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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1192_Библиотеки_им_академика_М_И_Перельмана
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114
mesenter
Ureter
B. J. Champagne and M. L. Manwaring
terclockwise. The surgeon holds the IMA in the
right hand retracting in a caudad direction. The
left hand is used to create the window on the far
side of the vessel with monopolar cautery and a
Maryland grasper. The assistant retracts the colon
more proximally to optimize tension.
The mesentery around the IMA can be taken
with bipolar energy prior to ligating the vessel to
expose the most proximal extent of the vessel. An
endolumenal stapling device with a vascular load
is very safe and effective as well (Fig.7.5). After
the high ligation, the IMV can be isolated in a
similar fashion and divided, along with the left
colic, as they are in close proximity.
After division of the IMA and IMV, medial to
lateral dissection can be performed with blunt
dissection and gentle sweeping, to facilitate the
lateral dissection.
Step 6: Mobilization oftheLeft Colon
Following division of the inferior mesenteric
artery, the left mesocolon is separated from the
retroperitoneum in a medial-to-lateral direction
using a spreading movement. The patient is taken
out of steep Trendelenburg position and airplaned
to right side down, as necessary to move the small
bowel out of the operating eld. Upward traction
is maintained on the ligated vessels and mesoco-
lon with the left hand, while the right hand sweeps
down additional retroperitoneal attachments.
Dissection can continue laterally to the white line
of Toldt and left gutter and superiorly toward the
pancreas. The more medial the dissection, the
easier mobilization of the left colon will be.
The atraumatic bowel grasper is used through
the right upper quadrant port to retract the
descending and sigmoid colon medially. Scissors
are inserted through the right lower quadrant
port. Cauterization 1mm medial to the white line
will elevate the left colon and free it from the retroperitoneum. Dissection continues in a cephalad
direction just enough to allow adequate reach of
the colon to the planned colostomy site to the
abdominal wall (Tip 7.5).
Tip 7.5 Stoma Length
c
The end of the colon used for the
colostomy should reach without
tension to the abdominal wall.
Insufflation may falsely overestimate
the amount of colon mobilization
needed, so desufflating may be helpful
when checking length. Additionally,
too much length may actually increase
the rate of hernia or prolapse.
Fig. 7.5 Isolation of the
IMA for high ligation.
Windows have been
created proximal and
distal to the vessel, and
the mesentery around
the IMA has been
dissected. The assistant
provides proximal
tension on the colon,
while the surgeon’s right
hand holds the IMA
with caudal retraction.
The surgeon’s left hand
can then create the
window on the right side
of the vessel
Descending
colon
Mesentry
Left colic
Inferior
mesenteric vein
Inferior
ic artery
Aorta
Rectum
Ureter
Hypogast
7 Abdominal Perineal Resection
115
Step 7: Total Mesorectal Excision
The patient is returned to steep Trendelenburg
position, and the small bowel reected cranially.
The rectosigmoid junction is elevated away from
the sacral promontory, to enable entry into the
presacral space. An open atraumatic grasper is
used to facilitate traction on the sigmoid and rectum as if mimicking the role of the St. Mark’s
retractor in an open pelvic dissection (Tip 7.6).
Tip 7.6 Open Retractor Tension: In
c
Up and Out!
To facilitate retraction in the pelvis, an
open long bowel grasper can be placed
behind the mesorectum. The direction of
traction is gently into the mesorectum,
up toward the abdominal wall (anteriorly)
and slightly out of the pelvis (cephalad).
A near bloodless plane is expected for the
mesorectal dissection except for the caudal lat-
eral stalks, which are amenable to division with
bipolar energy or electrocautery. Identify the
lmy plane of the posterior mesorectum and dissect with cautery scissors. Take care to preserve
the hypogastric nerves laterally as they pass into
the pelvis anterior to the sacrum. Continue the
dissection in this avascular, loose areolar plane
toward the pelvic oor (Fig.7.6).
When the tension is lost secondary to anterolateral attachments, switch to the peritoneum on
the right side of the rectum. Retraction on the rectum should be toward the left side of the pelvis to
facilitate traction. Attachments are divided laterally, up to the level of the seminal vesicles or rectovaginal septum. They should be avascular,
except at the lateral stalks, where a small amount
of adipose tissue and the middle colic vessels
cross from the side wall to the mesorectum.
