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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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as possible.
When present, a pelvic abscess must be properly drained.
Phlegmonous and devitalized tissues are debrided.
Remove any chronic inflammatory rind in the pelvis to avoid
continued sepsis.
The pelvic floor is often very fibrotic and rigid. This makes
passage of the conduit through the levator hiatus difficult.
Leave a pelvic drain.
Construct a diverting loop ileostomy if it was not created before.
Perineal phase
TIPS
Maintaining the marginal artery is crucial as this is the only supply for
the colonic conduit.
TIPS
Identifying the ureter at the pelvic brim does not guarantee any injury
distal in the pelvis. The chronic scarring draws both the ureters
toward the midline.
TIPS
Radial slits along the floor can create an accommodating space for the
colonic conduit in preparation to exteriorization.
Pre-exteriorization
Exposure to the perineum is key. The legs should be placed in a high
lithotomy position to properly access the perineum.
Place four to six perianal eversion sutures for better exposure of the distal
anal canal (Fig. 20-1A).
FIGURE 20-1 A. Eversion sutures are placed circumferentially for optimal exposure.
B. Lone Star retractor in place with good exposure of anal canal.
Alternatively, a Lone Star retractor can be used with good exposure (Fig.
20-1B).
A circumferential mucosectomy is performed starting at the dentate line to
ensure no mucosa is left behind and ensure proper adherence between the
conduit and anal canal.
Saline with epinephrine solution (1:100 000) can be used to infiltrate the
submucosal plane to facilitate with dissection (Fig. 20-2).
FIGURE 20-2 The mucosectomy after completion. Note this is at the level of the
dentate line.
Eight sutures, 2-0 polyglactin, are placed along the circumference of the
anal canal to allow for maturation of the anastomosis in the second stage.
In this step, the first bite is passed including mucosa and some fibers of
the internal anal sphincter. The sutures are then secured to the drape (Fig.
20-3A).
FIGURE 20-3 A. The sutures are in place and colonic conduit pulled through. B. The
colonic conduit is delivered to the anal canal in a properly oriented manner.
Exteriorization
The colonic conduit is now pulled through the anal canal, ensuring proper
orientation. In cases of an underlying complex rectovaginal or
rectourethral fistula, the colon may be rotated 180 degrees to lay the
mesenteric side against the vaginal or urethral fistula (Fig 20-3A and B).
The exteriorized colonic segment is wrapped with a petroleum gauze and
cotton gauze (Fig. 20-4). To avoid needle punctures, the sutures are rolled
over 4 × 4 gauze. 2-3 sutures for one rolled gauze. These are then
incorporated in the gauze wrap around the colon (Fig. 20-4B).
FIGURE 20-4 A. Inner gauze wrap around the conduit. B. Petroleum gauze and
cotton gauze wrapped around the conduit. The preplaced sutures are protected within this
wrapping.
Stage II—Delayed Anastomosis
This phase takes place after 5-10 days after stage I, and after adhesions
between the colon and anal canal had occurred; maturation of the coloanal
anastomosis can now be completed.
Anesthesia general
No need for urinary catheterization
Position
Lithotomy position
The gauze wrap is unraveled, and sutures are placed in organized manner
(Fig. 20-5).
FIGURE 20-5 The gauze is removed, and the eight previously placed sutures are
placed in an organized manner.
The exteriorized colon is now amputated at level of the anoderm. Avoid
amputating too much as this can lead to dehiscence and stricture (Fig. 20-
6).
FIGURE 20-6 The exteriorized colon is amputated at the level of anoderm.
The anastomosis is matured in a progressive manner while amputating the
colon. The second suture bite is now passed through full thickness of the
colon (Fig. 20-7A-C).
FIGURE 20-7 Amputation of the exteriorized colon continues in a consecutive manner
(A and B), while respective sutures are completed (C).
The sutures are then tied, and the delayed anastomosis is now completed
(Fig. 20-8A and B).
FIGURE 20-8 A. Completing the anastomosis. B. Anastomosis completed.
Postoperative Care
Between Stages I and II
The patient may ambulate and resume a diet.
Avoid sitting directly on the conduit.
There is no need for routine removal of the gauze unless there is a concern
for an ischemic or necrotic conduit, which should be appropriately
evaluated and managed.
There is no need for prolonged antibiotics.
Patients may shower.
Multimodality, narcotic-sparing, pain control
Venous thromboembolism (VTE) chemoprophylaxis
Following Stage II
Patients may resume routine enhanced recovery care pathways.
Avoidance of nasogastric tube
Early urinary catheter removal
VTE chemoprophylaxis
Early ambulation
Multimodality, narcotic-sparing, pain control
Suggested Readings
Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW. Outcomes following Turnbull-Cutait
abdominoperineal pull-through compared with coloanal anastomosis. Br J Surg.
2009;96(4):424-429.
Rosselli Londono JM, Aytac E, Gorgun E. Turnbull-Cutait abdominoperineal pull-through: a safe
approach for recurrent sacrococcygeal teratoma complicated by rectovaginal fistula. Tech
Coloproctol. 2014;18(8):761-763.
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