Modified Bacon's Rectal Cancer Surgery

Modified Bacon's radical rectal cancer surgery for rectal cancer surgery. The mid-rectal cancer (the tumor is 8 to 10 cm from the anus) can retain the levator ani muscle and the anal canal, and is used as a pull-through resection of the abdominal cavity and anal canal. First, the abdominal resection is performed, the rectal lesion is removed, the colon is released, and a fixed line that is sewn to the stump of the sigmoid colon is sent from the top to the bottom, and the perineal wound is pulled out to continue the anal operation. Treatment of diseases: rectal cancer Indication 1. The lower edge of rectal cancer is located at the peritoneal reflex or at a distance of more than 8 cm from the tooth line, and the disease is earlier and the degree of malignancy is lower. 2. As a palliative resection, the lower margin of the tumor is within 8cm from the anus, more than 5cm, and the whole body is better. When the cancer is detected, the liver has metastasis and the liver can be removed. Surgical procedure Abdominal surgery The same procedure as the "rectal and anal canal combined with perineal perineal resection" operation. However, in order to pull the sigmoid colon out of the anus, it is necessary to cut the lateral peritoneum of the descending colon, free descending colon and sigmoid colon, and sometimes even need to open the gastric collateral ligament and spleen colon ligament, and release the colon spleen, and then can pull the colon out of the anus. There is no tension outside. The sigmoid colon was ligated as a marker with a thick wire at a predetermined resection line. The rectum was lifted and the rectum was ligated with a thick non-absorbent line 5 cm below the tumor. 2. Perioperative first stage surgery 1 Rinse the rectum and perineum with a large amount of disinfectant water. After drying, disinfect the perineal skin and rectal mucosa with 0.1% thimerosal. 2 fully expand the anal canal sphincter. A tissue forceps is placed on the left and right sides of the anal edge, and is pulled around to make the anal canal valgus the tooth line. 3 Use an electric knife to make a circular incision at the distal end of the tooth line 1 to 2 mm, through the anal canal skin and the submucosal muscle layer of the anal canal, deep into the internal sphincter, and continue to peel upward to the levator ani muscle plane with the elbow scissors. Then, the rectum above the levator ani muscle is cut inwardly and outwardly, and the rectum and sigmoid colon are pulled out through the anal canal. 4 The length of the sigmoid colon is generally about 5 cm outside the anus without the absorption line at the upper part. Then check whether the tension of the colon and its mesentery in the abdominal cavity is too large, whether the intestine is twisted, and whether the blood circulation of the colon is good. 5 Use the fine absorbable line to fix the skin of the intestinal wall and the anal canal with a few needles to prevent the colon from retracting. The colon was cut 5 cm from the anus. A soft rubber tube about 1 cm in diameter is placed in the colon, about 10 cm deep, to facilitate venting. The colon and the rubber tube were wrapped about 1 cm proximally at the insertion of the rubber tube with a thick non-absorbent line, and tightly ligated to narrow the intestinal wall to control bleeding of the intestinal wall and mesentery. The end of the 7 rubber tube is connected to the drainage bottle so that the feces does not contaminate the wound and soil the mattress. 8 The surrounding colon is wrapped with Vaseline gauze and a softer dressing. Finally, the colon is fixed in a new position in the abdominal cavity. Stitch the pelvic peritoneum. A pair of cannula drainage is placed in the anterior sacral space and is drawn from the perineum. The layers of the abdomen are sutured in layers. 3. Perioperative second stage surgery 7 to 10 days after surgery, the colon and surrounding tissue to be pulled out have been initially healed, and then the second operation of the perineal can be performed. Use low waist and anesthesia. After washing the perineum with soap and water, remove the suture of the anus, cut off the excess sigmoid 1 cm below the end of the rectum, and suture the sigmoid and the rectal end with a 3-0 chrome gut. After suturing, the edema of the colonic mucosa may still protrude outside the anus, but after rest for 1 to 2 days in bed, it can be retracted into the anus. complication Urinary retention After Miles, all patients had varying degrees of urinary retention, especially after pelvic posterior visceral resection or