Abdominosacral perineal rectal prolapse anoplasty

Abdominal perineal rectal rectal prolapse anusplasty for the treatment of middle and high rectal anus deformity. About 10% of high-grade anal-free children have more than 10% of rectal blinds in the peritoneal reflex. After the sagittal approach, it is difficult to find the rectal blind end and treat the rectal bladder fistula, rectal prostatic urethra and rectal high vagina (female). ), in addition to the female high point aus can not complete the separation of the vagina and urethra from the perineal surgery. The advantage of this operation is that the posterior sagittal incision is performed to fully dissect the external anal sphincter and levator ani muscle and cut in the midline. Then the rectum is fully dissected from the abdomen and the combined fistula is treated, and the rectum is pulled out from the middle of the striated muscle complex to ensure The physiological relationship between the reconstructed rectum and the levator ani muscle and striated muscle complex. The incidence of anal incontinence has been greatly reduced. At present, this operation has basically replaced the abdomen perineal rectum and anal angioplasty. Treatment of diseases: congenital rectal anal deformity Indication High rectal anal atresia combined with perineal fistula is relatively thick, can expand the fistula to maintain defecation, after the age of half, perineal or abdominal perineal perineal anusplasty. Preoperative preparation 1. The position of the blind end of the rectum should be determined before surgery to determine which type of deformity it belongs to. 1 Photograph of inverted pelvic X-ray lateral film: Newborn swallowing air must reach the rectum for more than 12 hours, so the film should be taken 12 to 24 hours after birth, and the inversion time is more than 2 minutes. Anal crypt disposal lead type sign. At the moment of filming, choose the inhalation of the sick child. Attention should be paid to the X-ray projection angle when shooting, generally perpendicular to the film, and the illuminating point is the pubic symphysis so that important anatomical landmarks can be clearly displayed. This test result is often higher than the actual position of the rectal blind end, mainly because the rectal blind end is filled with sticky fetus, sometimes the gas is not easy to reach the apex, and the sick child is crying, the levator ani muscle contraction is large, and sometimes the rectum can be compressed. Blind end retraction. 2 In recent years, the application of B-ultrasound, CT and magnetic resonance imaging (MRI) has been helpful in determining the position of the blind end and estimating the state of the sphincter before surgery. 3 Some people also advocate the use of puncture and suction to determine the position of the blind end of the rectum. The specific method is to use a thick needle to puncture from the anal crypt, while sucking into the needle. Once the fetus is taken out, the depth of the needle is the distance between the blind end of the rectum and the skin. When puncture, it should be noted that the needle angle is inclined from the vertical line of the anus by 5° to 10° to prevent the needle from entering too deep and the needle is too strong to penetrate the bladder or other organs in the abdominal cavity. 2. Conduct a comprehensive physical examination to determine whether there are other system malformations. In particular, attention should be paid to whether congenital malformations such as congenital heart disease, esophageal atresia, and paralysis directly threaten the life of sick children. 3. The urethra should be preserved before surgery as a sign to separate the rectum during surgery to prevent damage to the urethra during free rectum. 4. Preoperative infusion to correct water and electrolyte disorders. For those who have no vomiting without digestive tract obstruction, it is not necessary to infusion. 5. Place the gastrointestinal decompression tube. 6. Prophylactic antibiotics. At the same time, vitamin K1110mg was given, intramuscular injection, 2/d to improve coagulation function. 7. Patients with combined fistula or colostomy should be cleaned before surgery to remove all feces. The blind end can be injected with 1% neomycin solution or metronidazole solution 12 hours before surgery. Surgical procedure 1. The posterior sagittal incision is cut from the top of the gluteal groove above the tailbone along the midline to the anal crypt. 2. After the subcutaneous tissue is cut, the external sphincter sagittal fibers and the external sphincter subcutaneous fibers are seen to be annular, and there is an external sphincter complex in the deep. The levator ani muscle is separated from the middle and the anal external sphincter complex is cut open, and the upper part of the peritoneal reflex is separated upward. 3. Place 2 anal canals in the middle of the levator ani muscle and the external sphincter complex, and the apex reaches the peritoneal reflexed site. The levator ani muscle is then sutured in situ. 4. Turn over, take the supine position, remove the position cushion. 