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_697_Библиотеки_им_академика_М_И_Перельмана.pdf
468
26 Posterior Sagittal Approach for the Treatment of Other Conditions
A posterior sagittal trans-anorectal incision is
done, dividing, as previously mentioned, the
sphincter mechanism posterior to the anus, as
well as the anterior one, dividing also the posterior and anterior rectal walls. Figure 26.16 shows
a picture of the intraoperative aspect of the transanorectal incision. Both posterior and anterior
rectal walls have been divided. Figure 26.17 is a
diagram showing both blind ends of the urethra
deep in the operative fi eld. Multiple fi ne silk
sutures are placed in each end of the urethra in
order to apply uniform traction and mobilize
them to be able to create a non-tense end-to-end
anastomosis. Figure 26.18 shows both urethral
ends already open and with the silk sutures
placed. The gap between both ends is about 3 cm,
and therefore both sides require a signifi cant
mobilization. Figure 26.19 shows after the mobi-
Fig. 26.17 Diagram showing both urethral blind ends.
Multiple fi ne silk sutures are placed in both ends to mobilize them
Fig. 26.16 Intraoperative aspect of the trans-anorectal
approach. Both posterior and anterior rectal walls have
been divided. The urethral ends will be found deep in the
incision
Fig. 26.18 Operative fi eld showing both urethral ends
open. The distal one has a metallic sound
26.4 Acquired Urethral Atresia
Fig. 26.19 Operative fi eld. The anterior wall of the ure-
thra has been reconstructed. A Foley catheter is in place,
and the posterior wall is being sutured
469
lization both urethral ends come together, the
anterior wall has been already sutured, a Foley
catheter is passed through the penis into the bladder, and the fi nal step is the reconstruction of the
posterior urethral wall. Reconstructing the
perineal body as well as the rectum will complete
the operation (Fig. 26.20 ). Figure 26.21 shows
the reconstruction suturing of the anterior rectal
wall with two layers of fi ne, long-term absorbable sutures. The reconstruction of the anterior
rectal wall must be done simultaneously with the
reconstruction of the sphincter. Figure 26.22
shows the completion of the urethral suturing,
perineal body reconstruction, as well as the
sphincter mechanism and rectum. The perineal
body is already reconstructed, as well as the
sphincter mechanism anterior to the rectum and
the anterior rectal wall. The next step will be to
suture the posterior rectal wall and to approximate meticulously the sphincter mechanism posterior to the anus and rectum. Figure
26.23 shows
a diagram of the completed operation. The patient
shown in this diagram has urinary control, as well
as sexual function. However, when dealing with
this kind of severe pelvic trauma, one cannot
Fig. 26.20 Diagram
showing the urethral
anastomosis and the rectal
reconstruction
470
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.23 Diagram showing the completed operation
Fig. 26.21 Operative view of the closure of the incision,
suturing the anterior rectal wall
Fig. 26.22 Diagram showing the completion of the ure-
thral reconstruction and the closure of the perineal body,
sphincter mechanism, and rectum
Fig. 26.24 Three-dimensional rotational scan of a
patient with an anorectal malformation with an acquired
urethral atresia
26.5 Acquired Rectourethral Fistula
471
Fig. 26.25 Intraoperative view of the urethral anastomosis
Fig. 26.26 Diagram showing a giant rectourethral fi stula
consecutive to the surgical treatment of prostatic cancer
guarantee good functional results in all patients
because each patient suffers from a trauma of a
different magnitude. Two of our six patients suffered from postoperative urinary incontinence
and required another type of urinary reconstruction, including the closure of the bladder neck.
More recently, the anatomy of these complex
conditions can be elucidated better by the use of
a three- dimensional rotational scan, which provides excellent images, like one shown in
Fig. 26.24 . That patient was also approached
trans-anorectally, and Fig. 26.25 shows the intra-
operative fi ndings, as well as the reconstruction
of the urethra. The patient also has urinary
control.
26.5 Acquired Rectourethral
Fistula
Our colleagues, adult surgeons, and urologists
referred adult patients to us. Those patients were
suffering from acquired rectourethral fi stula. This
type of problem represents a serious surgical
challenge and has been treated in different ways
[ 61 – 63 ]. Some authors used the transanal ante-
rior approach [ 64 – 67 ], and others adopted the
transanal posterior approach [ 68 , 69 ].
We had the opportunity to operate on adult
patients who originally suffered from prostatic
cancer and were treated either surgically by
implantation of radioactive seeds or using cryosurgery. As sequelae of those treatments, the
patients developed a huge communication
between the rectum and the posterior urethra.
