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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_630_Библиотеки_им_академика_М_И_Перельмана
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153
PLATE
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68
DETAILS OF PROCEDURE Next, control and division of
the mesenteric vessels is accomplished. e mesocolon is incised. e
course of the ureter should be reveri ed at this point. A window is made
in the peritoneum near the inferior mesenteric vessels. e mesenteric
vessels may be divided with linear vascular staples, individually doubly
clipped or with coagulation devices designed for this purpose (figure 6).
Figure shows the line of division of the mesentery. Staple application
provides the most e cient method, but most costly as well. A medial to
lateral dissection may be employed, reserving the mobilization of the
lateral attachments and splenic exure until the mesocolon has been
divided. Once the mesentery is divided, the transverse colon is brought
into the pelvis ensuring adequate mobility for a tension-free anastomosis. e distal colon/rectum is divided using a reticulated linear stapler
(figure 7). is results in the distal staple line are shown in the gures
labeled B. e proximal colon may be divided intracorporally with an
endoscopic stapler or a er the bowel is exteriorized with a linear stapler through extension of the midline or le lower quadrant trocar incisions. is results in the proximal staple line A. e umbilical incision is
extended inferiorly to permit extraction of the specimen, extracorporeal
division of the bowel and preparation of the proximal colon for the anastomosis. Alternatively a le lower quadrant transverse incision may be
made. Prior to bringing the colon through the abdominal wall a plastic
wound protector is usewd to prevent contamination of the subcutaneous tissue and skin. e anastomosis between A and B is created using a
double staple technique. e exteriorized proximal colon is cleaned and
the staple line removed. Dilators are used to dilate the opening of the
C, L L
proximal colon (A). A purse-string suture is placed in the proximal colotomy (figure 8). e anvil for the circular stapler is placed in the bowel
(figure 9). e purse-string suture is tied and the colon returned to the
peritoneal cavity. e circular stapler is inserted transanally and the stapler spike is placed through the distal staple line or posterior to it under
direct vision (B). e spike is removed with a laparoscopic forceps and
removed. e end of the anvil is then inserted into the circular stapler.
e stapler is closed and discharged (figure 10). e stapling device is
removed and the donuts are inspected for completeness. An incomplete
donut indicates an incomplete suture line that will require oversewing.
e abdomen is lled with saline and rigid proctoscopy with air insuf ation performed in order to examine the anastomosis and to detect
air leakage. If air bubbles are encountered, the anastomosis is oversewn
with nonabsorbable - sutures and the air insu ation repeated to verify
anastomotic integrity. e mesenteric defect is closed with simple interrupted sutures. e abdomen should be visually inspected for bleeding.
CLOSURE e incision is closed with running or interrupted absorbable
sutures. No drains are used. e fascia at all trocar sites greater than mm
are closed. e skin is closed with staples.
POSTOPERATIVE CARE e orogastric or nasogastric tube is removed in
the postoperative care unit. Intravenous uids are administered and urine
output and vital signs monitored every hours. Prophylactic antibiotics
are discontinued within hours of the surgery. e bladder catheter is
removed on postoperative day or . Clear liquids are started on postoperative day or and advanced as tolerated. ■
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69
INDICATIONS Abdominoperineal resection of the lower bowel is the oper-
ation of choice for very low rectal malignancies that involve the sphincter
complex or cannot be removed with a -cm distal margin. In special circumstances, young patients may be candidates for a coloanal anastomosis, whereas others may be candidates for local wide excision and adjuvant
treatment for low-grade super cial lesions. e surgeon must be familiar
with all methods, including resection of the tumor and anastomosis of the
intestine within the hollow of the sacrum.
PREOPERATIVE PREPARATION e patient’s general condition must
be studied and improved as much as possible, since the operation is one
of considerable magnitude. Unless there is evidence of acute or subacute
obstruction, the patient is placed on a liquid diet for a day. Most patients
receive a bowel preparation the a ernoon or evening prior to surgery.
Following complete evacuation of the colon with laxatives or purgative,
appropriate nonabsorbable antibiotics may be given. Parenteral antibiotic coverage is given just prior to surgery. In the presence of low-lying
tumors, it may be advisable to evaluate by cystoscopy whether or not the
bladder or other portions of the genitourinary tract are involved. Basal
carcinoembryonic antigen levels are determined before and a er resection of the neoplasm. e extent of extramural spread or xation to adjacent organs may be evaluated with endorectal ultrasound plus computed
tomography (CT) imaging.
In males, an indwelling catheter is inserted into the bladder the morning
of operation to maintain complete urinary drainage throughout the procedure and to aid in identifying the membranous urethra. Indwelling catheter
drainage of the bladder in females is likewise advisable.
Currently, rectal carcinomas below the level of the peritoneal re ection
in the pouch of Douglas are usually given combined radiation therapy and
chemotherapy prior to surgery.