extensive resection of the pelvic lateral iliac lymph nodes. The reasons are: 1 damage to the bladder nerve supply: manifested as detrusor relaxation, bladder neck contraction and bladder swelling feeling disappeared. Bladder pressure measurement found that when filling the bladder, the pressure increased, the bladder capacity increased, and there was often no bladder swelling and the feeling of hot and cold. In most cases, when the catheter is indwelled, the bladder is not inflated, and the urinary tract infection is strictly controlled, the detrusor muscle tension can be partially restored. After 2 to 3 weeks, if the urine is urinating, the abdominal wall muscle can be contracted and pubic. Pressurized by hand, the bladder may be emptied satisfactorily, forming a so-called autonomous neurogenic bladder: the final residual urine gradually decreases to within 60 ml. 2 posterior shift of the bladder: after rectal resection, a large cavity is left in front of the humerus in the posterior part of the pelvis. In the supine position, the bladder is tilted backwards and toward the anterior humerus due to lack of support, so that the bladder and urethra The angle is more pronounced than normal. When the patient leaves the bed, dysuria can sometimes improve, so the patient should be encouraged to urinate in the proposition or standing up. 3 The bottom of the bladder and its nerve supply damage: This can cause the urinary muscle to temporarily lose the contractile force. If it is mild injury, such as indwelling the catheter for 7 to 14 days after surgery, the bladder contraction force will often return to normal. 2. Complications of colostomy (1) retraction: This is a rare early complication, more common in the intestinal wall and peritoneal open suture method, the main reason for retraction is the colon and its mesentery pulled out of the abdominal wall during surgery is too short or tension High due to. In the case of mild retraction, when the mucosa at the edge of the stoma is still visible, the dressing and finger expansion are used to prevent stenosis. If the stenosis is serious, the mouth should be rebuilt. In the case of severe retraction, the edge of the stoma can not be seen, or there are signs of local peritoneal irritation, and should be treated immediately. Open sutures should not be performed in patients with colonic obstruction or poor bowel preparation. (2) ischemic necrosis: more due to other complications after the merger, such as sputum, prolapse and stenosis, etc., affecting the blood circulation of the middle cerebral artery. Necrosis is mostly limited, usually a few centimeters from the mesenteric side of the stoma, light indwelling observation, the mucosa will self-necrosis, grow out of granulation tissue or epithelial self-healing. If the intestinal segment is extensively necrotic, it should be treated immediately. The incision extends obliquely upward from the stoma, and the proximal colon is freed, then pulled out to the extravasation of the abdominal wall, and the necrotic intestine is removed. The method of prevention should be used to protect the blood supply of the stoma section from accidental injury to prevent accidental injury; the pulled colon and mesentery should not be tensioned or twisted; the opening of the abdominal wall stoma should not be too small to squeeze the intestinal wall and mesentery. . Active treatment should be performed when acute ostomy is prolapsed to avoid deterioration and necrosis. (3) stenosis: This is a more common late complication, more common in external stoma. Because the intestines are pulled out of the abdominal wall by about 3 to 4 cm, the layers of the abdominal wall are sutured intermittently with the serosa, so the serosa is easily stimulated by feces, secretions, etc., causing serositis, inflammatory granulation tissue hyperplasia, long-term scar contracture, An annular stenosis that causes the plane of the colostomy skin. If the stenosis is in the plane of the skin, and it can still accommodate all the little fingers, it will expand with fingers every day, and it can be gradually improved until it can pass all the indicators. If the narrow area can not pass the little finger, it is necessary to use colostomy repair, and a circle of scar and contracture tissue around the colostomy and the skin plane are removed, and the intestinal wall and the skin edge are sutured intermittently with a chrome thin sausage line. If the stenosis is below the level of the skin, the severe abdominal layer is also needed for surgical repair, but it can be corrected if it is expanded with fingers. At present, the stenosis tendency has been greatly reduced since the stoma method using mucosal and skin sutures. Anyone who uses an external stoma should have an early expansion after surgery. In order to prevent narrowing. 