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11
Abdominoperineal Proctectomy
for Benign Disease
INDICATIONS
Infl ammatory bowel disease, including ulcerative colitis and Crohn’s colitis with intractable rectal involvement that precludes restorative proctocolectomy.
PREOPERATIVE PREPARATION
See Chapter 10.
PITFALLS AND DANGER POINTS
Operative damage to or interruption of pelvic autonomic nerves in male patients, leading to sexual
impotence or failure of ejaculation
Pelvis sepsis, especially in patients who have perineal fi stulas
Inadequate management of perineal wound, resulting in a chronic perineal draining sinus
OPERATIVE STRATEGY
Abdominoperineal proctectomy is not a cancer operation. Resection should be conservative, and every
attempt should be made to avoid damage to adjacent
structures.
Transection of the hypogastric sympathetic nerve
trunks that cross over the anterior aorta causes ejaculatory failure in men. Beyond the aortic bifurcation
these nerves diverge into two bundles going toward
the region of the right and left hypogastric arteries,
where they join the inferior hypogastric plexus on
each side. According to Lee et al. (1973) the parasym-
pathetic sacral autonomic outfl ow is interrupted if the
lateral ligaments are divided too far lateral to the
rectum or if the nerve plexus between the rectum and
prostate is damaged. Parasympathetic nerve damage
results in failure of erection. Proper strategy requires
that the mesentery in the region of the rectosigmoid
be divided along a line just adjacent to the colon,
leaving considerable fat and mesentery in the presacral space to protect the hypogastric nerves. The
remainder of the pelvic dissection should be carried
out as close to the rectum as possible, especially in
the region of the lateral ligaments and prostate.
So long as there are no multiple perineal fi stulas,
it is generally possible to achieve primary healing of
the perineum if deadspace between the closed leva-
tors and the peritoneal pelvic fl oor is eliminated.
Because there is no need for radical excision of the
pelvic peritoneum, preserve as much of it as possible
and mobilize additional pelvic peritoneum from the
lateral walls of the pelvis and the bladder. If there is
suffi cient peritoneum to permit the pelvic peritoneal
suture line to come down easily into contact with
the reconstructed levator diaphragm, close this layer.
Otherwise it is much better to leave the pelvic peritoneum entirely unsutured to permit the small bowel
to fi ll this space. To aid in preventing perineal sinus
formation due to chronic low-grade sepsis, insert
closed-suction catheters into the presacral space and
instill an antibiotic solution postoperatively.
Lyttle and Parks (1977) advocate preservation of
the external sphincter muscles. They begin the perineal dissection with an incision near the dentate line
of the anal canal and continue the dissection in the
intersphincteric space between the internal and
external sphincters of the anal canal. Thus the rectum
is cored out of the anal canal, leaving the entire
levator diaphragm and external sphincters intact. We
have used this technique and found that it causes less
operative trauma, minimizes deadspace, and may
further reduce the incidence of damage to the prerectal nerve plexus.
OPERATIVE TECHNIQUE
Abdominal Incision and Position
With the patient positioned on Lloyd-Davies leg rests,
thighs abducted and slightly fl exed, make a midline
incision from the mid-epigastrium to the pubis (see
170
Op
erative Technique
1
n
h
peritoneum as possible. Accomplish this fi
-
fi
stula, free the mucous fi
-
.
M
-
1
71
Fig. 6–3a). If the patient has previously undergone
subtotal colectomy with ileostomy and mucous
stula from its attachments
o the abdominal wall. Ligate the lumen with umbili
cal tape and cover it with a sterile rubber glove
esenteric Dissection
Divide the mesentery between sequentially applied
Kelly clamps along a line close to the posterior wall
of the rectosigmoid. Continue the line of dissection
well into the presacral space. This leaves a considerable amount of fat and mesentery behind to cover
he bifurcation of the aorta and sacrum(Fig. 11–1).
The fat and mesentery prevent injury to the hypo
gastric nerve bundles, which travel from the preaortic area down the promontory of the sacrum toward
the hypogastric vessels on each side to join the
hypogastric plexuses on each side (see Figs. 6–4,
–6).
Rectal Dissectio
ncise the pelvic peritoneum along the line where the
peritoneum joins the rectum, preserving as muc
rst on the
right and then on the left side (see Fig. 6–5). Note
the location of each ureter (see Fig. 6–6). Divide the
posterior mesentery to the mid-sacral level. The pos
terior wall of rectum can now be seen, as at this point
Fig. 11–
172
A
bdominoperineal Proctectomy for Benign Disease
eal
-
ake a
v
p
h
u
W
p
ssectio
p
ssection.
ig. 11–2
he blood supply of the rectum comes from the lateral
wall of the pelvis. Elevate the rectum from the distal
acrum by blunt dissection and with Metzenbaum
cissors incise Waldeyer’s fascia close to the rectum.
