Combined resection of abdominal and perineal rectal cancer

A combination of abdominal perineal resection, Miles surgery, Miles surgery as a radical surgery for lower rectal cancer and anal canal cancer, is commonly used in clinical practice. Correct perioperative management to accurately estimate the extent of the lesion and the extent of surgical removal, correct and safe operation during surgery and correct postoperative intestinal stoma is to reduce the impact on the patient's normal function and improve the patient's postoperative life and survival. The key to quality. Treatment of diseases: anal canal cancer Indication Anal canal cancer or lower rectal cancer, the lower edge of the tumor is within 6cm of the tooth line (such as low tumor differentiation, deep local infiltration, can be extended to within 8cm), and there is no long-distance transfer. Contraindications General anesthesia or continuous epidural anesthesia. Preoperative preparation 1. Check liver and kidney function. Patients with bladder irritation should be treated with cystoscopy to understand whether the bladder or ureter has tumor invasion. 2. Improve the general condition of the patient and give a high protein, high calorie and low slag diet. If the anemia is obvious, it is advisable to interrupt a small amount of blood transfusion to increase the hemoglobin to more than 10g%. 3. Change slag-free or less slag diet 3 days before surgery. 4. Start 24 hours before surgery, only take neomycin 0.5g, metronidazole 0.4g, once every 6 hours. 5. Clean the intestines. For patients without colonic obstruction, take oral liquid paraffin 30ml or castor oil 15ml daily for 2 days before surgery, and enema with warm saline 2000ml every night. Some patients have oral obstruction. Oral liquid paraffin 30ml per night before surgery, and pass the narrow anal canal through the narrow In the segment, a warm saline enema is injected above the tumor. Clean the enema 1 day before surgery. 6. Female patients were given a vaginal rinse daily for 2 days before surgery. 7. Place the stomach tube before surgery. 8. Place the catheter under anesthesia. If the tumor is relatively fixed, it is estimated that there may be adhesions around the tumor, and the ureter can be intubated through the cystoscope to safely separate the ureter. Surgical procedure Abdominal surgery: 1. Position: The stone position, the legs are as far as possible, the hips are 6 to 7 cm high and 4 to 5 cm beyond the edge of the operating table, and the waist is soft. Disinfect the abdomen and perineum. 2. Incision: 5 cm from the umbilicus to the pubic symphysis in the left lower abdomen. The anterior rectus sheath is opened and the rectus abdominis muscle is pulled outward. The tapered muscle at the lower end of the incision should also be cut open to the pubis. Push the peritoneal fat and the top of the bladder and cut the peritoneum into the abdominal cavity. If the spleen of the colon is not well exposed, the incision can be extended to the upper left. 3. Exploring the abdominal cavity: The liver, spleen, omentum, all colon, transverse mesenteric, abdominal aorta and inferior mesenteric artery, the root of the sigmoid mesenteric and the lymph nodes around the iliac vessels were examined in sequence. If there is a suspicious metastatic tumor in the liver, intestinal wall or lymph nodes, the living tissue should be cut for frozen section examination. Finally, the sigmoid colon is lifted, and the location, size, mobility, and invasion of the serosal layer or surrounding tissue are gently explored to determine the surgical procedure and extent of resection. Sometimes there is an inflammatory infiltration around the tumor, which seems to have been fixed, but after careful separation, the tumor can be removed, so surgery should not be abandoned easily. Once the cut is decided, the head of the operating table can be lowered by 10° to 20°. After pushing all the small intestines into the upper abdominal cavity, they are separated by a large gauze pad and pulled up with a large deep hook. 4. Separation of the sigmoid colon and its mesentery: the intestinal lumen is tightened with a thick thread or gauze tape at the proximal end of the tumor to avoid the tumor cells falling off during operation and spreading to the proximal intestinal lumen. Lift the sigmoid colon to the upper right, cut the peritoneum on the left side of the sigmoid mesenteric root, and extend it up and down. According to the height of the tumor and the length of the descending colon, the length of the incision is determined, and the upper end can reach the splenic curvature when necessary. The lower end along the left edge of the rectum, cut to the rectal bladder depression (female cut to the rectum uterus depression), and about 2cm above the bladder to bypass the anterior side of the rectum, cut