ANESTHESIA General anesthesia with endotracheal intubation and mus-
cle relaxants is the preferred method.
A R
ABDOMINAL RESECTION
POSITION e surgeon stands on the patient’s le side. Most prefer a two-
team approach with the patient in the semilithotomy position using Allen
stirrups. is allows the perineal portion of the procedure to be carried
out either simultaneously or a er the abdominal portion without redraping, etc. A folded sheet is placed under the lower back so that the buttocks
are li ed up o the bed, allowing better access to the posterior part of the
perineal dissection. A er an enema with a povidone-iodine solution, the
anus is sutured shut at the anal verge (not distal to it) with a running-locked
silk suture. A moderate Trendelenburg position may facilitate retraction,
as long as it is well-tolerated by the patient.
OPERATIVE PREPARATION e lower abdomen, perineal, and rectal
areas are prepared in the usual manner.
INCISION AND EXPOSURE A midline incision is made and extended to
the le and above the umbilicus. A self-retaining retractor is inserted.
DETAILS OF PROCEDURE With the le hand, the surgeon thoroughly
explores the abdomen from above downward, palpating rst the liver to
ascertain the presence or absence of metastases and then the region of the
aorta and common iliac and hemorrhoidal vessels for evidence of lymph
gland involvement. Finally, by palpation and inspection, the surgeon determines the extent and resectability of the growth itself (figure 1). e infe-
rior mesenteric artery and vein may be ligated distal to the origin of the
le colic artery or at its point of origin from the aorta before the tumor is
mobilized, but a er identi cation of the ureters.
A er the small intestine has been walled o in a plastic bag, the next
procedure is the mobilization of the sigmoid, which is usually anchored
in the le iliac fossa. e sigmoid is grasped and re ected medially in
order that the surgeon may obtain a clear view of the brous bands that
anchor the sigmoid to the re ection of the peritoneum of the le pelvic wall
(figure 2). e adjacent adhesive bands are divided with long curved scissors or electrocautery, and the peritoneal re ection is retracted laterally
with forceps. Following this procedure, the sigmoid is usually mobilized
easily toward the midline. e peritoneal surface on the le side of the
colon is picked up with forceps and divided with long, curved, blunt-nosed
Metzenbaum scissors, which are gently introduced downward beneath the
peritoneum to separate the underlying structures, such as the le spermatic,
or ovarian, vessels or ureter, from the peritoneum to avoid their accidental
injury. e peritoneum is incised down to the cul-de-sac on the le side
(figure 3).
e next important step in the operation is the visualization of the le
ureter throughout its course over the pelvic brim and down to the bladder.
is is very important because, on the le side, the ureter may be in close
proximity to the root of the mesentery of the rectosigmoid and may be
included in the division of the latter structures unless it is carefully retracted
to the le side of the pelvis (figure 4). e ureter will respond with peristaltic waves that progress along its length a er it is pinched with forceps.
e next step involves the division of the peritoneum on the right side of
the rectosigmoid. e same technique that has been described for the le side
may be utilized, or the surgeon may mobilize the rectosigmoid over the pelvic
brim from the le side by blunt nger dissection. e ngers of the surgeon’s
le hand can be passed completely behind the bowel toward the right side.
With the ngers used as blunt dissectors, the right peritoneal re ection can
be tented upward, separating it from the underlying structures, including the
right ureter. is enables the surgeon to divide the peritoneum readily and
safely with scissors or electrocautery (figure 5).
CONTINUES
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1
Bladder
Left ureter
Line of
incision
Marginal artery
of Drummond
Symphysis
Left
colic artery
Sigmoid artery
Inferior
mesenteric
artery
External iliac
artery and vein
Involved node
Superior
hemorrhoidal
artery
3
Bladder
2
Rectum
Right ureter
Incision
Left
ureter
Spermatic
vessels
4
Incision
5
Right
ureter
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A R, T
M E
For almost years, the pelvic dissections for rectal cancers requiring a low anterior or an abdominoperineal resection have been
accomplished with blunt dissection. As described by the English surgeon
Miles, the surgeon’s hands and ngers mobilized this section of rectum.
Little sharp dissection is required except for division of the lateral suspensory ligaments, as shown in previous editions of the Atlas. Known
complications from this blunt dissection include hemorrhage from torn
presacral veins, perforation into the rectum, and injury to the pelvic
autonomic nerves. An improved dissection, the total mesorectal excision
(TME), has been shown to lessen these complications and to provide a better radial margin of tumor clearance. e TME requires meticulous sharp
or electrocautery dissection under direct vision. e procedure takes signi cantly more time to perform, but it is associated with a lessened rate
of local recurrence for rectal cancers. e TME technique is widely used
both with sphincter preservation in very low rectal anastomoses and with
abdominoperineal resection.