3. Complications of perineal wounds (1) Perineal wounds: Early bleeding is caused by incomplete hemostasis or ligature detachment during surgery. Cases of anterior venous plexus injury are more likely to occur. If there is more bleeding, the blood transfusion can not be corrected, and surgery should stop bleeding. Under general anesthesia, take the low bladder lithotomy position, remove all the sutures, rinse the wound with hot saline (50 °C) to remove the blood clots, and control the bleeding point by electrocoagulation or suture method, and add drainage. If bleeding is still difficult to control, you can use a long gauze or iodoform gauze to fill the anterior chamber to stop bleeding. Gradually removed 5 to 7 days after surgery. (2) delayed healing of the perineal wound: common causes are wound infection, residue of foreign bodies such as ligature, and the external port of the drainage is too small. Therefore, the perineal surgery should use an electric knife to stop bleeding as much as possible to reduce the retention of foreign bodies. If there is still a deep perineal sinus in the first month after surgery, the external orifice should be enlarged for detailed examination to remove foreign bodies such as necrotic tissue and ligature, and the unsound wound should be scraped. 4. Acute intestinal obstruction Often due to: 1 unsealed stoma intestinal fistula and the abdominal wall formed by the gap, causing internal hemorrhoids. This complication can be avoided if an extraperitoneal colostomy is used. 2 The small intestine adheres to the colon or pelvic peritoneum of the stoma. If the small intestine is well arranged during surgery and the omentum is covered well, this complication can often be reduced. 3 The pelvic floor peritoneal suture was split and the small intestine was prolapsed. This complication is rare, and this complication can be avoided if the pelvic floor peritoneum is carefully sutured. 5. Ischemic necrosis of the colon outside the anus This is the most important postoperative complication, mostly due to poor blood supply to the colon or pull-out tension, especially due to the tension of the mesentery; or due to postoperative anal sphincter contraction Blood circulation in the intestine. If the extent of necrosis is limited to the part remaining outside the anus, it will not cause serious consequences. If the necrosis range extends into the pelvic cavity, it will cause pelvic infection and abscess formation. In this case, transverse colostomy should be performed immediately, and feces should be transferred to control the infection. After the local condition is improved, the retracted colon is further processed. . 6. Anal colon segment retraction This is due to the fact that the colon segment that is pulled out is too short, and there is tension or pull-out colon necrosis when pulled out. In order to avoid retraction, the length of the colon that is well-suppressed outside the anus should be 6 to 7 cm during surgery, and the colon should not be pulled too tightly. Once the pulled out colon is retracted to the anal canal, it is often due to the release of tension and the gradual adhesion of the serosal surface of the colon to the pelvic wound. It usually does not require special treatment, and it can gradually heal with the proximal end of the anal canal, but this healing is very It is easy to cause an annular stenosis of the colon anal canal close to the anastomosis. 7. Anal external colon mucosal eversion Mostly due to excessive resection of the skin below the anal canal, or due to insufficient resection of the colon or removal of the anus. If you pay attention to the above operation details during surgery, you can avoid it. 8. Colon and anal canal close to the anastomosis Due to the frequent contraction of the anal sphincter and levator ani muscles, the annular scar at the anastomosis is easily contracted to cause stenosis, which is more likely to occur when the feces, which are often not formed or pulled out, have retracted. Therefore, an anal canal rectal examination must be performed regularly to prevent stenosis. If there is a tendency to narrow, the anal canal should be expanded regularly. 9. Pelvic abscess It occurs mostly in the anterior tibiofibular space due to poor drainage. After the operation, in addition to keeping the circulation clear, if there is an infection, immediate drainage is required.