Posterior pelvic organ removal

Exenteration of posterior pelvis is a surgical procedure for the treatment of pelvic conditions. Applicable conditions include: gynecological advanced cancer and rectal, vaginal, can not retain the rectum, and the paravaginal and para-uterine tissue is not affected by the pelvic wall, the patient's general condition, psychological quality is good, can withstand large surgery. Treatment of diseases: endometrial cancer ovarian cancer Indication All gynecological advanced cancer tumors and rectum, vagina, can not retain the rectum, and the paravaginal, para-uterine tissue is not affected by the pelvic wall, the patient's general condition, psychological quality is good, can withstand major surgery. Contraindications The general condition is poor and cannot tolerate the operator. Preoperative preparation 1. Start a half-flow diet 2 to 3 days before surgery. 2. Oral antibiotics were taken 5 days before surgery. 3. Oral laxative 24 hours before surgery. 4. Clean the enema before the night before surgery and on the day of surgery. Surgical procedure 1. Position: The person's font position, or supine first, after the end of the abdominal group surgery, the use of the stone. 2. Abdominal incision: mid-lower incision in the middle and lower abdomen, the length of which can fully expose the surgical field. 3. Exploration: Understand the pelvic condition and determine the possibility of surgery. 4. Extensive total hysterectomy: see extensive hysterectomy. 5. Separation of the sigmoid mesenteric membrane: pull the uterus toward the commissure joint, cut the left mesenteric root of the sigmoid colon, expose the left ureter, then cut the right mesenteric root of the sigmoid colon, ligature the superior rectal arteriovenous, and observe the superior rectal artery. In the case of branching and arterial network, the intestine segment of the sigmoid colon fistula is selected according to the blood supply condition. 6. Separation of the rectum: Incision of the peritoneal pelvic side peritoneum, separation of the loose tissue adjacent to the rectum, close to the anterior sacral direction of the rectum to separate the loose tissue of the posterior wall of the rectum, until the appendix bone (the levator ani muscle plane), so that after the rectum The wall is completely free. Be careful not to damage the anterior venous plexus during separation, otherwise bleeding is not easy to control. 7. Cut the rectal ligament and the posterior wall of the rectum is fully free, then pull the rectum up and to one side, revealing one side of the rectal ligament, the palpebral ligament and the paravaginal tissue, all clamped, cut, stumped, until the stump is sutured. The rectum is almost completely free. 8. Cut the sigmoid colon: Hold the upper part of the sigmoid rectum with two toothed forceps, cut between the two clamps, and wrap the two end cuts with plastic bags. 9. Resection of the posterior wall of the vagina or the vagina: If the tumor is confined to the upper part of the posterior wall of the vagina or between the vaginal rectum, the anterior or posterior wall of the vagina may be retained. The extent of the resection depends on the location and length of the infiltration. If you need a total vaginal resection or a total vaginal posterior wall resection, you need to cooperate with the perineal surgery group. 10. Sigmoid colostomy: If the entire rectum or residual rectal segment is not to be anastomosed with the sigmoid colon, the lateral left inferior superior iliac spine and the umbilical cord are at the midpoint or the outer 1/3 of the anterior skin incision. , make a circular incision about 3cm in diameter, cut off the skin and subcutaneous tissue, the external oblique muscle aponeurosis for cross-shaped incision, open the transverse abdominis muscle, intra-abdominal oblique muscle, cut the peritoneum, in order to reach into the two fingers degree. The proximal end of the colon (ostomy) was pulled out from the circular incision of the left lower abdominal wall by about 3 to 5 cm. 11. Stoma fistula suture: suture the base of the external sigmoid colon wall with the peritoneum and extra-abdominal oblique aponeurosis, and suture the mucosa of the intestinal wall and the skin. The suture ligation was fixed with a circle of iodoform yarn, and the surface of the mouth was covered with Vaseline yarn and cotton pad. 12. Fixing the internal wall of the fistula: suture and fix the peritoneum and colon wall of the ostomy from the abdominal cavity. In order to prevent the retraction or prolapse of the fistula. Repair the left colon colon and the mesenteric root posterior peritoneum. 13. Perineal surgery: Usually in the abdominal surgery group, the rectum and the vagina are mostly free, that is, the perineal surgery begins. 14. Perineal incision: Make a fusiform incision around the vaginal opening and the anus. A gauze was inserted into the anus and the perianal was sutured with a thick string purse. 15. Treatment of perianal and vaginal: use an electric knife to cut deep under the skin along the perineal incision, cut and ligation of the iliac vessels on the outside of the anal canal. The anal ligament was cut off and the anterior tibiofibular space was inserted. The surgeon inserted the anterior tibiofibular space with his fingers, and separated and splayed the levator ani muscle forward and outward. When separating the levator ani muscle, cut it away from the rectum as far as possible. Then, the ischial corpus cavernosum muscle is separated upwards, and the blood is cut and sutured. 16. Separate the posterior wall of the rectum: use your fingers to bluntly separate upward along the posterior wall of the rectum and penetrate to the bottom of the basin. 17. Treatment of paravaginal tissue: The method is the same as extensive uterine + total vaginal resection with extensive uterine and total vaginal resection. After the sigmoid colon, rectum, anus and uterus attachments are completely free, they are pulled out from the vagina. 18. Stitching: the pelvic floor, perineum, and vaginal defects are large. The bleeding should be stopped carefully, and the surrounding tissues should be sutured intermittently to minimize the wound surface. And try to suture the pubic skin intermittently. The pelvic floor defect was blocked with Vaseline yarn and iodoform yarn to pressurize the hemostasis and drain the hose between them. The outer cotton pad and the T-belt are fixed. Methods See extensive uterine and vaginal resection. complication 1. Vaginal bleeding: postoperative vaginal drainage, color bright red, may have active bleeding, should use hemostatic drugs, if necessary, re-clogging the vaginal yarn. When conservative treatment is ineffective, it should be stopped in time to stop bleeding. 2. Postoperative infection: This operation has a large wound surface and is easy to be contaminated. Strong antibacterial drugs should be used after surgery. If the body temperature continues to be above 39 °C, vaginal secretions and blood samples should be taken for bacterial culture and drug susceptibility test in time, and the drug should be used under the guidance of drug susceptibility results.