the right side of the rectum. After lifting the outer edge of the peritoneal incision, the peritoneum was separated by a gauze ball, and the left side was moved and the vein was revealed. The left ureter can be found in front of the bifurcation of the left common iliac artery. It should be separated up and down and then pulled open with gauze tape. Pay attention to protection so as not to be mistaken for blood vessel ligation and cutting. Then, carefully separate the retroperitoneal adipose tissue with lymph nodes around the left iliac vessels, the roots of the sigmoid mesenteric and the inferior mesenteric artery, and prepare for a total resection. Lift the sigmoid colon to the upper left again, cut the isolated posterior peritoneum on the right side of the sigmoid mesenteric root, and extend the incision upward and downward; the upper end reaches the lower edge of the duodenum and the lower end reaches the rectal bladder lacuna (female) Up to the rectal uterus lacuna), which meets the contralateral incision that bypasses the anterior side of the rectum. After lifting the outer edge of the peritoneal incision, the right retroperitoneal adipose tissue and its lymph nodes were carefully separated, and the inferior mesenteric artery, right axillary vein, vein and right ureter located outside the common iliac artery were exposed and protected. 5. Ligation of the mesenteric artery and vein: pull the transverse part of the duodenum upwards. The inferior mesenteric artery root was exposed on the anterior side of the abdominal aorta, and the inferior mesenteric vein was exposed 2 to 3 cm on the left side. The vein is first separated, ligated, and cut to avoid the cancer cells being squeezed into the vein and into the liver during the operation. Then check whether the left ventricle artery and the left ventricle between the ascending and descending branches of the arterial network are intact. It is estimated that after the root of the inferior mesenteric artery is cut off, the upper part of the sigmoid colon that remains can have sufficient blood supply to ligature the inferior mesenteric artery. Otherwise, it should be ligated below the left colon of the colon. First, the medium wire is ligated, and then cut between the tongs, the proximal end is added for suture, and the distal end is simply ligated. 6. Separation of the posterior side of the rectum: Lift the sigmoid colon, use the fingers along the rectal intrinsic fascia, at the aortic bifurcation, the anterior tibial plexus, the fifth lumbar vertebrae and the humeral condyle in front of the looser anterior sacral space, the rectum and its back The fat and lymph nodes surrounded by the intrinsic fascia are separated from the left and right branches of the anterior tibial plexus, the fascia fascia and the anterior tibialis fascia, and reach the tip of the tailbone and the levator ani muscle; both sides are divided into the rectal ligament and the ligament. edge. If the fiber bundles are tightly bonded, they can be cut with long bends. 7. Separate the anterior side of the rectum and pull the bladder forward with a wide hook. Use a hemostat to clamp the upper edge of the rectal incision before the rectum to facilitate traction. The rectum is pulled back, and the front of the peritoneal fascia (Denovilliers fascia) is placed in front of the peritoneal fascia (Denovilliers fascia). The bottom of the bladder, the vas deferens, the seminal vesicle, and the prostate (the female is the posterior wall of the vagina) are separated from the rectum to the tip of the prostate. The levator ani muscle plane is divided into the upper anterior edge of the rectal ligament. 8. Cut the rectal ligament: Use your left hand to reach the pelvis, tighten the rectum to the left, and push the right ureter forward. Under the guidance of the left finger, the right rectal ligament was clamped close to the pelvic side wall with a long curved hemostatic forceps, and then cut with a long curved shear and then ligated (the lower rectum in the lateral ligament was simultaneously cut and ligated). If the ligament is wide, it can be clamped and cut in several times, and it can reach the levator ani muscle plane. In the same way, the rectum is pulled to the right side, and the left rectal ligament is ligated and ligated. 9. Cut the abdominal wall for colostomy: use the tissue forceps to pull the skin and muscles of the left edge of the abdominal wall into the midline. Above the midpoint of the umbilical and left anterior superior iliac spine, the outer edge of the rectus abdominis, a 3 cm diameter skin and subcutaneous tissue were removed to prevent contraction of the colostomy caused by scar contraction in the future. The extraperitoneal oblique aponeurosis is cut into a shape (or the same piece is removed), and the intra-abdominal oblique muscle and the transverse abdominis muscle are pulled apart by a pulling hook, and the peritoneum is cut open, so that the incision can accommodate 2 fingers. 