Transabdominal rectal resection

Transabdominal resection of the rectum is a common treatment for rectal anal canal cancer. The resection range is large, including all the rectum and the lymphoid tissue in the intrinsic fascia, most of the sigmoid colon and its mesenteric and lymphoid tissues, the lymphoid tissue below the root of the aortic anterior mesenteric vascular root, the peritoneal pelvic floor, the rectal ligament, the anus Lifting muscles, anal sphincters, lymphoid tissues of the ischial rectal space, anal canal and skin around the anus. Rectal cancer with lymph node metastasis should be completely removed as much as possible, that is, the levator ani muscle is cut off from the attachment of the pelvic wall, and the tissue in the ischial rectal space is removed. In women, the uterus and vagina have been involved and should be removed at the same time. Treatment of diseases: rectal cancer Indication 1. Obstructive rectum, sigmoid colon cancer, although the primary tumor can be resected, but the preoperative cleansing preparation of the intestine is not good, the difference between the proximal and distal intestinal caliber is too large to be consistent with one-stage anastomosis. 2. Rectal cancer with local pelvic dissemination, although the primary tumor can be removed, but the pelvic dissemination can not be radically removed, whether it is not suitable for abdominal perineal resection or low anterior resection, the operation is palliative, reduce load, Postoperative comprehensive treatment creates conditions. Contraindications 1. Old and frail, the general condition is too poor, with heart, lung, liver and kidney dysfunction, can not tolerate abdominal surgery. 2. Local extensive infiltration of rectal cancer is unremovable in frozen pelvic cavity. 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 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 5cm 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. Explore the abdominal cavity to detect the liver, spleen, omentum, all colon, transverse mesenteric, abdominal aorta and inferior mesenteric artery, sigmoid mesenteric root and lymph nodes around the iliac vessels. 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 sigmoid colon and its mesent At the proximal end of the tumor, the intestinal lumen is tightened with a thick thread or gauze tape 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 mesenteric artery and vein Pull the duodenum up. 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 rectum posterior side Lift the sigmoid colon, use your fingers along the intrinsic fascia of the rectum, at the aortic bifurcation, the anterior tibial plexus, the 5th lumbar vertebrae and the humeral condyle in front of the looser anterior sacral space, and the rectum and the fat surrounded by the intrinsic fascia The lymph nodes were separated from the left and right branches of the anterior tibial plexus, the fascia wall layer and the anterior tibialis fascia, and reached the tip of the tailbone and the levator ani muscle; the two sides were divided into the upper edge of the rectal ligament. If the fiber bundles are tightly bonded, they can be cut with long bends. 7. Separation of the anterior rectum The bladder was pulled forward with a wide hook, and the upper edge of the rectal incision was clamped with a hemostat 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 Extend the pelvic cavity with your left hand, 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 incision toward 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. Cut off the sigmoid colon The site of the sigmoid colon was selected according to the plan for the site of sigmoid colostomy, the distribution of the vascular arch in the mesentery, the distribution of the marginal arterial network, and the blood supply of the isolated sigmoid colon. 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. Sigmoid colon fistula The straight hemostatic forceps that clamped the proximal sigmoid colon were placed about 2 cm from the abdominal wall of the abdominal wall, taking care 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. sutured peritoneum After the perineal resection of the sigmoid colon, rectum, anal canal and pelvic cavity to completely stop bleeding, the two sides of the incision of the posterior peritoneum were closed and closely 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 and level 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 Cut the clamped intestinal wall (if the bowel is longer, you can cut more), so that the length of the skin is about 1 ~ 2cm. 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.