Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_665_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 265
Figure 15-2
Figure 15-3
mesenteric vein
mesenteric artery
Inferior mesenteric vein
Inferior vena cava
Inferior
Inferior
Ureter
Aorta
Mesentery
Ureter
Inferior
mesenteric artery
266 Chapter 15 • Open Resection Rectopexy for Rectal Prolapse
u
The presacral space is entered at the sacral promontory, and the areolar tissue is divided down
to the pelvic floor along the mesorectum (Figure 15-4). Dissection in this areolar tissue plane
(Figure 15-5) allows release of the mesorectum in its envelope around the circumference of
the pelvis (Figure 15-6). A Thorlakson retractor is useful for maintaining traction of the
redundant mesorectum (Figures 15-7 and 15-8).
Figure 15-4
Areolar tissue
plane
Planes of
dissection
Waldeyer’s fascia
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 267
Figure 15-5
Sacral
promontory
Figure 15-7
Malleable
retractor
Areolar
tissue
Figure 15-6
Sacral promontory
Figure 15-8
268 Chapter 15 • Open Resection Rectopexy for Rectal Prolapse
u
The anterior rectovaginal septum is identified. It is frequently thickened owing to chronic
prolapse. An incision is made along the anterior surface of the rectum through the rectovaginal peritoneal reflection, and dissection is done in this areolar plane (Figure 15-9) down to
the level of the pelvic floor. The anterolateral ligaments entering from the pelvic side walls
are preserved to protect the splanchnic nerves and middle rectal vessels within the fatty
structure.
u
The distance of dissection in the anterior and posterior plane is checked by placing a gloved
finger within the anal canal to assess mobilization to the pelvic floor.
u
The redundant rectosigmoid is resected. Because the descending colon is typically not redun-
dant and is a retroperitoneal organ, the proximal resection margin is chosen just distal to this
point. The mesentery of the distal descending colon is mobilized along the left gutter (Figure
15-10). The left colon mesentery is ligated and divided up to the edge of the colon. A proxi-
mal purse-string suture is placed at the distal descending colon junction, a Kocher clamp is
placed distally, and the bowel is divided (Figure 15-11).
u
A 29-mm circular stapler head is placed within the purse-string suture, and the purse-string
is tied.
u
The redundant rectum is retracted toward the sacral promontory, and the distal resection
margin is chosen at a point where the anastomosis can be done without redundancy but also
without tension. This point is typically in the upper rectum.
u
The mesentery is divided and ligated to this point, and the rectal wall is isolated and divided
with a linear cutter stapler (Figure 15-12).
u
The circular stapler is passed through the rectal stump, and the point is brought out just
anterior to the staple line. The instrument is coupled, engaged, and then fired.
u
After removal of the circular stapler, the pelvis is filled with fluid, and air is insufflated through
the rectum via a proctoscope. The anastomosis is checked for air leakage and repaired with
3-0 polyglactin Lembert sutures as needed.
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 269
Figure 15-9
Cul-de-sac
Figure 15-10
Figure 15-11
Figure 15-12
270 Chapter 15 • Open Resection Rectopexy for Rectal Prolapse
u
A sutured rectopexy is performed at the sacral promontory with No. 1 polypropylene suture
(Figure 15-13). The suture is placed through the left lateral ligament (Figure 15-14) and then
through the periosteum at the level of the sacral promontory (Figure 15-15). Care must be
taken to avoid the left internal iliac vein. The suture is passed back through the left lateral
ligament. The right lateral ligament is affixed in a similar fashion (Figure 15-16). The sutures
are tied snuggly, and the pelvis is irrigated with saline (Figure 15-17). A drain is typically
not used. The abdominal fascia is closed with No. 1 absorbable suture.