10. Severing the sigmoid colon: According to the plan for the site of sigmoid colostomy, the distribution of the vascular arch in the mesentery, the distribution of the peripheral arterial network, and the blood supply of the isolated sigmoid colon, the site of the sigmoid colon is selected. After cutting, the proximal intestinal tube should not cause ischemia or necrosis, and there is no tension or too long to be placed in the ostomy incision, so that the fistula retraction or valgus bulge does not occur. The mesenteric membrane between the upper end of the incision edge of the sigmoid mesenteric root to the site where the intestine is cut is cut, the branch of the blood vessel is ligated, and the anastomosis of the ascending branch and descending branch of the left colon of the colon is retained. After the gauze is placed and the abdominal cavity is not contaminated, a straight hemostatic forceps is inserted into the abdominal cavity from the abdominal wall, and the proximal end of the sigmoid colon is selected. The hemostat is clamped at the distal end, and the sigmoid colon is cut between the forceps. After wiping the intestinal lumen with red mercury solution, wrap the proximal end with dry gauze to avoid contamination. Tighten the distal end with a thick thread, remove the hemostatic forceps, then cover the distal end with a rubber sleeve and double-tighten it into the pelvic cavity. 11. Proposed sigmoid colon fistula: The straight hemostatic forceps that clamp the proximal sigmoid colon are placed about 2 cm from the abdominal wall and the abdominal wall is taken out. Be careful not to contaminate the ostomy incision. Lift the left margin of the median side incision, suture the proposed sigmoid mesenteric and the peritoneum of the outside of the ostomy incision with a thin thread, and directly reach the left side of the colon to eliminate the gap, to prevent the possibility of postoperative intestinal fistula, and Fix the colon and avoid retracting or bulging out of the fistula. The colon wall and the peritoneal incision were sutured and fixed 4 to 6 needles. In order to avoid the residual fecal contamination incision through the fistula in the early postoperative period, a 4-6 cm long intestine can also be proposed. After the intestinal wall and the peritoneum are fixed, the apical fistula can be inserted into the intestine through the fistula. Gas defecation. Ligation and fixation at 2 to 5 cm from the skin. 12. Peritoneal suture after suture: After the hemorrhagic resection of the sigmoid colon, rectum, anal canal and pelvic cavity, the two sides of the incision are closed and tightly sutured. The knot is struck outside the peritoneum, and the pelvic floor is re-formed between the bladder (female for the uterus) and the fifth lumbar vertebra. The bilateral ureters and the cut-off mesenteric vessels are re-covered by the retroperitoneum to prevent the small intestine from entering the pelvis. Even prolapse from the perineal incision can reduce the chance of intestinal adhesions. 13. Suture the abdominal wall incision: shake the operating table, reset the small intestine, cover the abdominal wall incision with the omentum. The gauze covering the slit is sealed with a tape and separated by a rubber film. 14. Sewing the colostomy of the colon: the incision of the intestine wall is removed (if the intestine is longer, more cuts may be made), so that the length of the skin is retained outside the skin by about 1 to 2 cm. Hemostasis, after ligation, the whole layer of the incision of the intestine wall and the deep and intermittent suture of the ostomy mouth 8 ~ 10 needles. Cover the Vaseline gauze around the ostomy mouth, cover with gauze, cotton pad, or directly put on a sterile anal fistula bag. If there is more feces in the colon, the proposed colon can be kept about 4-6 cm, and a funnel-shaped soft rubber tube can be inserted into the fistula (which can be cut off from the distal end of the fistula catheter) and fixed by thick wire ligation ( The proximal ligature should be more than 1 cm from the skin, draining the intestine and reducing the chance of incision contamination. Remove the excess after 7-10 days. Perineal surgery: Usually, when the rectal ligament is cut off during abdominal surgery, another group of operators can start the perineal surgery. 