Draw the rectum in a cephalad direction and place
e peritoneum of the rectovesical or rectouterine
ouch on stretch. This peritoneum can now be
ivided easily with Metzenbaum scissors. Division of
e lateral ligament can also be accomplished wit
good hemostasis by inserting a right-angle clamp
nderneath the ligament and dividing the overlying
issue with electrocautery (see Fig. 6–9).
ith cephalad traction on the rectum and a LloydDavies retractor holding the bladder forward, divide
Denonvilliers’ fascia at the level of the proximal
ortion of the prostate (see Fig. 6–11b). Keep the
i
rostate. In female patients, the dissection separates
he rectum from the vagina. When the dissection has
ontinued beyond the tip of the coccyx posteriorly
nd the prostate anteriorly, initiate the perineal
i
n
ose to the anterior rectal wall which
ould be bluntly separated from the body of the
Perin
lose the skin of the anal canal with a heavy purs
string suture
ircumferentially in the skin just outside the sphinc-
er muscles of the anus. Carry the dissection down
ose to the outer margins of the external sphincter
o the levator muscles (Fig. 11–3). The inferior
hemorrhoidal vessels are encountered running
oward the rectum overlying the levator muscles.
cclude these vessels by electrocautery. After the
ncision has been deepened to the levators on both
sides, expose the tip of the coccyx. Transect the
anococcygeal ligament by electrocautery and enter
he presacral space posteriorly. The fascia of
Waldeyer, which attaches to the anterior surfaces
f the lower sacrum and coccyx and to the poste-
ior rectum, forms a barrier that blocks entrance
nto the presacral space from below even after
he anococcygeal ligament has been divided. If
his fascia is elevated from the sacral periosteum
by forceful blunt dissection in the perineum,
enous bleeding and damage to the sacral neural
Incision
Fig. 11–2) Then m
n incision
Op
erative Technique
173
-
D
fi
nger into the opening to the presacral space and
p
p
.
b
-
w
-
w
fl
oor with continuous 2-0 PG sutures using the
y
e
oor, irrigate the abdominal cavity and
-
3
Fig. 11–
components of the nervi erigentes may occur. Con
sequently, divide this sharply from above (Fig. 6–
0) or below before an attempt is made to enter the
presacral space from below.
ivision of Levator Diaphragm
From the perineal approach, insert the left index
lace it in the groove between the rectum and the
levator muscles. Use electrocautery to divide the
levators close to the rectum on either side. Then
deliver the specimen from the presacral space down
rough the posterior perineum, so the anal canal is
attached only anteriorly. Visualize the prostate gland.
Using electrocautery, transect the puborectalis and
ectourethralis muscles close to the anterior rectal
wall. Carry this dissection down to the level of the
rostate and remove the specimen
rought up from the presacral space into the pelvis
nd out through puncture wounds of the abdomi-
nal wall.
lose the defect in the levator diaphragm using
interrupted sutures of 2-0 PG after thoroughly irrigat
ing the pelvis with an antibiotic solution and achieving perfect hemostasis
ith subcuticular sutures of 4-0 PG. Attach the cath
eters to suction for the remainder of the procedure
hile an assistant closes the peritoneum of the pelvic
bdominal approach.
Fig. 11–4). Close the skin
Ileostom
hoose a suitable site and construct a terminal ileostomy as described in Chapter 50 (if not already performed during a previous operation).
Closure of Pelvic Floor
Insert one or two large (6 mm) plastic catheters
hrough the skin of the perineum and the levator
muscles into the presacral space for closed-suction
drainage. Alternatively, these drains may be
Abdominal Closur
After checking the integrity of the peritoneal pelvic
suture line and making certain it is contiguous with
pelvis. Approximate the abdominal wall with inter
17
4
A
.
S
324.
6
.
panp
h
l
.
4
bdominoperineal Proctectomy for Benign Disease
ig. 11–
ed Smead-Jones
REFERENCE
echnique
Lee JF, Maurer VM, Block GE. Anatomic relations of pelvic
POSTOPERATIVE CARE
ee Chapter 7.
OMPLICATIONS
ee Chapter 7.
autonomic nerves to pelvic operations. Arch Surg 1973;
107:
Lyttle JA, Parks AG. Intersphincteric excision of the rectum.
Br J Surg 1977;
O’Bichere A, Wilkinson K, Rumbles S, et al. Functional
outcome after restorative
ulcerative colitis decreases an ot
qua
ity of life. Br J Surg 2000;87:802
4:413
roctocolectomy for
erwise enhanced
12
End-Ileostomy
INDICATIONS
An end-ileostomy is generally done in conjunction
with a subtotal or total colectomy for infl ammatory
bowel disease. Continent alternatives have been
developed (see References).
Occasionally a temporary end-ileostomy and mucous
fi stula of the distal end of the bowel is constructed
after resection of a gangrenous segment of intestine
or a perforated cecal lesion, when primary anastomosis is contraindicated.