DETAILS OF PROCEDURE e peritoneum along the right side of the rec-
tosigmoid junction is incised lateral to the inferior mesenteric and superior
hemorrhoidal vessels (figure 6). is incision extends down to the pouch
of Douglas. e right ureter is identi ed beneath the residual peritoneum,
and its course over the iliac vessels is exposed with blunt gauze dissection.
e proximal bowel is retracted anteriorly and laterally. Alternatively, the
proximal division of the bowel and vascular pedicles can be completed
allowing the proximal end of the specimen to be moved around to aid visualization (figure 11). If the tumor is very large, this should be avoided at
this point, as it commits one to an excision prior to complete mobilization
of the tumor. e superior hypogastric nerves are visualized just below the
iliac vessels and the ureters. e dissection proceeds behind the superior
hemorrhoidal vessels toward the entrance of the presacral space behind the
sacral promontory. Division of the retrosacral fascia or ligament just below
the sacral curvature at about S is done sharply in the midline with scissors or electrocautery, using a long, insulated tip (figure 7). e rectum
is retracted anteriorly with a beroptic lighted deep pelvic retractor, which
may be straight or curved. Under direct vision, the posterior dissection continues down to the level of the coccyx. e sacral veins are clearly visualized
beneath the parietal fascia, which is kept intact, thus minimizing bleeding.
e peritoneal re ection in the pouch of Douglas is incised about cm
up its anterior re ection over the bladder in men (shown in this illustration) or behind the uterus in women. e bladder or uterus is retracted
anteriorly using a beroptic lighted deep pelvic retractor. e sharp dissection proceeds anterior to Denonvilliers’ fascia until the prostate and
seminal vessels (figure 8) or the rectovaginal septum is seen. e paths of
the anterior and posterior dissections (figure 9) show the close adherence
to the presacral fascia posteriorly and to the actual prostate and seminal
vesicles anteriorly.
CONTINUES
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6
Left ureter
Super
hemorrhoidal
artery
Inferior
mesenteric artery
Incision
Involved nodes
Right
ureter
7
Electrocautery
Sacral
promontory
Lighted deep
pelvic retractor
Middle
rectosacral
fascia
Left ureter
Hypogastric
nerve
9
Parietal
fascia
Sacrum
8
Prostate
Seminal vesicles
Seminal vesicles
Coccyx
Tumor
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Prostate
PLATE
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A R, T
M E
DETAILS OF PROCEDURE e two lateral dissections in the
TME are time-consuming, as the surgeon carefully proceeds to expose the
parietal fascia over the lateral pelvic wall structures. e beroptic lighted
deep pelvic retractors are essential for clear visualization during lateral
retraction of the rectum and anterior elevation of the bladder or the uterus
and vagina. Better lighting may also be obtained with the use of a headlamp.
e preservation of the pelvic autonomic nerve plexus and the anterior roots
of sacral nerves S, S, and S is essential for anal continence and sexual
function. e plexus is seen as a dense plaque of nerve tissue that comes
close to the rectum at the level of the prostate or upper vagina. e TME
does not encounter “lateral suspensory ligaments” but rather a fusion of the
lateral mesorectum with tissue that may contain the middle hemorrhoidal
arteries as the dissection heads toward the autonomic nerve plexus. is tissue is divided with electrocautery, and the middle hemorrhoidal vessels may
require a ligature. e course of the ureters and the autonomic plexus is
noted as the dissection is carried down to the levators (figure 10).
A er the rectum is transected, the specimen should have a wide zone
of relatively smooth fat about the middle and upper rectum. In a thin
patient, the pelvic nerves and autonomic nerve plexuses may just be visible
beneath the parietal fascia, whereas the prostate and seminal vesicles are
uncovered.
A er it has been determined that the rectal tumor can be completely
freed from the adjacent structures, the blood supply to the rectosigmoid is
divided. e venous drainage should be ligated as early as possible to keep
the vascular spread of tumor cells to a minimum. Although involved lymph
nodes may not be evident in the mesentery over the bifurcation of the aorta,
it is desirable to ligate the inferior mesenteric artery just distal to the origin
of the le colic artery (figure 11). e contents of the proximal clamps are
tied, and the ligation is reinforced by a trans xing suture. Some prefer to
ligate the inferior mesenteric artery as near its point of origin from the aorta
as possible. Usually, this level is surprisingly near the ligament of Treitz. e
blood supply to the sigmoid to be used as a colostomy is now derived from
the middle artery through the marginal artery of Drummond.
Following this, the abdominal cavity and pelvis are completely walled o
with gauze as a preliminary to transection with a stapling instrument that
divides the bowel between double rows of staples such as a cutting linear
stapler (GIA) (figure 12). e bowel must be divided at a point su ciently
low to provide adequate room for it to be tucked down into the hollow of
the sacrum and to permit subsequent closure of the pelvic peritoneum. e
sigmoid is covered with a warm, moist gauze pack and re ected upward.
