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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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15
Left ureter
Bladder
Right
ureter
16
Peritoneum of
pelvic oor
Marginal artery
17
19
Stab wound
18
Colostomy
Perineal oor
Rectal pouch
Omentum
20
5 cm
163
21
PLATE
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73
A R—P
R
PERINEAL RESECTION
e surgeon must be satis ed with the patient’s condition before proceeding with the perineal excision of the rectosigmoid. e estimated blood loss
from the abdominal procedure, o en more than realized unless accurately
determined by the circulating nurse, should be replaced by blood transfusions, and the pulse and blood pressure should be established at a satisfactory level. Some prefer the two-team approach so that the perineal excision
is carried out simultaneously with the abdominal procedure.
POSITION Historically, Miles then placed the patient on his or her le side
in a modi ed Sims’ position. Some surgeons prefer to change the patient to
the lithotomy position by adjusting the stirrups to hold the legs. Some place
the patient in prone-jackknife to complete the perineal resection. e change
in position must be done gently and carefully; sudden shi s have been known
to precipitate hypotension and shock. e pulse and blood pressure should be
stabilized a er the change in position before the nal resection is started.
OPERATIVE PREPARATION e anus and adjacent skin surfaces are pre-
pared with the usual skin antiseptics. e legs and buttocks are covered with
sterile drapes.
INCISION AND EXPOSURE e extent of the perineal excision is indi-
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.
DETAILS OF PROCEDURE e posterior portion of the incision is extended
backward over the coccyx, and the anus is tipped upward to enable its attachments to the coccyx to be severed more readily. A er the anococcygeal raphe
is severed and the presacral space is entered, the accumulated blood from
above is suctioned out. e surgeon can then insert the index nger into
the presacral space (figure 6). e nger is swept laterally to identify the
levator and muscles on either side. e levator muscle is exposed on one side
and, with the nger held beneath it, is divided between paired clamps as far
from the rectum as possible (figure 7). Curved clamps should be applied to
the levator ani muscles as they are divided to prevent the retraction of bleeding points. Following the ligation of all bleeding points on one side, a similar
division of the levator ani muscles is carried out on the opposite side. Alternatively, the levator muscles may be transected with electrocautery, which
can also control bleeding vessels. Vessels that are not easily coagulated with
electrocautery should be individually secured with mattress or gure-ofeight absorbable sutures.
CONTINUES
164
1
Incision
Tumor
Pelvic peritoneum closed
Rectum and lower
sigmoid to be removed
Bladder
Prostate gland
Bulbocavernosus
muscle
2
Edge of
operating
table
5
3
Incision
4
Clamps on inferior
hemorrhoidal vessels
Purse-string suture
closing anus
7
6
Anococcygeal raphe
Levator
ani muscle
165
PLATE
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74
A R—P
R
DETAILS OF PROCEDURE e procedure in the male is illus-
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.
e upper end of the bowel segment is grasped and delivered posteriorly
over the coccyx (figure 9). A retractor is introduced anteriorly to assist in
exposure, while any remaining anterior attachments of the rectum are divided
(figure 10). e large pelvic space is thoroughly inspected under direct illumination in order to clamp and ligate any active bleeding point. e cavity is
packed with dry sponges until the eld is free of oozing (figure 11). When a
two-team approach is used, irrigation may now be carried out from above.
CLOSURE It is usually possible to approximate the divided levator ani
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).