This process is repeated for the peritoneum on
the left side of the rectum with the surgeon’s left
hand retracting the rectum out of the pelvis and to
the right, with the assistant providing countertraction on the side wall (Fig. 7.7). This facilitates
further posterior dissection along the back of the
mesorectum down through Waldeyer’s fascia to
the anal canal. In many cases, particularly with
Fig. 7.6 Posterior
mesorectal dissection.
The posterior mesentery
makes an inverted “U”
providing a visual of the
lmy plane for
dissection. The assistant
facilitates visualization
by providing upward
tension on the rectum.
Caution should be taken
to ensure preservation of
the hypogastric nerves
Ureter
ric
nerves
116
s
villiers
B. J. Champagne and M. L. Manwaring
Fig. 7.7 Right lateral
dissection. The
surgeon’s left hand
retracts the colon to the
left and out of the pelvis,
while the assistant tents
up the side wall away
from the plane of
dissection. Dissection
proceeds along
Denonvilliers’ fascia
Fig. 7.8 Anterior
dissection. Tension is
placed anteriorly on the
bladder or vagina. The
plane is carefully scored
with electrocautery,
preserving the vagina or
seminal vessels unless
contraindicated for
oncologic margins
Bladder
Denonvillier
fascia
Rectum
Bladder
Denon
fascia
obese patients or males with a narrow pelvis,
some or all of the anterior and lateral dissection
must be completed to create lift of the rectum out
of the pelvis and obtain adequate visualization to
complete the posterior dissection.
After the posterior and lateral dissection have
been completed, the assistant places an atraumatic
bowel grasper, via the left iliac fossa port, to
retract the peritoneum anteriorly to the rectum.
The rectum is pushed down and pulled out of the
Rectum
pelvis simultaneously. The anterior peritoneal dissection is continued from the free edge of the lateral peritoneal dissection with monopolar cautery
(Fig.7.8). The anterior dissection is an extension
of the lateral peritoneal incision from each side of
the rectum toward the middle. The plane is developed anterior and parallel to the rectum, leaving
Denonvilliers’ fascia intact unless contraindicated
from an oncologic perspective. The dissection
will separate the posterior vaginal wall of the
n
7 Abdominal Perineal Resection
117
prostate and seminal vessels from the anterior
wall of the rectum (Tip 7.7).
Tip 7.7 Vaginal Retraction
c
In females, a sponge stick in the vagina
that is elevated in an anterior direction
can also help with this dissection.
It is critical not to “waist” the specimen. The
mesorectum should be left intact, and attachments/adhesions from the mesorectum to the
levator muscles after radiation should be left
intact and taken with the specimen (Fig.7.9).
The difculty of dissection will vary depending on the body habitus of the patient, the diameter of the pelvis, and the size and level of the
tumor. Rectal mobilization can be very difcult
to perform laparoscopically under some circumstances. Low bulky anterior rectal tumors, morbidly obese men, or tumors adherent to the
posterior wall of the vagina may need to be completed in an open fashion via a lower midline or a
Pfannenstiel incision (Pitfall 7.2).
Pitfall 7.2
c
If there is any difficulty determining the
difference between tumor and radiation
fibrosis in the anterior position, the
pelvic dissection should be converted
to an open or hybrid approach.
After the anterior dissection is performed,
recheck the lateral and posterior planes to determine
if more tissue can be divided. The dissection is continued until the levators are visualized laterally and
the coccyx is palpated posteriorly. Conrmation
with concurrent digital vaginal exam that the extent
of dissection has reached tissues accessible from the
perineal dissection is helpful (Fig.7.10).
