Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_629_Библиотеки_им_академика_М_И_Перельмана

cated in figure 3. If the lesion is low and near the anus, a more radical excision is carried out. Operations for anal cancer will need to be extensive enough to excise the tumor with negative margins. If a large excision is con­templated, preoperative consultation should be made with a plastic surgeon, as myocutaneous  ap reconstruction may be necessary. If the dissection has been carried down far enough from above, the perineal excision of the

rectum and anus should be accomplished easily without undue loss of blood (figure 1). To prevent contamination, the anus is sealed securely, either by several interrupted sutures of heavy silk or by a purse-string suture, and the skin is again cleansed with antiseptic solutions (figure 3). An incision is outlined around the anus with anterior and posterior midline extensions (figure 2).  e skin in the region of the anal ori ce is seized with several Allis forceps, and the incision is made through the skin and subcutaneous tissue at least  cm away from the closed anal ori ce (figure 4). All blood vessels are clamped and tied to prevent further loss of blood as the opera­tion progresses (figure 5).  e margins of the wound are retracted later­ally to assist in the exposure.

trated because the dissection between the rectum, membranous urethra, and prostate poses more problems than dissection in the female. Palpa­tion of the inlying urethral catheter will facilitate the procedure by local­izing the urethra and preventing accidental injury to the above-mentioned structures (figure 8).  e skin and subcutaneous tissue of the perineum are retracted upward, while the anus is pulled downward and backward to assist in the exposure.  e rectum is pulled down, the remaining attach­ments of the levator animuscles and transversus perinea are divided, and all bleeding points are ligated. In the female the dissection between the rectum and vagina is more easily accomplished if counterresistance is applied to the posterior vaginal wall by the surgeon’s  ngers. In the presence of exten­sive in ltrating growths it may be necessary to excise the perineal body as well as a portion of the posterior vaginal wall.

muscles in the midline (figure 12). Two closed suction Silastic catheter drains are placed in the presacral space and brought out through the skin lateral in the incision and secured to the skin.  e subcutaneous tissue and skin are closed with very large and widely spaced interrupted vertical mat­tress sutures of no.  nylon or silk.  ese are tied loosely (figure 13).

 e patient is instructed in the care of a colostomy before being dis­charged from the hospital. ■

emergency procedure, e orts should be made to improve the patient’s nutritional status with a high-protein, high-calorie diet. Total parenteral nutrition may be used.  e blood volume is restored and supplemental vita­mins are provided.  e surgeon must carefully evaluate the status of the steroid therapy.  e patient requires special psychologic preparation for the ileostomy.  is should include a visit by an enterostomal therapist who can demonstrate successful rehabilitation following this procedure.  e patient should be shown the permanent type of ileostomy appliance and should be encouraged to read the literature available from an ileostomy club to pre­pare him or her for postoperative management. In addition, the site of the ileostomy should be selected away from bony prominences and previous scars as described in Plate . A permanent type of appliance may be glued to the patient’s skin for  to  days to allow him or her to move about with it in place and make any  nal adjustments in its eventual location.  is point is marked with indelible ink to assure accurate placement of the stoma. A liquid diet is given for  or  days, followed by laxative purging the a er­noon and evening prior to surgery.  e male patient should be informed of the possibility of postoperative impotence, retrograde ejaculation, and di culty in voiding.

For total proctocolectomy during the perineal portion of the operation,

omentum is retracted upward in preparation for its separation from the trans­verse colon. An incision is made in the omental re ection along the superior surface of the colon (figure 5). Since the omentum may be quite adherent to the colon, it may be easier to divide the gastrocolic omentum nearer the stomach than the transverse colon.  is can be facilitated if the surgeon places his or her le hand, palm upward, in the lesser sac in order to better de ne the gastrocolic omentum. Most of the dissection can be done with electrocautery, especially if the relatively avascular plane is present where the omentum joins the transverse colon. If large vessels are encountered, paired curved clamps are applied and their contents ligated.