Left colon
Anastomosis
Figure 15-13
S1
Large
retropexy suture
12 cm
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 271
Figure 15-14
Sacral promontory
Left common iliac A
Pelvic brim
Figure 15-15
Left colon
Rectum
Anastomosis
Sacral promontory
Figure 15-16
Rectum
Left colon
Staple line
Right
Left
Sacral promontory
Figure 15-17
272 Chapter 15 • Open Resection Rectopexy for Rectal Prolapse
Step 4: Postoperative Care
Intravenous fluid replacement is given to maintain a urine output of approximately 30 mL/hr.
Nasogastric decompression is not required unless the patient becomes nauseated. Patients are
ambulated early, and deep vein thrombosis prophylaxis should be given. Antibiotics are given
for the first 24 hours, and patients are encouraged to use incentive spirometry. Postoperative
analgesia is usually maintained with patient-controlled analgesia followed by oral analgesics.
Patients are initially given a liquid diet and advanced as tolerated. The usual hospital stay is
approximately 4 to 5 days.
Step 5: Pearls and Pitfalls
The risk of anastomotic leak can be minimized by ensuring the use of well-vascularized tissue
in the descending colon and rectum. Although resection of the redundant colon is one of the
goals of this procedure, the anastomosis should be done under minimal tension. Checking for
an air leak may not eliminate the risk of anastomotic leakage but helps to identify trouble spots
that can be repaired at the time of operation.
Chapter 15 • Open Resection Rectopexy for Rectal Prolapse 273
Placing the rectopexy suture is best accomplished with a single pass through the periosteum
of the central sacral promontory. If bleeding is encountered, it often stops when the suture is
tied. Lateral placement of the suture risks injury to the internal iliac vessels. Sharp or cautery
dissection of the rectal mesentery in the areolar tissue plane under direct vision helps to minimize the tearing of presacral veins that can occur with blunt dissection.
Most patients have frequent, loose bowel movements when their bowel function returns.
Reduced rectal vault capacity and absence of the sigmoid “brake” results in urgency. Stretch
injury to the anal sphincter from chronic prolapse may prevent complete return of fecal
continence.
Selected Readings
Karas JR, Uranues S, Altomare DF, et al. No rectopexy versus rectopexy following rectal mobilization for full-thickness rectal prolapse:
a randomized controlled trial. Dis Colon Rectum 2011;54:29–34.
Riansuwan W, Hull TL, Bast J, et al. Comparison of perineal operations with abdominal operations for full-thickness rectal prolapse. World
J Surg 2010;34:1116–22.
Step 1: Clinical Anatomy
The left colon lies along the left side of the abdomen suspended from the splenic flexure to the
pelvic brim by lateral peritoneal attachments. The mesentery of the left colon arises from the
midline of the abdomen along the aorta. The sigmoid colon has no lateral peritoneal attachments
other than some congenital adhesions, which fix the apex of the sigmoid to the pelvic brim and
the iliac fossa. Otherwise, the sigmoid colon is attached to the retroperitoneum through a
midline mesentery arising from the inferior mesenteric artery (IMA) and extending down into
the pelvis to the mesorectum. The splenic flexure is attached to the undersurface of the tip of
the spleen, the lower edge of the tail of the pancreas, and the anterior surface of the left kidney
by various levels of suspensory ligaments and peritoneal extensions. The blood supply to the
left colon is based on the IMA, which arises from the anterior surface of the aorta just above
the bifurcation of the common iliac arteries (see Figure 16-3). The IMA extends anteriorly and
bifurcates to produce the superior rectal artery feeding the sigmoid colon and the rectum. The
left colic artery extends cephalad to provide the left colon and distal splenic flexure with blood
supply through the arcade at the mesenteric edge known as the marginal artery of Drummond.
The retroperitoneum behind the left colon contains the left ureter and the gonadal vessels lying
over the psoas muscle. The ureter crosses the iliac vessels at the bifurcation of the iliac vessels
into the external and internal iliac branches (Figure 16-1).
C H A P T E R
16
Laparoscopic Rectopexy
Matthew G. Mutch
274