IMA
Colo
Fig. 7.9 Complete abdominal perineal resection. For a
complete abdominal perineal resection, the specimen
should contain signicant portions of the levator ani without waisting of the specimen. The correct planes for an
extra-levator APR are shown above
Step 8: Division ofMesocolon and
Sigmoid Colon
The sigmoid mesentery and colon are left in continuity until this point to prevent the sigmoid from
falling into the operative eld during pelvic dissec-
Fig. 7.10 Conrmation of dissection location. When the
dissection has reached the levator ani from above, a digital
exam can be done to conrm location of the dissection. It
is important not to “cone” in on the specimen and to take
appropriate oncologic margins including the levator ani
for oncologic resection
118
B. J. Champagne and M. L. Manwaring
tion. In some cases, dividing the colon mesentery
and sigmoid early in the case may improve exposure and is reasonable if this is the case.
Retract the inferior mesenteric artery pedicle
with a bowel grasper through the right lower
quadrant port, and insert bipolar energy through
the right upper quadrant port. The assistant continues to retract the colon in an anterior fashion. A
well-perfused location on the colon with adequate
reach to the stoma site should be chosen. The
mesentery is divided perpendicular to the colon
and proximal to the transected IMA/left colon
pedicle. After the residual mesentery is divided
completely with an energy device, the colon is
divided with a laparoscopic stapler. Introduce the
stapler through the 12mm port at the umbilicus
with the assistance of a 5mm camera from a right
port (Fig.7.11). Care must be taken not to devascularize the terminal of the colon during mesocolic division. Preserving the marginal vessel is
typically sufcient to prevent ischemia.
Step 9: Omental Pedicle Flap
Prior to extraction of the descending colon through
the abdominal wall, an omental pedicle ap is raised
if adequate omentum is available. This helps prevent
small bowel loops from entering the deep connes
of the pelvis and may reduce the incidence of complicated small bowel obstruction or perineal hernia.
The omental pedicle ap is created by releasing
attachments of the omentum from the left side of the
transverse colon and gastroepiploic arcades.
The gastroepiploic artery is identied and preserved just lateral to the falciform ligament. The
energy instrument is used to open the omentum
just inferior to the gastroepiploic artery at this
point. The energy device is used to continue
along the inferior aspect of the gastroepiploic
artery to the splenic exure, freeing all the attachments from the lateral left side wall and spleen.
The omentum is also separated from the
colon, starting at the midline. Either electrocautery or bipolar is used to free the omentum from
the colon, again continuing to the splenic exure
as described in Splenic Flexure Mobilization,
Chap. 4. This should completely free the omentum from the left side, allowing a signicant,
tension-free extension down into the pelvis.
The omental pedicle can be lengthened to lie
down the left paracolic gutter into the pelvis. It
can be secured with a 2-0 absorbable braided
suture to prevent migration after closure.
Step 10: Colostomy Creation
andClosure
The colonic limb is then grasped with an atraumatic clamp through the right lower quadrant
port, and attention is turned to making the colostomy site (Tip 7.8).
Tip 7.8 Timing of Stoma Creation
c
The creation of the stoma can be
delayed until after the perineal phase of
the operation. Advantages include
ability to continue dissection from the
abdomen and ability to irrigate the
pelvis fully. Disadvantages are decreased
efficiency and return to the abdomen
after “dirty” phase of the operation.
The stoma site is created with excision of a
nickel-sized piece of skin and vertical incision of
the subcutaneous tissues. Appendiceal retractors
facilitate visualization and separation (Tip 7.9).
Separate the fascia vertically and spread the muscles using a Kelly clamp. The muscles should be
spread and not cut. The peritoneum is then
scored, which will desufate the abdomen. If the
bowel is close to the incision, the peritoneum can
be lifted using Kelly clamps and then incised.
The tissues are opened just enough to admit the
colonic conduit without vascular compromise;
excessive dilation should be avoided as this will
predispose the patient to hernia.
Tip 7.9 Pneumoperitoneum
c
During Trephine Creation
Maintain pneumoperitoneum during
creation of the stoma incision. This will
help prevent inadvertent injury to the
bowel as the peritoneum is opened.
Monitor
7 Abdominal Perineal Resection
Phase I
Monitor
Assistant
119
Anesthetist
Monitor
Surgeon
Monitor
Fig. 7.11 Port relocation for colon transection. To facilitate colon transection, a 5 mm camera is moved to the right
upper quadrant port, and the infraumbilical port is used for insertion of the stapler
120
B. J. Champagne and M. L. Manwaring
A Babcock clamp is placed through the stoma
incision, and the colon is passed from the laparoscopic grasper to the Babcock (Tip 7.10). The
end of the colon is grasped, extracted, and maintained with a Babcock clamp. After reinsufation, evaluate mesentery to ensure the
colon and vascular supply have not been twisted.