PITFALLS AND DANGER POINTS
Devascularization of an excessive amount of terminal ileum, with resultant necrosis and stricture
formation
Ileocutaneous fi stula resulting from a too-deep stitch
in the seromuscular layer of the ileum when fashioning the ileostomy
OPERATIVE STRATEGY
Prevention of peristomal skin excoriation (due to
escape of small bowel contents underneath the
faceplate of the ileostomy appliance) requires formation of a permanently protruding ileostomy.
Properly performed, the ileostomy resembles the
cervix of the uterus. A permanent protrusion of
2.0 cm is desirable, which allows for the likelihood
that an underweight patient accumulates a subcutaneous layer of fat following successful surgery for
colitis. To prevent herniation of the small bowel,
close the gap between the cut edge of the ileum
and the lateral abdominal wall when fashioning a
permanent ileostomy.
OPERATIVE TECHNIQUE
Preoperative Selection of Ileostomy Site
Apply the face-plate of an ileostomy appliance tentatively to various positions in the right lower quadrant
of the patient to make sure it does not come into
contact with the costal margin or the anterosuperior
spine when the patient is in a sitting position. The
face-plate should not extend beyond the mid-rectus
line or the umbilicus. During emergency operations,
when an ileostomy has not been contemplated, the
site for the ileostomy should be placed approximately 5 cm to the right of the midline and about
4 cm below the umbilicus.
Incision
Because ileostomy generally is not the main part of
the contemplated operation, a midline incision has
already been made. Now make a circular incision in
the previously selected site in the right lower quadrant and excise a circle of skin the diameter of a
nickel (2 cm) (Fig. 12–1). The incision then spontaneously stretches to the proper diameter. Make a
linear incision down to the anterior rectus fascia and
insert retractors to expose the fascia. Do not excise
a core of subcutaneous fat unless the patient is signifi cantly obese.
Make a longitudinal 2 cm incision in the fascia,
exposing the rectus muscle (Fig. 12–2). Separate the
muscle fi bers with a Kelly hemostat (Fig. 12–3) and
make a longitudinal incision in the peritoneum. Then
dilate the opening in the abdominal wall by inserting
two fi ngers (Fig. 12– 4).
Fashioning the Ileal Mesentery
At least 6–7 cm of ileum is required beyond the point
at which the ileum meets the peritoneum if a proper
175
17
6
E
ffi
cient width of mesentery to ensure vas-
p
fascia
6)
p
F
1
Fig
F
nd-Ileostomy
ig. 12–
. 12–2
ig. 12–3
ig. 12–4
leostomy of the protruding type is to be made. More
length may be required in the obese patient. If the
ntire mesentery is removed from this length of
leum, necrosis of the distal ileal mucosa takes place
n many patients. Consequently, the portion of the
leum that passes through the abdominal wall must
etain a su
ularity. The “marginal” artery can be visualized in
he mesentery within 2 cm of the ileal wall. Preserve
his segment of vasculature while carefully dividing
e mesentery. Complete removal of the mesentery
s well tolerated at the distal 2–3 cm of the ileum.
Closure of Mesenteric Ga
Insert a Babcock clamp into the abdominal cavity
hrough the opening made for the ileostomy. Grasp
he terminal ileum with the clamp and gently bring
t through this opening, with the mesentery placed
n a cephalad direction
between the ileum and the peritoneum or the rectus
Fig. 12–
Using a continuous 2-0 PG suture, suture the cut
dge of the ileal mesentery to the cut edge of the
aracolic peritoneum. This maneuver completely
bliterates the mesenteric defect (Fig. 12–7).
Fig. 12–5). Place no sutures
Op
erative Technique
1
5
6
77
Fig. 12–
Fig. 12–
178
E
nd-Ileostomy
ig. 12–7
8
9
w
mucocutaneous fi
.
POSTO
E
.
.
sk.
S
s
stula
s
y
y
ber
n
CE
k
.
Referenc
e
179
Mucocutaneous Fixation of Ileostomy
onstruct a “cervix” by inserting interrupted 4-0 PG
sutures through the full thickness of the terminal
ileum; then, using the same needle, take a shallow
seromuscular bite of the lateral wall of the ileum,
hich is situated opposite the level of the skin. Complete the suture by taking a bite of the subcuticular
layer of skin
in a hemostat and place identical stitches in each of
the other quadrants of the ileostomy. After all the
sutures have been inserted tighten them gently to
evert the ileum
lace one additional suture of the same type between
each of the four quadrant sutures, completing the
Fig. 12–8). Temporarily hold the stitch
Fig. 12–9) Then tie the sutures.
xation
PERATIVE CAR
asogastric suction may be required, depending on
the nature of the primary procedure
rescribe perioperative antibiotics
Apply a Stomahesive disk to the ileostomy in the
operating room; place an ileostomy bag over the
i
nstruct the patient in ileostomy care.
Fig. 12–
Fig. 12–
COMPLICATION
arly problem
ccasional necrosis of the distal ileum (although
rare when good technique is used)
Late problem
Prolapse of ileostom
tricture of ileostom
Peristomal skin ulceratio
REFEREN
ozois RR. Alternative to Conventional Ileostomy. Chicago,
Year Boo
, 1985