4 8 S E C T I O N I X • C O L O N

After induction of general anesthesia, the patient is placed in a lithotomy position with the legs in padded stirrups at 30-degree abduction. The coccyx is placed near the end of the table and elevated with a stack of towels (Figure 65-1). A nasogastric tube is placed to prevent gastric distention, and a urinary catheter is placed to decompress the bladder. The rectum is irrigated with povidone-iodine (Betadine) solution until clear. The anus is closed with a 0 silk purse-string suture (Figure 65-2).

STEP 3: OPERATIVE STEPS

1.INCISION

A midline abdominal incision is made from the pubic symphysis to approximately 5 cm cranial to the umbilicus.

The midline fascia is divided with electrocautery. The peritoneum is elevated with tissue forceps, and after ensuring that no bowel is entrapped by the graspers, the peritoneum is incised sharply with a scalpel.

For the perineal dissection, an elliptical incision is made 2 cm away from the closed anus (see Figure 65-2).