Follow the free edge of the mesentery to verify
absence of mesocolic torsion.
Tip 7.10 Recreating Pneumo-
c
peritoneum with an Incision
If the colon is dropped or there is cause
for concern for twisting of the
mesentery, the stoma incision can be
temporarily closed with penetrating
towel clamps.
A JP drain is placed in the pelvis through the
right lower quadrant port site. The uterine retraction suture is released, if present, and hemostasis
at all sites is assured. Trocars are removed, closing ports larger than 5 mm with a CarterThompson suture passer or 5/8 circular needle.
The skin is closed at the laparoscopic port sites
and the wounds covered with a towel. Mature the
stoma by amputating the staple line and sewing
the bowel wall to the dermis circumferentially
using an absorbable suture.
Step 11: Perineal Dissection
The patient is transitioned to a high lithotomy position, with the table raised, to allow the surgeon and
assistant to sit. A small Mayo stand cover or sterile
sheet is secured to the surgeon’s gown and the
drapes to protect instruments from dropping off of
the eld. A headlight assures adequate lighting.
Morbidly obese patients sometimes benet from a
single retraction suture on each buttock to expose
the dissection site. A Lone Star Retractor can also
be used to facilitate exposure in a complete extralevator dissection (Fig.7.11 and Tip 7.11). Palpate
both ischium and the coccyx and mark the skin for
a cylindrical resection. The location and extent of
the dissection is based on pathology and preoperative imaging. Inadequate resection can result in
close or positive margins. If primary closure is not
possible, secondary to radiation changes or laxity of
tissue, consider use of a myocutaneous muscle ap.
There are few external landmarks for use in this
Tip 7.11 Perineal Retraction
c
An alternative to a commercial available
perineal retractor is 2-0 polysorbable
braided sutures. These should be placed
wide to the dissection field and placed
under tension in a circumferential manner.
portion of the surgery. Using a marking pen, trace
the planned borders of the skin incision.
Electrocautery is used to score the dissection markings (Tip 7.12). After the dermis has been incised,
move the Lonestar (R) retractor into the dermis for
improved retraction. As the dissection continues in
a cylindrical shape, larger deep retractors including
Deaver’s may be necessary. Intermittently relax the
retraction, and pay close attention to the shape of
the developing specimen to avoid coning-in or
waisting of the specimen (Fig.7.12).
Tip 7.12 Begin with Posterior
c
Dissection
Working posteriorly first can prevent
bleeding into the dissection plane and
also generally provides the most
consistent landmark, the coccyx, for
borders of dissection.
Initially when dissecting through the ischiorectal spaces, working circumferentially can
maintain the surgeon’s sense of the specimen
shape and allow for necessary adjustments.
Concentrating on the posterior dissection toward
the coccyx provides a landmark as the dissection
deepens. Make an incision through the ligamentous attachments to the coccyx to open the supra-
Retractor
7 Abdominal Perineal Resection
Fig. 7.12 Perineal
setup and Lone Star
Retractor placement.
The perineum should be
redraped as soilage may
have occurred during
manipulation of the
rectum. Place a suture
on the anus to prevent
further soilage. Lonestar
is placed outside the
margins of resection.
Starting posteriorly
prevents rundown of
bleeding and is the most
uniform location to enter
the peritoneum,
secondary to the location
of the coccyx
3
Anus
1
121
22
coccyx
levator space. This should promptly expose the
abdominal dissection planes. From this location,
extend the incision anterolateral by hooking the
levator musculature with a cocked nger or rightangle clamp, and divide the muscle and soft tissue with electrocautery.