POSTOPERATIVE CARE e blood loss must be replaced during the oper-
ation and postoperatively. Intravenous Ringer’s lactate solution is given and
the hourly urine output monitored. With accelerated postoperative care
pathways, urinary catheters are now o en removed on the rst postoperative day. is does not obviate the need for careful attention to voiding as
described in the more traditional approach below.
e patient is traditionally maintained on constant bladder drainage
for to days. In males the loss of bladder tone may result in one of
the most distressing postoperative complications. Frequent and thorough
evaluation of the patient’s ability to empty the bladder is essential until
good function has returned. e catheter should be clamped for several
hours at a time to determine whether the patient actually has retained the
sensation arising from a full bladder. In many cases, especially in males,
a cystometric study should be considered before removing the catheter.
e catheter should be removed early in the morning to permit all-day
observations on the patient’s ability to void. Overdistention should be rigorously avoided by catheterizing the patient for residual urine every to
hours, depending upon his or her uid intake. Diuretic liquids, such as
co ee and tea, should be withheld from the evening meal in an e ort to
avoid overdistention of the bladder during the night. Frequent urination
of small amounts indicates retention, and reinsertion of the catheter for
a few days should be considered. Rigid attention to the care of the bladder with assistance from the urologic surgeon pays rich dividends in the
patient’s postoperative progress.
e suction catheters are removed in a few days when the drainage output has markedly decreased.
e patient is instructed in the care of a colostomy before being discharged from the hospital. ■
166
8
Bulbocavernosus
muscle
10
Bulbocavernosus
muscle
Rectum
Prostate
Ampulla
of rectum
9
Sigmoid end
12
Bulbocavernosus
muscle
Levator ani
muscle
13
Coccyx
11
Prostate
Bladder
Ligated inferior
hemorrhoidal
vessels
Levator ani
muscle
Coccyx
Jackson-Pratt
drain
167
PLATE
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75
T C T
P
INDICATIONS e most common elective indications for total colectomy
are ulcerative colitis and familial polyposis. However, sphincter-conserving
procedures such as the ileoanal anastomosis (Plate ) should be considered
in good-risk patients. In the very poor risk patient with ulcerative colitis,
particularly with a complication such as a free perforation, it is judicious to
perform the operation in two stages. e removal of the rectum is delayed
until the patient’s condition is less critical. e possibility of malignancy in
patients with ulcerative colitis of many years’ duration must be considered.
Conservation of the anus and lower rectum by ileoproctostomy should be
considered in congenital polyposis, where the polyps in the retained rectum
that do not disappear spontaneously can be destroyed by repeated fulguration. Total colectomy is also performed for severe colitis of other etiologies,
especially pseudomembranous colitis.
PREOPERATIVE PREPARATION Unless total colectomy is done as an
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.
ANESTHESIA General endotracheal anesthesia is preferred.
POSITION e patient is placed in a moderate Trendelenburg position.
For total proctocolectomy during the perineal portion of the operation,
the patient may be repositioned in the lithotomy position with the thighs
widely extended. Alternatively, the legs may be placed in the modi ed lithotomy position using the Allen stirrups for support of the feet and knees.
is allows a single positioning for preparation and draping but may compromise the perineal exposure. A large rectal tube is used to lavage out
the rectosigmoid with a povidine-iodine solution. is tube may be le to
dependent drainage until the perineal resection begins, or the anus may be
sutured closed a er the enema and before skin preparation.
OPERATIVE PREPARATION e skin is prepared in the routine manner,
and the ileostomy site just below the halfway mark between the right anterior iliac spine and the umbilicus is re-marked, usually by scratching the
skin with the side of a hypodermic needle prior to skin preparation.
INCISION AND EXPOSURE e surgeon stands to the patient’s le side.
e incision must extend su ciently high in the epigastrium to provide
an easy exposure of the colonic exures, lest undue traction of the friable
bowel result in perforation and gross contamination (figure 1).
