Miles' procedure

Miles' surgery is used for the surgical treatment of rectal cancer. Rectal cancer includes cancer between the tooth line and the rectosigmoid junction and is one of the most common malignant tumors in the digestive tract. Rectal cancer has a low position and is easily diagnosed by digital rectal examination and sigmoidoscopy. However, due to its deep pelvic cavity, the operation is difficult, it is not as easy to completely cure the colon cancer, and the local recurrence rate is high. The middle and lower rectal cancer is close to the anal sphincter, and it is difficult to keep the anus. It is also a difficult problem in surgery. In colorectal cancer in China, rectal cancer accounts for 60% to 75%, and more than 80% of rectal cancer can be accessed by rectal examination. Therefore, it is necessary to pay attention to digital rectal examination. In addition, rectal cancer is more common in young people in China than in foreign countries. Therefore, the epidemiological characteristics of rectal cancer in young people should be fully understood, and the possibility of colorectal cancer should not be neglected because of youngness. Radical resection is still the main treatment for rectal cancer. According to the tumor, preoperative and postoperative radiation therapy, chemical therapy and immunotherapy can improve the curative effect. The principle of rectal cancer surgery is to remove the distal and proximal segments of the intestine including the tumor. The distal intestine should be excised at least 3 to 5 cm, along with lymph nodes that may be metastasized around it and surrounding tissues and organs that may be invaded. If the uterus has been invaded, the vaginal wall can be removed simultaneously. For those with isolated liver metastases, the corresponding hepatectomy or wedge resection is performed at the same time as radical resection of rectal cancer. The scope of surgical resection includes the lower part of the sigmoid colon and its mesentery and rectum, the inferior mesenteric artery and surrounding lymph nodes, the levator ani muscle, the fat in the rectal fossa, the anal canal and the skin around the anus about 5 cm in diameter and all the anal sphincters. The proximal end of the sigmoid colon is a permanent artificial anus in the left lower abdominal wall. Surgery is characterized by complete resection of the lesion and high cure rate, which is the standard surgery for lower rectal cancer. The disadvantage is that the surgical injury is large and a permanent artificial anus is required. The operation consisted of two surgical groups, the abdomen and the perineum, which were performed sequentially or simultaneously. Treatment of diseases: rectal cancer Indication Miles' surgery is suitable for rectal cancer within 7-8 cm above the tooth line. Contraindications If the patient's obstruction is obvious, it is advisable to perform a second-stage operation, and the colostomy should be performed in advance. After the obstruction is relieved, the resection is performed. Preoperative preparation 1. Explain to the patient the reason why colostomy (artificial anus) must be performed. If properly handled, it can still adapt to normal life. It is best to introduce a colostomy patient who can live normally. Talking to him is more convincing. 2. Try to improve the general condition of the patient, such as correcting anemia, hemoglobin should be above 12g; if serum protein is too low or weight loss is significant, intravenous nutrition should be done first. 3. Female patients should have a vaginal examination to find out if there is cancer infiltration. Those who need to remove the posterior wall of the vagina should wash the vagina every day for 2 days before surgery. 4. The tumor with a lower fixed position, or the cancer is located in the anterior wall of the rectum and has urinary symptoms. Cystoscopy and retrograde ureterography or intravenous pyelography should be performed to understand whether there is any invasion of the genitourinary system. 5. After anesthesia, place the catheter under strict aseptic technique, preferably with a Foley balloon catheter, and then fix the scrotum and penis (along with the catheter) to the inside of the right thigh with an adhesive plaster. The catheter is connected to the operation. Under the bottle. 6. All patients should estimate the position of the colostomy in the supine position, sitting position and standing, and make a mark. It is best to inject a little disinfection ink to avoid improper positioning during operation. Surgical procedure 1. Line the middle right lower abdomen next to the midline incision, from the umbilicus 2 ~ 4cm, down to the pubic symphysis. After entering the abdominal cavity, the patient was examined for the presence or absence of cancer metastasis in the abdominal cavity. First, touch the liver for induration, and then check for lymph node metastasis in the anterior abdominal, inferior mesenteric and inferior iliac vessels. Finally, the extent of the cancer and its surroundings are ascertained. If it is determined that it can be removed, the small intestine is pushed up to the abdomen with a wet saline gauze pad to fully expose the surgical field. Use gauze strips to puncture the intestines at the proximal end of the cancer. Lift the sigmoid colon, pull to the right side, cut along the left flank of the sigmoid mesenteric and descending colon of the descending colon, and extend to the pelvic cavity to the rectal bladder depression (female is the rectum uterus depression). The pelvic peritoneum is separated to the left to reveal the left ureter, spermatic vessels or ovarian blood vessels to avoid injury. Free sigmoid mesenteric to the right to the bifurcation of the abdominal aorta, pay attention to the separation and removal of lymph nodes near the left anastomosis. 