The anterior dissection is taken through the
rectovaginal septum in women or through the
perineal muscles and to the retro-prostatic plane
in men. Frequent digital vaginal exams can help
avoid inadvertent injury during the dissection. In
men, the urinary catheter can be palpated as the
122
symphysis
r
B. J. Champagne and M. L. Manwaring
urethra passes posterior to the symphysis pubis
and is an important structure to avoid during the
dissection. Avoid blunt dissection of the levators
to decrease the risk of entering the tumor. The dissection is carried anteriorly on both sides staying
wide to maintain a cylindrical specimen, leaving
only anterior attachments. At this point, the specimen can be folded posteriorly and pulled through
the aperture, leaving the anterior prostatic or vaginal attachments. Amputate the specimen in the
proper plane from this nal attachment.
After assurance of hemostasis, close the
incision with interrupted braided absorbable
sutures in layers from the perineum. The levators cannot be approximated given xed lateral
attachments to the pelvis. Perform closure of
the fatty layers, and position a Penrose drain
from the pelvis to the inferior portion of the
wound. Prior to skin closure, the wound is irrigated with a Pulsavac (R) (Zimmer) lavage of
triple antibiotic solution (1 liter). The perineal
skin is closed with 0 nonabsorbable monolament in a vertical mattress technique. Dry
gauze dressing is applied and the legs returned
to a low lithotomy position.
Special Considerations
Umbilicus
Anterior superio
iliac spine
Pubic
Fig. 7.13 The stoma triangle. The stoma triangle,
bounded by the umbilicus, pubis symphysis, and anterior
superior iliac spine, is the ideal location for a stoma for
many patients
Additional considerations include skin creases
as possible and prior abdominal incisions. With
supine, sitting, and standing positions, the site
should have a at surface amenable to pouching.
It should be visible to the patient, and not interfere with pant lines, belts of daily activities.
Ideally, a site is selected at a preoperative visit
designed to educate the patient about postoperative colostomy care.
Preoperative Stoma Marking
Preoperative preparation for a laparoscopic
abdominal perineal resection must include leftsided preoperative stoma site marking, preferably
by a stoma therapist. Placement of the stoma is
critical, as this will be a permanent colostomy.
Although every patient is different, a stoma
triangle is a well-known concept that facilitates
placement of a stoma. A triangle is drawn
between the umbilicus, the pubis, and the anterior superior iliac spine. This locates the stoma
within the supporting rectus sheath. A location
within this stoma triangle is ideal for many
patients (Fig.7.13).
Varying theApproach
Prone Dissection
In the setting of morbid obesity, limited hip
mobility, or tumors requiring an extra-levator
dissection based on preoperative MR imaging,
a prone perineal-rst approach has distinct
advantages. Though it adds to positioning time,
visualization is superior, and an assistant can
be more effective in assisting with exposure.
When performed, this approach begins with
the patient in the prone jackknife position with
the buttocks taped apart to optimize exposure.
The perineal dissection, as outlined above, is
7 Abdominal Perineal Resection
123
performed rst and taken above the levators
into the mesorectal plane. The perineum is then
sealed with an occlusive dressing and the
patient rotated to the lithotomy position. The
trans-abdominal dissection is then performed
as outlined.
T4b Tumors
T4b tumors can also be challenging laparoscopically, but may be possible. In a woman who has
had a prior hysterectomy, the vagina can be
removed en bloc laparoscopically. The vagina
can be entered from above with the assistance of
a sponge stick in the introitus held by a second
assistant standing between the legs. With the
sponge stick in place, the vaginal apex can be
opened with monopolar cautery. The vaginal
walls can then be divided with bipolar energy
down each side. This part of the dissection needs
to be reserved until after the posterior and lateral
dissection is complete to prevent a loss of pneumoperitoneum. In a thin female, this is easily
accomplished from the perineum, but in a morbidly obese patient, it helps to do this from the
abdomen. T4b tumors into the prostatic capsule
or seminal vesicle should not be approached
laparoscopically.
Intra-levator Dissection
Recently, advocates of the complete extra-levator approach have espoused this technique be
used in all cases to obtain superior oncologic
outcomes. The data has not substantiated this
claim and each case should be looked at individually. In elderly patients with several comorbidities and a tumor limited to one location, the
radial margin should be wide on the side of the
tumor, but it is not necessary on the contralateral side. A massive defect may warrant a complex closure with a ap, adding time and
complexity to the operation. The importance of
a solid radial margin and complete TME cannot
be overstated, but each patient must be evaluated independently.
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