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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 215
End Colostomy
Operative incision site
Stoma site (through incision
or through rectus muscle)
descending colon
Distal
Mesentery
A
Skin
Fat
Fascia
Rectus
abdominis
Peritoneum
B
Mesentery
Parietal
peritoneum
C
Figure 12-27A-C Netter illustration from www.netterimages.com. © Elsevier Inc. All rights reserved.
216 Chapter 12 • Open Abdominal Perineal Resection
rectus muscle in the middle of the bundle to deliver two fingerbreadths (Figure 12-28). The
cut end of the bowel is brought out through the anterior abdominal wall and “matured” to
the skin with circumferential interrupted 3-0 absorbable suture (Figure 12-29). The large
Blake drain is brought out through a stab wound in the lower abdomen, and the abdominal
wall is closed with a running absorbable suture. The skin is closed with skin staples, and the
ostomy appliance and dressing are applied.
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The patient is moved to a stretcher and rolled back onto the operating table to the prone-
jackknife position with a roll under the hips and rolls under the chest, with the buttocks
taped apart (Figure 12-30). The perineum is prepared and draped, and the anal canal is
closed with a subcutaneous circumanal suture at the anal verge (Figure 12-31).
Chapter 12 • Open Abdominal Perineal Resection 217
Figure 12-28 Figure 12-29
Figure 12-30 Figure 12-31
218 Chapter 12 • Open Abdominal Perineal Resection
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An elliptical incision is made on the perineal skin from the tip of the coccyx to the anterior
perineal body outside the external sphincter and carried into the ischial rectal fossa
(Figure 12-32). The dissection in the ischial rectal fossa extends up to the undersurface of
the levator muscles separating the fat from the outer aspect of the external sphincter. The
bear claw St. Mark’s retractor is useful to maintain exposure during this portion of the dissection (Figure 12-33). The pudendal nerves and vessels are identified and controlled in the
lateral aspects of the ischiorectal fossa space. The tip of the coccyx is either incised and
removed or exposed for the transverse incision made in the pelvic floor anterior to the tip of
the coccyx (Figure 12-34). The posterior pelvic space is entered, and the previously dissected
space is easily exposed (Figure 12-35).
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The muscles of the levator plate are incised along each side of the rectum over a finger placed
into the pelvic cavity through the posterior incision (Figures 12-3 and 12-36). Depending
on the size of the tumor, a cuff of muscle can be left, or the entire muscle can be removed.
As the dissection moves anteriorly, the posterior aspect of the vagina or prostate is eventually
encountered. The vagina, or a portion thereof, can be excised to provide anterior clear margins
(Figure 12-37). The dissection must be maintained in the vagina posterior to the lateral aspect
of the vagina where the nerves and vessels are found. A portion of the coccyx can be removed
during this dissection to provide clear margins for a posteriorly placed tumor. This removal
is easily accomplished with an incision along the edges of the coccyx and transection of the
osteocartilaginous junction with rongeurs (bone cutters). This maneuver also facilitates total
excision of the pelvic floor.
Chapter 12 • Open Abdominal Perineal Resection 219
Figure 12-32 Figure 12-33
Figure 12-34
Tip of coccyx
Left levator
ani muscle
Undersurface of
the levator ani
Muscles at
the base of the
ischiorectal fossa
Tip of coccyx
Posterior
pelvic space
Figure 12-35
Vagina
Figure 12-36
Figure 12-37
220 Chapter 12 • Open Abdominal Perineal Resection
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The rectum and sigmoid colon are delivered through the posterior aspect of the pelvic floor
opening (Figure 12-38). The posterior aspect of the bladder and the deep pelvis are now
exposed (Figure 12-39). The Blake drain from within the abdominal cavity is brought down
into the pelvis. The decision is made whether the closure can be accomplished with sutures
to approximate the muscle cuff in the midline or whether a biomesh replacement is needed
(Figure 12-40).