A er general exploration of the abdomen, the small bowel may be placed
in a plastic bag. e dissection is started in the region of the tip of the cecum
(figure 2). e right colon is retracted medially as the peritoneum in the
right lumbar gutter is incised with curved scissors (figure 2). Because of
the tendency to increased vascularity, it may be necessary to ligate a number of blood vessels in the free margin of the peritoneum along the right
lumbar gutter.
e peritoneal attachments to the terminal ileum are divided and the
cecum and terminal ileum mobilized well outside the wound (figure 3). e
peritoneum is tented upward before it is incised to avoid injuring the underlying right spermatic vessels and ureter. Blunt gauze dissection is utilized to
push these structures away from the adjacent mesentery. e right ureter
should be identi ed throughout its course up to the right kidney and down to
the pelvic brim. Any adhesions between gallbladder, liver, and hepatic exure
are divided. During the mobilization of the ascending colon and hepatic exure, care must be taken to identify the retroperitoneal portion of the duodenum, which may come into view rather unexpectedly. Blunt gauze is utilized
to sweep away the duodenum from the overlying mesocolon. e thickened,
contracted, and highly vascular greater omentum is divided between curved
clamps and ligated (figure 4). e greater omentum is retracted upward and
the lesser omental sac entered from the right side.
CONTINUES
168
1
Site of
ileostomy
Anterior
superior spine
2
Umbilicus
Incision
Line of incision
Cecum
Cecum
Gallbladder
4
3
Ileum
Duodenum
Colon
Right ureter
169
PLATE
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76
T C T
P
INCISION AND EXPOSURE e thickened and vascular greater
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.
Special attention is required during the division of the thickened sple-
nocolic ligament to avoid tearing the splenic capsule by undue tension
(figure 6). e splenocolic ligament is divided at some distance, if possible, from the inferior pole of the spleen (figure 7). When the splenic
exure and descending colon have been partially freed down to the
region of the sigmoid, the surgeon may wish to return to the region of
the right colon and control the blood supply to the bowel before removing it in order to facilitate the eventual exposure of the pelvis for the
exploration of the rectum. e mobilized right colon is drawn outside
the peritoneal cavity, and the vessels in the mesentery can be identi ed
easily (figure 8). Enlarged lymph nodes o en ll in the arcades about
the mesenteric border. Unless malignancy has been found, the blood
supply can be ligated near the bowel wall as shown in figure 8. Before
the blood supply is ligated, the ureter is protected posteriorly by warm,
moist packs.
CONTINUES
170
5
6
Omentum
Line of
incision
Colon
8
Pancreas
Middle
colic vessels
Spleen
Colon
7
Spleen
Splenocolic ligament
Right colic
vessels
171
PLATE
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77
T C T
P
INCISION AND EXPOSURE A er the blood supply to the
region of the appendix and the right colon has been divided, the terminal
ileum may be further mobilized. An incision is made into the mesentery of
the terminal ileum with a clear view of the ureter at all times to avoid its
injury. It is o en necessary to remove a portion of the terminal ileum because
of its possible involvement with the in ammatory process (figure 9).
Considerable time is required to separate the blood supply proximally from
the site where the ileum is to be divided. Several centimeters of ileum can be
denuded of blood supply in preparation for the development of an ileostomy
(figure 9). e blood supply to this portion of the ileum should be divided
very carefully, almost one vessel at a time, maintaining the large vascular
arcade at some distance from the mesenteric border. A noncrushing vasculartype clamp is applied to the ileal side and a straight Kocher clamp to the cecal
side in preparation for the division of the intestine (figure 10). Most commonly, however, the ileum is divided with a cutting linear stapler (GIA) stapling instrument. e contents of the Kocher clamp can be ligated with heavy
silk or absorbable suture to facilitate handling of the right colon (figure 11).
e colon is then retracted medially, and the mesentery is divided up to
the region of the middle colic vessel (figure 12). Two half-length clamps
should be applied proximally on the middle colic vessels because of their
size and the increased vascularity in ulcerative colitis. e mesentery of
the transverse colon is divided rather easily between pairs of clamps and
the contents carefully ligated. is can be done at some distance from the
inferior surface of the pancreas. As additional portions of colon are freed,
they are incorporated in towels to avoid tearing the bowel wall and possible
gross contamination.
CONTINUES
172
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