Following this, the closed end of the bowel is covered with a rubber
glove or gauze sponge, which is secured in position by an encircling heavy
silk suture (figure 13). e distal segment of bowel is then tucked down
into the hollow of the sacrum as a preliminary to the construction of a new
pelvic oor (figure 14).
e redundant sigmoid, which has been retracted upward over the
abdominal wall, is inspected to determine the best site (figure 11, A–A⬘)
for dividing the bowel to serve as a permanent colostomy. e sigmoid is
divided where it appears to be viable and will extend beyond the surface of
the skin for to cm without being under undue tension. It is better to err
in having extra colon beyond the skin margin rather than too little. Consideration must be given to the thickness of the subcutaneous tissues as well
as postoperative distention in testing the length of colon mobilized for the
permanent colostomy. e proximal end of the specimen is then divided at
this point with a cutting linear stapler (GIA). Excessive fat tabs and thick
fatty mesentery, if present, should be excised about the terminal end of the
colon in anticipation of inversion of the mucosa with immediate xation to
the adjacent skin.
CONTINUES
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DETAILS OF PROCEDURE e margins of the peritoneum are
mobilized in order to close the peritoneal oor securely. e peritoneum
is grasped with toothed forceps and mobilized by the surgeon’s hand or by
blunt gauze dissection (figure 15). e peritoneum in the pouch of Douglas
is mobilized as widely as possible to facilitate closing the pelvic oor. e
location of the ureters is rea rmed from time to time to avoid their accidental ligation or injury. In females the uterus and adnexa may be used, if
necessary, to close the new pelvic oor. At times it may be possible to close
the pelvic oor in a straight line, but, more frequently, a radial type of closure is necessary to avoid undue tension on the suture line (figure 16). All
raw surfaces should be covered whenever possible. e omentum is placed
over the peritoneal closure (figure 17). Some make no attempt to close the
peritoneum and rely on muscular closure.
When the patient’s anatomy permits, a pedicled omental ap based on
the le or right gastroepiploic artery can be created and laid into the pelvic
defect. When enough omentum is available, this both lls the volume of the
pelvis and covers the raw surfaces of the dissection. Some surgeons prefer
to anchor the sigmoid to the lateral parietal peritoneum in order to close
the le lumbar gutter and to avoid the possibility of an internal hernia.
Whenever possible, these sutures should include the fat tabs or mesentery
to avoid possible perforation of the bowel.
CLOSURE e omentum is returned to the region of the new pelvic oor
and the table is leveled. e colostomy is created through a separate -cm
(¼ in.) opening selected and marked prior to surgery. In general, it is midway between the umbilicus and the le anterior superior spine (figure 18).
As this colostomy will be a permanent one, it is wise to choose the site in
consultation with the enterostomal therapist. e adhesive ring of the colostomy bag must conform to the contour of the abdomen and must be secure
A R
when the patient is standing, bending, or sitting. A er excision of the circle
of skin, a two- nger-sized opening is made through the abdominal wall. e
colon is grasped with Babcock forceps and brought out through the opening without undue rotation of the mesenteric blood supply. Late herniation about the colostomy can be minimized by tailoring the opening in the
abdominal wall such that the colon plus one nger is a snug t.
e abdominal wall is closed with interrupted silk sutures or
synthetic absorbable sutures. Subcuticular closure of the skin should be
considered since this ensures a sealed wound about an area repeatedly contaminated from the adjacent colostomy. In patients with marked obesity or
cachexia, retention sutures may be utilized. e exteriorized portion of the
bowel is then inspected to make certain that active pulsation is present in
its blood supply. Su cient intestine should have been provided to ensure at
least to cm of viable bowel protruding above the skin level (figure 19).
Immediate opening of the colostomy a er the remainder of the wound has
been covered is preferred to leaving a clamp on the exposed area completely
obstructed intestine for several days. e stapled suture line is excised and the
mucosa within the lumen of the bowel grasped with one or two Babcock forceps to provide xation for the eversion of the mucosa (figure 19). It may be
necessary to excise several large fat tabs and additional thickened mesentery,
especially in the obese patient, to facilitate the eversion of the mucosa. e
mucosa is anchored to the margin of the skin with interrupted sutures or
synthetic absorbable sutures on a curved cutting needle (figure 20). A suf cient number of sutures is taken to control bleeding as well as to seal o the
subcutaneous tissue about the colostomy (figure 21). e mucosa should be
pink in color to ensure viability. e surgeon may insert a gloved nger into
the colostomy to make certain the lumen is free and adequate without undue
constriction within the abdominal wall. When the operation is complete, an
ostomy appliance is applied. ■
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