2. Turn the sigmoid colon to the left side, and cut the right root of the sigmoid mesentery in the same way, up to the root of the inferior mesenteric artery, down to the rectal bladder, meet the contralateral incision, and recognize the right The direction of the lateral ureter. 3. The inferior mesenteric vein is exposed on the right side of the inferior mesenteric artery root, and after injecting an anticancer drug (generally, 5-Fu 250 mg), two tubes are ligated with a medium-absorbent line. Then use three hemostats to clamp the inferior mesenteric artery (two proximal ends, one distal end), and then ligature two lines with non-absorption lines. If it has been found that the sigmoid mesenteric lymph nodes are enlarged and hard, and there is a suspected cancer metastasis, the root of the inferior mesenteric artery should be ligated. When ligating, care should be taken to avoid damage to the ureter. 4. Enter the anterior tibiofibular space before the iliac crest, and sharply separate the dorsal side of the free rectum to the pelvic floor under direct vision, beyond the tail bone dust. It is currently believed that radical resection of rectal cancer should include all mesorectal membranes or at least 5 cm of the mesorectal membrane under the tumor, so it is called total mesorectal excision (TME), because the residual tumor cells in the mesorectum are postoperative local One of the main causes of recurrence. In the past, blunt dissection by hand, easy to tear the rectal mesangium, resulting in incomplete resection, care should be taken not to damage the anterior venous plexus. In case of a large amount of bleeding, the pressure can be filled first with a gauze pad, followed by a finger pressing the vein hole on the humerus surface, and then nailed with a special stainless steel nail to obtain a satisfactory hemostasis effect. If there is no stainless steel nail, it can be filled with hot salt gauze pad to stop bleeding. 5. Lift the rectum up and back, and separate the anterior wall of the rectum with scissors, electric knife or stripper to separate it from the bladder, vas deferens, seminal vesicle, and posterior wall of the prostate (women should separate the rectum from the posterior wall of the vagina). 6. Separate the rectal ligaments on both sides. The rectum is lifted up to the left, and the right rectal ligament is exposed. After clamping with two long curved hemostats, the ligation is cut off (the lower rectal artery is also ligated). Care should be taken to avoid injury to the ureter during clamping or ligation. The left rectal ligament was then treated in the same manner. The rectum is separated from the levator ani muscle plane. 7. On the left side of the original incision, it is equivalent to the middle and outer 1/3 junction of the anterior superior iliac spine and the umbilicus (ie, the stoma mark before surgery). A circular incision with a diameter of about 2.5 to 3 cm was made to remove the aponeurosis of the skin, subcutaneous tissue, and extra-abdominal oblique muscle. The intra-abdominal oblique muscles and the transverse abdominis muscles were separated by the direction of the muscle fibers, and the peritoneum was incised. Use a toothed straight hemostat to extend into the abdominal cavity from the stoma, clamp the proximal sigmoid that is scheduled to be severed, and then hold a hemostat at the distal side to cut the sigmoid between the two clamps. The proximal sigmoid colon is pulled out from the stoma and pulled out about 4 to 6 cm outside the abdomen for artificial anus. Or, according to Goligher's approach, the proximal sigmoid colon is introduced through the retroperitoneal tunnel to the stoma site. The biggest advantage of the extraperitoneal colostomy is that the stoma section is extraperitoneally removed, eliminating the paracolic space between the colon and eliminating the potential risk of paralysis in the small intestine. Because the covered peritoneum has a certain protective effect, it can resist the occurrence of retraction, prolapse and paralysis of the stoma, and can reduce complications such as obstruction, stenosis and edema. 8. The proximal end of the colon is temporarily protected by gauze. The distal end of the colon is sutured with a thick non-absorbent line, so that the stump is embedded in the intestine, and then wrapped with gauze or rubber gloves. Inside. 9. When the sigmoid colon and rectum were removed from the perineal surgery group, the abdominal cavity was rinsed with warm saline. After complete hemostasis, the peritoneum on both sides of the pelvic cavity was continuously sutured with a 1-0 chrome gut to rebuild the pelvic floor. 