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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_953_Библиотеки_им_академика_М_И_Перельмана.pdf
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FIGURE12-8Digitalpressureonspongepresenting
operativefieldtosurgeon.
Ifthefistulaissmall,anothersimpleyeteleganttechniquefor fistulectomyutilizesapunchbiopsy.Alacrimalductprobeisinserted throughamoistsponge(Figs.12-9and12-10).Theprobeistheninserted transanallyintothefistuladefectandintothevagina.Thesponge protectstherectalmucosaoppositetheanteriorrectalaspectofthe fistulaandinsertionofone’sindexfingerintotheanusandbehindthe sponge,actstostabilizetherectovaginalseptumandpresentingthe vaginalmucosaandthefistulaforexcision.Apunchbiopsyisthen insertedoverthelacrimalductprobe,whichservesasaguide,andthe biopsydevicethenexcisesthetractasadonutoftissue(Fig.12-11).The exciseddonutoftissuecanbeinspectedtoverifyforcompleteexcisionof thescarexcisionafterwhichitissubmittedforhistologicevaluation.The resultingdefectisinspectedtoconfirmtheexcisionofthecicatrixand separationoflayerstoberepaired.
FIGURE12-9Punchbiopsy—fistulaprobeinsertedinto
lumenguidingexcision.
p.87
p.88
FIGURE12-10Punchbiopsyfistulectomy.
FIGURE12-11Fistulectomyspecimen.
Verticalincisions1–1.5cmproximalanddistaltothedefectare performedintothevaginalmucosaandsubmucosa(Fig.12-12).Sharp dissectionthenunderminesthevaginalmucosalflapsinalldirections (Fig.12-13).ThehooksoftheLoneStarretractorareadvancedontothe vaginalflapsfortheexposureofthedefectoftherectum(Fig.12-14). Exposureenablesonetoaddressanybleedingthatmayhaveresulted fromthesharpdissection.Ajudicioususeofcauteryisadvisedtoprevent thermalinjurytothelayerstoberepaired,inparticularthemucosal layers.Constantaspirationofbloodfromtheoperativefieldiscriticalfor precisecontrol.Continuousirrigationoftheoperativefieldwithan antibioticsalinesolution(bacitracin50,000unitsin1lnormalsaline)is alsohelpful.
FIGURE12-12Verticalincision—proximalanddistalto
fistuladefectthroughvaginalwall.
FIGURE12-13Sharpdissectionraisingflapsand
exposingrectaldefectatleast2cminalldirections.
p.88
p.89
FIGURE12-14Advancinghooksexposesrectalwall
defectforrepair.
Therectalmucosaldefectisfreshenedandisrepairedinlayersusing absorbableOOOVicrylmultifilamentsuture,invertingtherectalmucosa (Fig.12-15).TherectalmuscularlayersarethenrepairedusingOOVicryl suture,imbricatingthemucosalrepair.
FIGURE12-15Layeredrepairbeginningwithrectal
mucosausing000Vicryl.
Followingtherepairoftherectalwall,onethenperformsthe interpositionmeshinsertion.Generally,a2×2cmpieceofbiologicmesh (Fig.12-16)isinsertedtocoverthesuturelineoftherepairedrectalwall. Bioprostheticmeshpreferredbytheauthorisporcinebladdersubmucosa matrix,doublelayer.Themeshishydratedandfixedtotherectal muscularlayerusingVicrylabsorbableOOsuture(Figs.12-17and12-18). Therectovaginalfasciaisthentransverselyrepaired.Thevaginalmucosa isthenrepairedtransverselywithinterruptedVicrylOOsutures(Figs.12-
19and12-20).Thencarefullyinspecttheanalmucosalrepairandensure
completenessaswellashemostasis.Novaginaloranalpackingisused.
FIGURE12-162×2cmmeshgraft—porcinebladder
submucosa.
FIGURE12-17Meshsewnintoplace.
p.89
p.90
FIGURE12-18Meshsewnintoplace.
FIGURE12-19Closureofrectovaginalfasciallayerover
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