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The subcutaneous fat of the ischiorectal fossa is reapproximated in the midline with layers
of interrupted horizontal mattress sutures of absorbable suture to the level of the subcuticular
layer, which is left open. Polysporin ointment and a 4 × 4 gauze are applied (Figure 12-41).
Figure 12-38
Chapter 12 • Open Abdominal Perineal Resection 221
Figure 12-39 Figure 12-40
Figure 12-41
222 Chapter 12 • Open Abdominal Perineal Resection
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In cases where the coccyx is to be removed, this should be accomplished first (Figure 12-42).
The edge of the coccyx is cauterized, and the osteocartilaginous junction is transected to
allow the rectum and sigmoid to be pulled through the pelvic floor with the coccyx attached.
If a portion of the vagina is to be excised, the rectum is removed from the vagina as the final
maneuver (Figure 12-43). The posterior vagina is closed with a running full-thickness absorb-
able suture from the apex of the cuff out to the introitus (Figure 12-44). Over time, the vagina
restretches to accommodate space. The rest of the pelvic floor closure proceeds as previously
described.
Step 4: Postoperative Care
Instruction in enterostomal therapy and appliance change is very helpful for a new ostomate.
Patients require significant analgesia with patient-controlled narcotic and nonsteroidal antiinflammatory drug administration.
The perineum becomes a major concern and focus of the patient after this procedure. The
patient should not sit, scoot, or ride in a car sitting for at least 2 weeks. A shower or tub soak
is sometimes helpful to relieve some of the pain and to clean the area. There is a significant
amount of serous drainage in the first 2 weeks until the wound begins to seal. Patients who
have undergone chemoradiation for squamous cell cancer have an extremely high risk of wound
breakdown. This condition is easily treated with placement of a wound VAC in the wound after
it separates. In many circumstances, if the wound raises any suspicions of potential problems,
a wound VAC could be placed primarily at the time of the operation to begin healing and
improve tissue oxygenation and contraction. The Blake drain is left in the pelvis until the drainage has decreased to less than 50 mL/day and is clear serous in nature.
The patient can be started on a clear liquid diet and advanced quickly to a regular diet as
soon as nausea and bloating are gone. The patient should be able to care for the colostomy and
be having semiformed bowel movements before discharge.
Venous thromboembolism prophylaxis and patient-controlled analgesia are required for all
of these patients because they are at high risk for coagulopathy with a diagnosis of cancer and
pelvic dissection. The bladder catheter is left in the bladder in most male patients for at least
4 to 5 days because of the high likelihood of urinary retention and need for reinsertion if
removed earlier. Female patients can have the bladder catheter removed earlier and tend to do
well with voiding despite the pelvic dissection.
Chapter 12 • Open Abdominal Perineal Resection 223
S5-coccyx joint
Rectum
Figure 12-42
Figure 12-43 Figure 12-44
224 Chapter 12 • Open Abdominal Perineal Resection
Step 5: Pearls and Pitfalls
The colostomy represents a major source of complications because of blood supply, the possibility of retraction, and the difficulty of maintaining an appliance if poorly placed on the abdominal
wall. Preoperative marking can avoid most of these problems if the patient is placed in the
sitting position, standing position, and lying position and asked to visualize the ostomy site
(Figure 12-27). Doing this with the patient dressed in his or her usual clothes may also help
identify the path of the belt. Most of the time, it is better to ask the patient to change his or
her clothes style rather than move the ostomy to the upper abdomen.
As mentioned earlier, the perineal wound is the most likely site of complication. Close attention to avoiding sitting, scooting, or any lateral traction to the perineal wound can reduce the
risk of breakdown of the wound, infection, and future complications of perineal hernia. If an
abscess forms in the pelvis, a computed tomography (CT) scan can aid in the diagnosis, and
placement of a drain by a vascular interventional radiologist can be performed to eliminate the
collection. The pelvic drain placed at the time of operation can be left in place for longer periods
if there is an extremely high volume of lymphatic and serous fluid collecting in the now empty
pelvis.