10. The fat of the proximal colon wall and the peritoneum, fascia and subcutaneous tissue were each sutured with a small non-absorption line. The colon that was pulled out of the abdomen was still clamped with a toothed hemostat and released 24 hours after surgery. 11. At present, open sutures are often used at the colostomy. That is, the end of the colon that has been clamped by the toothed hemostat clamp is removed. After disinfection and hemostasis with red mercury, the whole layer of the edge of the intestinal wall and the surrounding skin are sutured intermittently with a 1-0 chrome gut, one needle separated by 1 cm. . 12. After the artificial anus surgery is completed, immediately disinfect the one-piece or two-piece artificial anus bag; it can prevent wound infection and reduce the burden of care. 13. The proximal sigmoid mesentery was sutured to the peritoneum of the lateral wall layer with a fine non-absorbent line to prevent postoperative internal hemorrhoids. Finally, the small intestine is returned to the normal position, and the omentum is pulled down on the small intestine so that the small intestine does not contact the incision of the abdominal wall to prevent postoperative intestinal adhesion. The incision is sutured in layers. 14. When the abdominal surgery group has completely separated the rectum, the perineal surgery group begins surgery. First use a piece of dry gauze to insert into the rectum, then use a thick non-absorbent line around the anus edge to make a purse suture, close the anus. Then make a fusiform incision 2 to 3 cm from the anus, front to the middle of the perineum, back to the tip of the tailbone. 15. Cut the skin and subcutaneous tissue and ligature the bleeding point. Hold the sides of the anal side skin incision with tissue forceps and wrap the anus. Hold the tissue forceps, pull the anus to the other side, use the hook to pull the outer edge of the incision outward, continue to separate along the medial edge of the ischial tuberosity and gluteus maximus, and remove the fat of the ischial rectum, and expose the levator ani muscle. Ligation of the anal artery. 16. Push the anorectal rectum forward, cut the anal talus ligament in front of the tip of the tailbone, and expose the levator ani muscle. 17. Use the left hand to insert the posterior rectal space above the levator ani muscle, and pull the left tibia coccygeal muscle downward, so that the left anterior tibial muscle is exposed more clearly. Cut it with an electric knife close to the outer attachment. Ligation of bleeding points. Then use the same method to cut the right humerus coccygeus with an electric knife. 18. The anorectal rectum was pulled forward, and the wall of the pelvic fascia was cut open with an electric knife. The fingers were bluntly separated and extended into the anterior humeral space to meet the abdominal surgery group. The distal sigmoid colon and rectum are then pulled out of the incision, and the rectal urethral muscle and part of the puborectal muscle are severed. In men, the urethra should be carefully separated according to the position of the urethra marked by the indwelling catheter to avoid damage to the urethral membrane; in women, the rectum should be separated from the vagina. This removes the anus, rectum, and sigmoid colon from the perineum. After the pelvic wound was thoroughly washed and hemostasis, two double cannula drainages were placed in the wound, and each of them was poked on both sides of the incision. The perineal skin incision was sutured with a non-absorbable line. In recent years, some people have designed a thin or gluteus maximus to replace the sphincter and the nested artificial anus. In the case of removing the anal sphincter, the proximal sigmoid is placed at the perineal incision in the Miles operation. , one or two stage sphincter angioplasty. Although there are good reports of efficacy at present, the follow-up time is short and needs to be summarized. If rectal cancer invades the pelvic organs, the radical resection can not be performed with Miles surgery, but the patient is in good health and can undergo extended surgery. It is feasible to remove the pelvic visceral resection of the pelvic organs, that is, to remove all organs and lymph nodes, including the rectum. Sigmoid colon, uterus, vagina or prostate and whole bladder, and do urinary diversion, ileal bladder surgery (Bricker urinary diversion). The indications for this operation should be strictly controlled, because the surgery has a greater impact on the patient, and the patient's survival is also extremely inconvenient. If the patient is unable to perform Miles surgery or primary resection and anastomosis due to old age, weakness, etc., it is feasible to undergo transabdominal resection and permanent colostomy (Hartmann surgery). That is, the tumor is resected through the abdomen, the distal rectum is closed, and the proximal colon is pulled out to make an artificial anus. The advantage of this method is that the operation is simple and rapid, the bleeding and complications are few, and the recovery period is short. The disadvantage is poor radicality. 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.