5. The lower abdomen curved incision is opened to the pelvic cavity to find the rectal blind end. If the rectal bladder fistula, the fistula is separated and ligated; if the rectal prostatic urethra spasm, the pelvic peritoneum is cut, and the fistula is cut at the proximal urethra side, so be careful not to pull too tight to prevent damage to the urethra. 6. Find the anal canal under the pelvic peritoneum and separate the distal rectum, but do not ligature the lower rectal artery to avoid necrosis of the distal rectum. If the blind end of the rectum is dilated, it needs to be shaped. 7. Fix the rectal blind end suture to the anal canal, and then pull the anal canal from the perineum to pull the rectum out of the perineum along the tunnel between the sutured levator ani muscle and the external sphincter complex. The pelvic peritoneum was then sutured intermittently, and the abdominal incision was closed layer by layer. 8. The sick child is transferred to the prone position, and the blind end of the rectum is trimmed, and it is fixed with the external sphincter complex and the anus, and the anus is formed, and the diameter of the anus is kept at about 1 cm. complication Rectal necrosis The most common cause is that the blood supply to the rim of the sigmoid colon and the superior rectal artery is damaged, resulting in a blood transfusion disorder at the distal end of the rectum. Another reason is that the length of the intestine is not enough, and the tension of the intestine is too large to make the mesentery Intestinal necrosis occurs when the blood vessels are involved, which is manifested as blackness and necrosis of the rectal mucosa of the anus, cracking of the anastomosis, retraction of the intestine, and secondary infection. If the necrosis is long, the infection may spread upward and cause pelvic peritonitis. When the above situation is found, the sigmoid colostomy should be made in time to quickly control the infection. After the infection control and the wound healing of the anus, the colostomy can be closed selectively or the abdominal sigmoid colon can be removed again. 2. Anal stenosis The most common cause is the lack of free length of the colon, the tension after pulling out is large, and some of the intestines are retracted to cause scar formation; part of the reason is that the anal expansion is not enough. Severe can lead to stenotic incontinence. Should insist on anal expansion for 3 to 6 months to relieve the stenosis. If the anal expansion is ineffective, the stenosis segment is shorter and the anus is angioplasty. The "Z" shape is modified or inserted into the flap. If the stenosis is long, abdominal abdomen surgery should be performed again. In this type of case, there are many scars and adhesions in the anorectal area. Repeated surgery has great damage to the external sphincter. The incidence of postoperative anal incontinence is high. If there is an anal stenosis in the case of secondary megacolon, the colostomy should be performed first, and the megacolon should be restored. After the abdominal perineal surgery. 3. Anal incontinence It is the most common complication of abdominal perineal anusplasty, mainly because of abdominal surgery, blind expansion and detachment to the pelvic cavity, damage to the external anal sphincter or dragging the intestine without passing through the muscle complex. In the latter case, you can choose to have a perineal anal angioplasty (Pena surgery) and reposition the rectum in the muscle complex. Anal incontinence caused by external sphincter injury, anal external sphincter replacement surgery should be performed. For anal stenosis incontinence, first anal sphincter treatment. If the anal expansion is not effective, the perineal anal angioplasty or perineal anal angioplasty is performed again. 4. Pelvic and abdominal infections Severe infection of the abdominal cavity should be drained in time. Anal infections, in addition to the use of effective antibiotics, if necessary, sigmoid temporary ostomy. The advantage of abdomen perineal colonic anesthesia is that it is not limited by the height of the blind end. It is convenient to treat the rectal bladder fistula, high rectal vaginal fistula and rectal urethral fistula once. The disadvantage of this procedure is that it has a greater impact on sick children and is prone to traumatic and hemorrhagic shock. During the operation, the pelvic cavity should be bluntly separated from the anterior iliac crest to the anus. During the process, the external sphincter complex cannot be revealed. Therefore, the intestines that are pulled out often cannot pass through the center of the muscle ring, or the external sphincter is damaged by blindly free pelvic cavity. Anal incontinence occurs. According to our statistics, 60% of the 98 cases of anal incontinence were admitted to the abdominal perineal anusplasty. This is the biggest drawback of this technique. In recent years, with the progress of pediatric surgery, there has been a trend of being replaced by abdominal aneurysm anusplasty.