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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 14-12 Dissection circumferentially around the rectum.
The mobilization continues until there is the cuff or sleeve of rectum that
can be advanced without tension to the neodentate line. The distal end is
amputated (Fig. 14-13), and the internal opening is closed, as discussed
earlier.
FIGURE 14-13 The distal bowel is amputated.
The sleeve is then sewn to the neodentate line and resembles a coloanal
anastomosis when completed (Figs. 14-14 and 14-15).
FIGURE 14-14 After the fistula is closed, the bowel is sewn to the neodentate line
circumferentially.
FIGURE 14-15 Final sutured sleeve.
When an abdominal mobilization is required, the rectum is mobilized in
the total mesorectal excision plan transabdominally, either open or by the
minimally invasive approach. The inferior mesenteric vessels are divided,
if required, for a tension-free reach.
We almost always use a stoma when performing a sleeve advancement.
Episioproctotomy
When there is a defect in the anterior muscle, an episioproctotomy would be
our choice for repair. I prefer that the patient be in the prone position.
A probe is placed through the fistula (Fig. 14-16A) and tract unroofed
(Figs. 14-16B and 14-17). It will resemble a fourth-degree obstetric injury
after it is unroofed (Figs. 14-18 and 14-19).
FIGURE 14-16 A probe is placed through the fistula. This patient has a full perineal
body, but the anterior sphincter has a defect both in the internal and external sphincter. A.
Intra-operative photo. B. Illustration depicting anatomy.
FIGURE 14-17 The Bovie is used to unroof the fistula.
FIGURE 14-18 The result will resemble a fourth degree obstetric tear.
FIGURE 14-19
An incision is made across the rectovaginal septum (Fig. 14-20).
FIGURE 14-20 An incision is placed across the rectovaginal septum.
The sphincter muscles are identified and mobilized from the lateral edges
of the wound. We do not separate the internal from external sphincter
(Figs. 14-21 and 14-22).
FIGURE 14-21 The anal sphincter muscles are identified.
FIGURE 14-22
Once the sphincter muscles are mobilized, the rectal and anal canal
mucosa is meticulously closed with 3-0 polyglactin sutures using a
mattress suture with interspersed single interrupted to ensure the edges are
meticulously approximated (Fig. 14-23). The suture line is carried out to
the anal verge. It is important to close the rectal and anal canal lining
tissue at this stage because if it is done after the sphincter is approximated,
visualization is greatly reduced. It is important to line up the dentate line
when closing the anal canal lining tissue.
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