1. Incision: After the perineum is rinsed and disinfected, the anus is stuffed with a gauze, and the skin around the anus is sutured with two layers of purse, the anus is locked and disinfected again. A fusiform or diamond-shaped incision is made from the midpoint of the perineum around both sides of the anus to the tip of the tailbone. Stitch with a thick thread, or use tissue forceps to close the inner edges of the two sides of the incision to further close the anus. Deepen the incision along the medial edge of the ischial tuberosity and gluteus maximus, and remove the adipose tissue in the rectal space of the ischial bone as much as possible to reveal the tailbone and levator ani muscle. Pay attention to cutting and ligation of the anal artery separated by the internal pudendal arteries. 2. Cut off the levator ani muscle: Tighten the anal canal forward and cut off the levator ani muscle attachment (anal talus ligament) at the tip of the tailbone. Use your fingers to penetrate the levator ani muscle, pull the left tibia coccygeal muscle down, and ligature it as close as possible to the pelvic sidewall attachment, and then ligature it to the prostate (the posterior wall of the vagina). Then cut the right tibia coccygeus muscle by the same method. 3. Cut the fascia wall layer: on the anterior side of the appendix, the posterior side of the rectal anal canal, and cut the anterior fascia (the part of the fascia wall layer thickened in the midline). Then cut the wall of the pelvic fascia to both sides, enter the posterior rectal space, and meet the abdominal surgery. 4. Pull out the sigmoid colon and rectum: In the abdominal operation group, the bilateral rectal ligaments were cut off, and the separated distal segment of the sigmoid colon and the upper rectum were sent to the posterior rectal space. The perineal surgery group was used to cut the intestine through the posterior side of the perineum. Pull out the mouth. 5. Cut the pubis caudal muscle: The anal canal is tightened backwards, and the posterior border of the superficial transverse muscle of the perineum and the posterior side of the urethral bulb are cut off layer by layer to cut the cross fibers of the deep anal external sphincter to reveal the perineal deep transverse muscle. Then pull out the sigmoid colon and rectum to the right and rear to reveal the pubic caudal muscle on the left side of the rectum. Use your fingers to puncture the left pubis caudal muscles, tighten them, and clamp, cut, and ligature. Cut the right pubis caudal muscle by the same method. 6. Cut the puborectal and rectal urethral muscles: the puberulent and deep transverse muscles will be pulled forward, and the anorectal rectum will be pulled back to reveal the puborectal and rectal urethra muscles thickened inside the pubis caudal muscle. The seminal vesicle and prostate can be seen from the anterior side of the rectum, with the fingers between the prostate and the rectum to push out the puborectal and rectal urethral muscles, in the urethral membrane (which can be identified by the position of the indwelling catheter) and the rectum. These muscles were clamped, cut, and ligated. At this time, all the rectum and anal canal are freed, and the sigmoid colon, rectum, anal canal, and retroperitoneal fat and lymph nodes can be taken out in one piece. 7. Rinse, drain, and suture the perineal incision: After careful ligation or electrocoagulation to stop bleeding, flush a large cavity left in front of the tibia with a large amount of saline to remove any cancer cells that may remain in the cavity. At the same time as the peritoneum was sutured in the abdominal surgery group, the perineal surgery group could place two large pieces of Vaseline gauze in the anterior cavity of the tibia, spread on the wound surface, and put 2 to 3 cigarettes. The skin incision can be partially sutured, leaving the drainage smooth. The outside of the slit is covered with a plurality of large cotton pads and fixed with a T-belt. The jejunum before sputum will be filled with granulation tissue after 2 to 3 weeks. Abdominal surgery perineal surgery (1) push the small intestine into the upper abdomen (1) perineal incision revealing the tailbone and levator ani muscle (2) incision of the left side of the sigmoid mesenteric root (2) cutting the left tibia coccygeal muscle (3) revealing the left ureter (3) cutting the right tibia coccyx Muscle (4) Incision of the right side of the sigmoid mesenteric root (4) Incision of the anterior tibialis fascia (5) Ligation of the inferior mesenteric artery (5) Pulling out the sigmoid colon and rectum through the perineal incision (6) Separating the rectum posterior side (6) Cutting the pubis caudal muscle (7) Separating the anterior rectum (7) Cutting the pubis Rectal and rectal urethral muscles (8) separate the bladder, vas deferens, seminal vesicles and prostate (8) resection of the sigmoid colon, rectum and anal canal (9) cut off the rectal ligaments on both sides (9) drainage, suture the perineal incision (10) cut off the sigmoid colon (11) bandage the colon near the distal end (12) to propose the sigmoid colon Ostomy (13) sutured peritoneum complication Shedding, twisting, pressure or blockage.