Chapter 25 Anorectal Surgeries 989
got high mortality of 10-20%. Restoration of the continuity is done only
after 3-6 months for benign conditions (Figs 25-17A to C).
4. Pelvic evisceration (Brunschwig’s operation): It is removal of
rectum with the tumour, all the lymph nodes, urinary bladder, fat,
fascia, uterus, vagina, with colostomy and urinary diversion. It is
neither favourable nor popular.
5. Palliative colostomy is done in advanced unresectable growth
which presents with intestinal obstruction.
ANTERIOR RESECTION/ABDOMINAL
RADICAL RESTORATIVE OPERATION/
ANTERIOR PROCTOSIGMOIDECTOMY
(OPEN METHOD)
It is called as anterior resection as dissection is done from above in front
through laparotomy. It is done in rectal carcinoma wherein tumour
is above, 6–14 cm from the anal verge; i.e. middle and upper thirds of
the rectum. Anterior resection is done as sphincter saving procedure
otherwise patient might have undergone abdominoperineal resection
with a permanent end colostomy.
Presently anterior resection of the rectum has widened definition
than the earlier one due to availability of the modern laparoscopic set
up. Anterior resection may be high (anastomosis above the peritoneal
reflection); low (anastomosis below the peritoneal reflection; ultra
low (anastomosis within 2 cm of the dentate line with sphincter
preservation). Coloanal anastomosis as sphincter saving procedure
A Dissection is done from bifurcation of the aorta downwards into the
B vein is separated. Inferior mesenteric artery originating from the front
C Sigmoid is retracted upwards and towards left to identify a tissue band
Figs 25-17A to C: Surgeries for carcinoma rectum (A) A-P resection,
(B) Anterior resection, (C) Hartmann’s resection.
is done by anastomosing the colon to the dentate line or below it.
Ultralow and coloanal types need laparoscopy for dissection and
stapler for anastomosis. Low anterior resection (LAR) is commonly
advocated either by open or through laparoscopy.
Preoperative evaluation and preparations are same—colonoscopy
and biopsy; CEA; CT abdomen and pelvis to check nodal status and
secondaries in liver; MRI pelvis to identify local infiltration; EUS is also
very useful. Bowel preparation is done as similar for colonic diseases
(please read in previous Chapter 24).
Technique
Position
Patient is kept in modified lithotomy position with steep head down
at 40°. Surgeon stands on left side. One assistant stands on right side;
another in between legs of the patient.
Incision
Lengthy midline incision is placed; abdominal cavity is explored for
secondaries; self retaining retractor is placed.
Sigmoid Dissection
Small bowel is pushed upwards and kept away from the pelvis. Distal
sigmoid may be occluded using a tape. Sigmoid colon is retracted
medially. Peritoneum on the left lateral paracolic gutter is exposed;
held between two haemostats and incised using scissor. Adhesions
in this lower pat are common which are released carefully. Peritoneal
incision on the lateral paracolic gutter is extended towards the
splenic flexure. Left ureter, left gonadals are identified. Left ureter
is dissected carefully and plastic loop is passed around it. Ureter is
dissected carefully downwards using scissor and bipolar cautery
down into the pelvis. Left hypogastric nerve in front of the internal
iliac artery is identified and safeguarded. Sigmoid colon is retracted
medially; incision is made on the right side of the sigmoid mesocolon.
pelvis. Right ureter is also identified as it crosses the bifurcation of the
common iliac artery in front of it. Right hypogastric nerve is identified
now. Incision is made on the rectovesical or rectouterine pouch to
mobilise the rectum from front. This also can be done at later period
during rectal mobilisation.
Vascular Ligation
Colon is mobilised and held upwards and left with traction. Gonadal
of the aorta is identified; fat and lymphatics (lymphovascular bundle)
are swept towards the specimen colorectum; inferior mesenteric artery
is divided 1.5 cm from its origin; it is also ligated and divided after it
gives off left colic branch to maintain the adequate blood supply in the
eventual anastomotic site which is essential. Preaortic sympathetic
nerve should be retained.
Presacral Dissection
between posterior aspect of the rectum. It should be divided using
cautery as it contains branches of the middle sacral artery. Loose