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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 12 • Open Abdominal Perineal Resection 205
Figure 12-4
Transverse
colon
Sigmoid colon
A
Spleen
Descending
colon
Figure 12-6
Left ureter
Figure 12-7
Stomach
Pancreas
B
Figure 12-5A-B
Spleen
Kidney
Inferior
mesenteric vein
Figure 12-8
206 Chapter 12 • Open Abdominal Perineal Resection
u
The splenic flexure is mobilized from the anterior surface of the kidney. An incision is made
over the dissecting finger to release the lateral attachments (Figure 12-9). The base of the
splenic flexure mesentery is released from the tail of the pancreas (Figure 12-10) and the tip
of the spleen (Figure 12-11). The transverse colon is released from the overlying omentum
by incising the avascular attachments on the antimesenteric surface to release the splenic
flexure completely (Figure 12-12).
Chapter 12 • Open Abdominal Perineal Resection 207
Figure 12-9 Figure 12-10
Figure 12-11 Figure 12-12
208 Chapter 12 • Open Abdominal Perineal Resection
u
The IMA and inferior mesenteric vein (IMV) are isolated at their origin along the aorta at the
base of the left colon mesentery (Figures 12-13 through 12-15). The vessels are identified,
ligated, and divided; this results in a complete release of the left colon mesentery to the pelvis
and full exposure of the retroperitoneum from the splenic flexure to the pelvic brim (Figure
12-16).
Figure 12-13
IMV
IMA
Chapter 12 • Open Abdominal Perineal Resection 209
Point of
1st branch
mesenteric vein
mesenteric artery
Inferior mesenteric vein
Inferior vena cava
Inferior
Inferior
Ureter
Aorta
Inferior
mesenteric artery
Mesentery
Ureter
Figure 12-14
transection
Tail of
pancreas
Window
Figure 12-15
Duodenum
Window
Aorta
of IMV
IMV origin
Ureter
Figure 12-16
210 Chapter 12 • Open Abdominal Perineal Resection
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The rectum is retracted anteriorly to expose the avascular areolar tissue plane at the sacral
promontory (Figure 12-17). The splanchnic nerves are protected at the pelvic brim (Figure
12-18). The areolar tissue plane is followed all the way to the pelvis protecting the hypogastric
nerve plexus (Figure 12-19), the splanchnic nerves, and the ureters on both sides of the
pelvis (Figure 12-20).
Chapter 12 • Open Abdominal Perineal Resection 211
Areolar tissue
Rectum
Splenic nerves
Figure 12-17
Figure 12-18
Ureter
Right ureter
Figure 12-19
Hypogastric nerves
Left pelvic
nerve
Figure 12-20
Right pelvic
nerve
Sacral promontory
212 Chapter 12 • Open Abdominal Perineal Resection
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The dissection is carried into the pelvis, releasing the mesorectum in toto from the sacrum,
exposing the entire pelvis, and resulting in a double-lobed mesentery of the rectum retracted
anteriorly (Figure 12-21). This maneuver allows the lateral pelvic nerves and the ureters to
be seen in detail and protected (Figure 12-22).
u
The anterior dissection of the rectum is begun at the cul-de-sac. An incision is made behind
the bladder, and a Thorlakson retractor can be used to lift the bladder anteriorly to open the
rectoprostatic or rectovaginal septum. The areolar tissue plane is followed all the way to the
anal canal (Figure 12-23). The anterolateral ligaments on either side of the rectum can be
divided with electrocautery to release the rectum from the deep pelvic side walls (Figure
12-24). During this dissection, it is important to know where the left ureter is and to protect
any other structures. Medial traction on the rectum exposes the areolar tissue along the left
pelvic brim.
Figure 12-21
Figure 12-22
Chapter 12 • Open Abdominal Perineal Resection 213
Figure 12-23
Left ureter
Left anterolateral
Figure 12-24
ligament
Sacral promontory
214 Chapter 12 • Open Abdominal Perineal Resection
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The descending sigmoid colon junction is divided with a 75-mm linear cutter stapler at the
site for the planned colostomy (Figure 12-25). The left lower quadrant colostomy site is
constructed by excising a 3-cm disk of skin (Figures 12-26 and 12-27A-C) and splitting the
Figure 12-26 Figure 12-25