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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_627_Библиотеки_им_академика_М_И_Перельмана
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FIGURE 3-30 Rod inserted into the tip of the catheter.
FIGURE 3-31 Inserting the catheter into the rectum.
If using irrigation washout from a bag, place the bag on a high pole and
spike with tubing (Fig. 3-32). Insert the tubing end into catheter and instill
a few hundred milliliters at a time, alternately emptying rectum through
the catheter, until irrigation returns clear (Fig. 3-33).
FIGURE 3-32 Irrigation fluid.
FIGURE 3-33 Return of rectal irrigation.
If using solution from a bottle, insert a bulb syringe into the end of
catheter and remove the bulb. Holding syringe upright and above the level
of the patient to act as a funnel, pour solution into the catheter until the
liquid level begins to rise in the syringe, indicating good fill and fluid
pressure (Fig. 3-34). If planning to keep fluid in the rectum for
sterilization, place a large clamp across the catheter such that it will not
pull the catheter out by gravity. This clamp can be removed mid-procedure
to release the fluid (Fig. 3-35).
FIGURE 3-34 Rectal irrigation from a bottle. Note that the level of the tube is above
the patient.
FIGURE 3-35 Clamp placed across the tube.
Place a bag over the end of the catheter to collect fluid during the case and
then tie gauze around the bag and catheter near the anus (Fig. 3-36). Then
tuck the gauze ends under the buttocks. The catheter and bag can be
removed during the surgery as needed.
FIGURE 3-36 Bag applied to the rectal tube to collect drainage.
Suggested Reading
Steele SR, Hull T, Read TE, Saclarides T, Senagore A, Whitlow C, eds. The ASCRS Textbook of Colon
and Rectal Surgery. 3rd ed. New York, NY: Springer Publishing; 2016.
Chapter 4
Advanced Endoluminal Surgery:
Endoscopic Mucosal Resection and
Endoscopic Submucosal Dissection
EMRE GORGUN
ENDOSCOPIC MUCOSAL RESECTION
Perioperative Considerations
Procedure can be performed in regular endoscopy suites under sedation or
in the operating room under general anesthesia.
The patient should be positioned based on the location of the lesion.
Position the lesion at 6 o’clock (ie, inferior midline).
The colonoscope is introduced, and a standard colonoscopic examination
is first performed to evaluate for other pathology.
Equipment
Colonoscope/endoscope
Methylene blue or indigo carmine dye mixed with local anesthesia
Eleview or other premixed solution (as desired)
Select snares, baskets, and injection needles for the colonoscope
Bipolar/monopolar unit
Endoscopic clips
Specimen trap
Technique
After standard colonoscopic examination, locate the lesion for endoscopic
resection.
Methylene blue or indigo carmine dye is added to the injectate to establish
better visualization between the lesion and the normal mucosa (Fig. 4-1).
FIGURE 4-1 Hypromellose solution that can be used to prepare the injectate.
Alternatively, premixed solutions such as Eleview can be used.
After locating the lesion, the special injectate is injected between the
mucosa and the submucosa.
Start injecting from the area that is difficult to access (typically start from
oral/proximal site). Adjust needle tip to be tangent to the lesion.
Solution is injected circumferentially around the lesion with a 2-mm
margin.
Be dynamic while injecting and adjust depth and amount of the injection
based on visual cues (Fig. 4-2).
FIGURE 4-2 Injection is started circumferentially around the lesion and continued until
adequate mucosal elevation is observed.
Injections are finalized when the lesion is adequately elevated and is
suitable for resection.
Select the snare size and shape according to the lesion dimensions (Fig. 4-
3).
FIGURE 4-3 There are various snare types available based on size and shape.
Appropriate snare should be selected based on lesion characteristics.
Snare removal can be done piecemeal or en bloc based on the size and
location of the lesion.
Start snaring from the edge that is difficult to access. Incorporate 2-3 mm
of normal mucosal margin when resecting.
Open the snare fully before aiming the lesion and position the snare on top
of the lesion (Fig. 4-4).
FIGURE 4-4 After injection is completed, locate the snare on top of the lesion and
then include the lesion in the snare and close the snare.
After including the lesion in the snare that will be resected, hold the snare
parallel and tilt, close the snare tightly.
During snare removal, perform additional injections when necessary. This
may be required if the injectate diffuses, or if additional lift and
demarcation of the lesion, are required.
Repeat until the lesion is completely removed.
After each snaring, clean the resected area with normal saline and
visualize the site for any defects or remaining lesions.
Use snare-tip coagulation or coagulation forceps to establish hemostasis
and reduce adenoma recurrence (Fig. 4-5).
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