The original urology surgeons unsuccessfully
tried to repair the fi stula through the perineum,
and the patients were referred to us. Figure 26.26
shows a diagram of one of these cases. The communication between the posterior urethra and the
anterior rectal wall is extremely large, and sometimes it measures 4 or 5 cm in diameter, making
these kinds of conditions a real surgical challenge. The dotted lines in Fig.
lines of resection that we do. The patient is
approached trans-anorectally. The portion of the
rectum located between the dotted lines is
resected, and the upper rectum is pulled down to
be anastomosed above the pectinate line in order
to preserve the bowel control. The goal of the
operation consists in leaving a completely normal rectal wall in front of the urethral suture, as
the only way to guarantee that the patient would
not suffer a recurrence. Figure 26.27 shows the
26.27 show the
472
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.27 Diagram showing the completed repair of the
urethra and a healthy rectal wall left next to the urethral
suture. The rectal anastomosis is performed above the
pectinate line to preserve bowel control
Fig. 26.28 Intraoperative picture. Trans-anorectal
approach, dissection of a giant seminal vesicle. Seminal
vesicle open
completed procedure, including the urethral
sutures and the anastomosis between the upper
rectum and the lower rectum above the pectinate
line.
Our experience includes six patients, two of
them actually had an operation for Hirschsprung’s
disease; the surgeons damaged the posterior urethra, as well as the anterior rectal wall, and the
patients came with anatomic fi ndings similar to
those shown in Fig. 26.28 . The other four patients
suffered from prostatic cancer originally. The fi stulas were successfully closed, except in one of
the patients who had excessive local radiation
that, we believe, interfered with the healing process of the local tissue.
26.6 Giant Seminal Vesicle
There is some confusion related with the terminology and embryogenesis of cystic structures
communicating with the posterior urethra.
Different authors use terms such as “prostatic
utricle,” “Müllerian duct remnants,” and “giant
seminal vesicle.” A good attempt to simplify this
was done by Currarino [ 70 ]. In his paper he pres-
ents a series of radiologic images of these abnormal structures.
The treatment of these conditions includes
transvesical approach [ 71 ], transurethral fulgura-
tion [ 72 ], and laparoscopic approach [ 73 ]. Kaplan
et al., following the original idea of Hunt, accumulated signifi cant experience with a posterior
approach without opening the rectum, but rather
pushing it laterally in order to have access to the
posterior urethra [
same approach [ 78 – 81 ].
A few surgeons tried the trans-anorectal
approach to resect one of these utricles [ 82 ].
Four cases were referred to us. Two of them
suffered from orchiepididymitis of unknown
origin. The patients did not have any other associated defects. They had a normal rectum and
apparently a normal urinary tract. The episodes
of orchiepididymitis were treated with antibiotics, but they had several recurrences. A full
urologic evaluation disclosed the presence of a
giant seminal vesicle connected to the posterior
74 – 77 ]. Other authors use the
26.8 Acquired Rectovaginal Fistula
473
Fig. 26.29 Giant seminal vesicle has been resected, and
the urethra will be closed
Fig. 26.30 Perineal appearance at the end of the
operation
urethra. One of the patients had been previously
approached unsuccessfully, through the abdomen
and another one through the perineum. We
decided therefore to approach the problem via
trans-anorectal. Figure 26.30 shows the operative
fi eld in one of these cases. The rectum has been
divided into two halves, and the giant diverticulum is shown. The upper part of it is actually connected to the vas deferens. Therefore, these
patients underwent a vasectomy in order to resect
the giant seminal vesicle, which was dissected
down to its neck that connected to the urethra. In
order to do that in a more precise way, we opened
the giant seminal vesicle, as shown in Fig. 26.28 ;
disconnected the vesicle from the urethra; and
sutured the posterior urethra as shown in
Fig. 26.29 . Figure 26.30 shows the fi nal aspect of
the perineum of the baby after the operation. Two
more patients were referred to us with a giant
seminal vesicle, but they also suffered from an
anorectal malformation and severe hypospadias.
In those patients, the approach was not real transanorectal, but rather we approached the giant
seminal vesicle posterior sagittally, directly, at
the same time that we pulled the rectum down to
repair the anorectal malformation. All patients
had bowel control, urinary control, and no evidence of orchiepididymitis after our operation.
26.7 Urethral Tumors
Two patients were referred to us because they
suffered from a rhabdomyosarcoma of the posterior urethra; they both received chemotherapy,
until the oncologists considered they achieved
the maximum reduction in tumor size. The pediatric oncology group requested a biopsy and if
possible a resection of the remnant of the tumor.
The patients were approached trans-anorectally,
and the tumor was resected. One case did not
require the division of the urethra, but the other
one case did. We performed a resection of part of
the urethra with the tumor and reanastomosed
both urethral ends. Both patients preserved bowel
control, but we do not have information concerning the long-term follow-up from the oncologic
point of view.
26.8 Acquired Rectovaginal
Fistula
Two adult patients were referred to us because
they suffered from cervicouterine cancer and
received local radiation. As a consequence of
that, they developed a giant communication
between the rectum and the vagina. Basically,
both the rectum and vagina became a single
474
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.31 Diagram showing a giant rectovaginal fi stula
in a patient with cervical cancer subjected to local
radiation
Fig. 26.33 Picture showing the perineum of a girl suffer-
ing from an acquired rectovaginal fi stula as sequelae of an
operation for Hirschsprung’s disease. The picture was
taken during the repair. A Hegar dilator is passing through
the fi stula
Fig. 26.32 Diagram showing the repaired fi stula
chamber, as can be seen in Fig. 26.31 . The
patients were considered cured from the cancer,
but were referred to us to try to close that wide
communication. The approach used was similar
to the one described in male patients. The rectum
was separated from the vagina and was divided
above the pectinate line, and we mobilized the
upper rectum enough to be sure to leave a completely normal rectum in front of the vaginal
suture, as shown in Fig.
