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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 10 • Open Low Anterior Resection of Rectum 165
Figure 10-13
mesenteric vein
mesenteric artery
Inferior mesenteric vein
Inferior vena cava
Point of
transection
Inferior
Inferior
Ureter
Aorta
Mesentery
Ureter
Inferior
mesenteric artery
Tail of
pancreas
Duodenum
Window
Aorta
IMA
Figure 10-14
Window
1st branch
of IMV
IMV origin
IMV
Ureter
Point of
transection
166 Chapter 10 • Open Low Anterior Resection of Rectum
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The left colon is stretched all the way to the pelvis bringing the splenic flexure to near the
pelvic brim. This maneuver allows the left colon to be evaluated for point of transection to
ensure adequate reach into the pelvis for the colorectal anastomosis (Figure 10-15).
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The left colon mesentery is divided so that the IMA pedicle goes with the specimen. A purse-
string instrument is used to place a purse-string, or a hand-sewn purse-string is placed at
the site of transection after dividing the mesenteric vessels. The purse-string is placed so that
adequate blood supply is available and there is no tension or twist (Figure 10-16). The anvil
for the stapler is placed into the colotomy, and the purse-string is cinched ensuring that all
edges of the colotomy are everted (Figure 10-17).
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The small bowel and proximal colon are packed in the upper abdomen, and the pelvic dis-
section is begun.
Left middle
colic artery
Chapter 10 • Open Low Anterior Resection of Rectum 167
Marginal artery
of Drummond
Figure 10-15
Figure 10-16
Figure 10-17
168 Chapter 10 • Open Low Anterior Resection of Rectum
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The distal colon is retracted anteriorly, and a pelvic retractor is used to place tension on the
mesorectum. The avascular plane of the presacral space is entered with sharp dissection
(Figures 10-18 and 10-19). Care is taken to preserve the sympathetic nerves and not violate
the mesorectal fascia (Figure 10-20). The posterior dissection is carried from 3 o’clock to
Figure 10-18
Chapter 10 • Open Low Anterior Resection of Rectum 169
Figure 10-19
Figure 10-20
170 Chapter 10 • Open Low Anterior Resection of Rectum
9 o’clock all the way down to the pelvic floor or low enough to perform a tumor-specific
mesorectal excision (Figures 10-21 and 10-22). A complete and intact mobilization of the
mesorectum reveals its bilobed configuration (Figure 10-23).
Left ureter
Left pelvic nerve
Figure 10-21
Right pelvic nerve
and ureter
Avascular areolar
tissue
Sacral promontory
Chapter 10 • Open Low Anterior Resection of Rectum 171
Figure 10-22 Figure 10-23
172 Chapter 10 • Open Low Anterior Resection of Rectum
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The lateral peritoneal attachments are incised down to the anterior peritoneal reflection. The
lateral dissection is performed by retracting the rectum medially and sharply dividing the
tissue in a posterior-to-anterior fashion (Figure 10-24). When adequate tension is created,
the plane of the mesorectal fascia can be seen ensuring that it is completely excised. The
anterior peritoneum is incised, the prostate or cervix is retracted anteriorly, and the rectum
is retracted posteriorly (Figure 10-25). The anterior dissection is carried down to the pelvic
floor, and any remaining lateral attachments are divided.
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The rectum is divided with a linear cutter stapler; the proximal rectum must be occluded so
that tumor cells are not spilled as the specimen is removed (Figure 10-26). If a mesorectalspecific resection is performed, the site of distal resection is identified, and the mesorectum
is divided at a right angle, and then the rectum is divided (Figure 10-27).
Left ureter
Left anterolateral
Figure 10-24
Anterior peritoneal
reflection
ligament
Sacral promontory
Rectum
Figure 10-25
Chapter 10 • Open Low Anterior Resection of Rectum 173
Figure 10-26
Mesorectum
Tumor-specific
bowel and
mesorectum
transection
mesorectal
excision
Tumor
5-cm margin
Rectum
Total
Figure 10-27
174 Chapter 10 • Open Low Anterior Resection of Rectum
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To perform the anastomosis, the stapler head is passed transanally up to the top of the rectal
stump. The spike is deployed posterior to the transverse staple line. The anvil is attached to
the stapler after it is confirmed that the cut edge of the left colon mesentery is straight (Figure
10-28). The anastomotic doughnuts are inspected, and an air test is performed (Figure
10-29). Typically, a closed suction drain is placed deep in the pelvis for 4 days postoperatively
to drain any fluid and blood that may accumulate.
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A diverting loop ileostomy can be created at the discretion of the surgeon (Figure 10-30).
The abdomen is irrigated and closed.