26.32 . The fi stulas were
successfully closed, and the patients preserved
bowel control.
Three little girls were referred to us, suffering
from acquired rectovaginal fi stulas, consecutive
to an operation for Hirschsprung’s disease. The
patients had been previously subjected to a Soave
type of pull-through for Hirschsprung’s disease,
and soon after the operation, the parents noticed
that the patients were passing stool through the
vagina. Figure
26.33 shows the perineum of one
of these girls. The diaper rash was extremely
severe, because the stool came out constantly
through the vagina. The patient is in prone position, the rectum has been opened posterior sagittally, and a Hegar dilator has been passed through
the wide communication between the anterior
rectal wall and the posterior vaginal wall. The
perineal body was divided, and Fig. 26.34 shows
the urethra, the vagina, and the rectum. The
vagina was reconstructed (Fig. 26.35 ), and the
rectum was also sutured, being sure not to leave
over-imposed the vaginal suture and the rectal
suture. The patient recovered uneventfully, and
the fi stula was successfully closed.
26.9 Rectal Tumors
475
Fig. 26.34 Operative picture. The perineal body was
opened. The picture shows the internal anatomy. V vagina,
R – rectum
26.9 Rectal Tumors
We have used the posterior sagittal approach to
resect a variety of tumors that affect the rectum
and sometimes the vagina. Figure 26.36 shows
the diagram of a sagittal view of the pelvis of an
adolescent girl who suffered from an “infl ammatory pseudotumor” that invaded the rectum and
vagina. This is considered a histologic benign
tumor but highly invasive. In an oncologic center,
she was offered a pelvic exenteration; yet, the
posterior sagittal approach proved to be very effi cient to resect the mass, including 75 % of her
rectum and one third of her vagina (Fig. 26.37 ).
We were able to preserve part of the pectinate
line of her rectum. The patient recovered very
successfully and preserved her bowel and urinary
control. Figure 26.38 shows the external appear-
ance of her perineum 6 months after the
operation.
We were invited to use the trans-anorectal
approach to resect rectal cancers, in adult
patients, localized to the rectal wall, without
local invasion, and located above the pectinate
line. In addition, we used the same approach to
Fig. 26.35 Operative picture. The rectum was mobi-
lized, and the posterior vaginal wall is being pulled down
Fig. 26.36 Diagram showing the sagittal view of the pel-
vis. “Infl ammatory pseudotumor” invading most of the
rectum and part of the vagina
476
26 Posterior Sagittal Approach for the Treatment of Other Conditions
Fig. 26.37 Same case in which the tumor has been
resected. A portion of the rectum with pectinate line has
been preserved
Fig. 26.38 External appearance of the perineum of the
same patient, 6 months after the operation
resect villous adenomas of the rectal wall. We
like to emphasize the fact that this approach,
when used with this specifi c purpose, should be
done only if the tumor is localized and is located
above the pectinate line. The rationality of this
Fig. 26.39 Diagram showing a small tumor located
above the pectinate line. The dotted lines represent the
limits of the resection
approach is to be able to preserve the anal canal,
as well as the sphincter mechanism and by
doing that, to guarantee that the patient will
have bowel control, and by doing that, we avoid
the possibility of an abdominoperineal resection and a permanent colostomy. Figure
26.39
shows a diagram of a patient with a small tumor
located on the anterior rectal wall about the
pectinate line. The dotted line shows the line of
resection preserving the anal canal and the pectinate line. Figure 26.40 shows a diagram illus-
trating the posterior sagittal incision and the
opening of the rectum. The dotted line represents the line of resection above the pectinate
line. Multiple silk sutures are placed, taking the
rectal wall above the pectinate line in order to
apply uniform traction to facilitate the dissection of the rectum with the tumor. Figure
26.41
shows the operative fi eld of one of these cases.
The pectinate line is perfectly obvious, and the
line of silk sutures are placed 2 cm above the
pectinate line. Figure 26.42 shows the effect of
uniform traction to facilitate the dissection of
the rectum. The dissection continues, remaining as close as possible to the rectal wall, until
a margin of about 5 cm above the location of
the tumor is reached. At that point, the rectum
is divided as shown in Fig. 26.43 and the upper
26.9 Rectal Tumors
Fig. 26.40 Diagram
showing the posterior
sagittal approach. The
entire sphincter mechanism
posterior to the rectum has
been divided, as well as the
posterior rectal wall. The
tumor can be seen. The
rectal wall is being divided
above the pectinate line
477
Fig. 26.41 Picture of the operative fi eld. The pectinate
line is clearly seen, and the traction sutures are placed
2 cm above the pectinate line
Fig. 26.42 Operative fi eld. Applying uniform traction