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Procedures

Procedures. Advanced Format: Abdominoperineal Resection. Definition/Purpose of Procedure. Through combined abdominal and perineal incisions, the anus, rectum, and sigmoid colon are removed en bloc. Also called Miles Resection

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Procedures

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  1. Procedures Advanced Format: Abdominoperineal Resection

  2. Definition/Purpose of Procedure • Through combined abdominal and perineal incisions, the anus, rectum, and sigmoid colon are removed en bloc. • Also called Miles Resection • The proximal end of the bowel is exteriorized thru a separate stab wound as a colostomy. The distal end is pushed into the hollow of the sacrum and removed via perineum • Performed to treat cancer of the lower rectum—and diseases are too low for use of EEA stapling devices

  3. Pathophysiology • Cancer of lower rectum: usually the lower third of the rectum, but may extend into the anal canal • The sigmoid colon is the primary site of colon cancer and is the section of colon most susceptible to volvulus.

  4. Abdominoperineal Resection

  5. Surgical Intervention:Special Considerations • Patient Factors • Requires the formation of a permanent colostomy in the abdominal wall for drainage of bowel contents • An indwelling foley catheter will be inserted and attached to closed drainage • Upper body thermia blanket • Room Set-up • Organize the room for space! If 2 teams, one works at abdomen and one works on perineal portion (ABD: ST stands slightly behind assistant and must take special care not to contaminate! Perineal: ST Stands next to surgeon)

  6. Surgical Intervention: Positioning • Position during procedure: when performed as two simultaneous procedures, modified lithotomy • Supplies and equipment • Probable Allen stirrups or “high impact knee-crutch stirrups” for positioning—can be adjusted for knee flexion and extension; Be sure to have additional padding (gel or foam) • Sequential Compression Devices • Special considerations: high risk areas: cause pressure to back of knees and lower extremities and may jeopardize the popliteal vessels and nerves

  7. Surgical Intervention: Draping/Incision • Types of drapes (Depends on position) • Laparotomy and perineal: Under buttocks, folded towels, Lap T-sheet (cut hole for perineal exposure) • Order of draping • Abdomen and perineal • Special considerations: “clean” closure of abdomen requires regowning, regloving, redraping, and a new minor tray • State/Describe incision: Abdominal midline

  8. Surgical Intervention: Supplies • Specific • Suture: Dexon and silk free ties; 3-0 chromic catgut (colostomy); closure: ) chromic catgut or Dexon • Medications on field (name & purpose) • Catheters & Drains • NG tube, Penrose drains (large and med available), Hemovac

  9. Surgical Intervention: Supplies cont’d • Special • Hemoclip appliers • Extra glove and umbilical tape (for proximal end of specimen before passed thru perineal wound • Vessel loop or umbilical tapes for retraction • Marking pen for stoma site

  10. Surgical Intervention: Instruments • Specific (If done simultaneously, 2 separate instrument set ups) • Major laparotomy short set • Long instrument set and intestinal set • Rectal set • Possibly a separate minor set for closure

  11. Surgical Intervention: Equipment • Specific • ESU, Suction, Stirrups

  12. Surgical Intervention: Overview of Procedure Steps • The abdomen is entered • The lesion is located and the bowel mobilized • The colon is divided in an area proximal to the lesion • A colostomy is performed and the abdomen is closed • Through a perineal incision, the lower sigmoid colon, rectum, and anus are mobilized and removed • The perineal incision is closed. Be sure to use multiple resources: concise but complete!

  13. Surgical Intervention: Procedure Steps Cont’d • Mobilization process: isolation of mesenteric tissue and omentum that caused diseased lymph nodes • Double-clamp • Divide tissue (cut using Metz scissors or ESU) • Sections ligated • Large blood vessels are clamped and ligated • Dissection and mobilization to level of levator muscles in pelvic floor • (2) clamps to proximal end of the mobilized area • Bowel is divided, distal end placed in pelvis

  14. Surgical Intervention: Procedure Steps Cont’d • To reconstruct the pelvic floor, a portion of omentum may be sutured to it. • Prepare colostomy site by incising small circle in abdomen w/skin knife. Deepened to inner abdomen with cautery. Specimen (small disk) is passed to STSR. • Proximal end of bowel is brought through the circular incision and temporarily clamped in place while the abdominal incision is closed in layers.

  15. Surgical Intervention: Procedure Steps Cont’d • To create colostomy, surgeon everts edges of bowel stoma and sutures edges of skin using interrupted sutures of 3-0 chromic catgut on a fine cutting needle.

  16. Surgical Intervention: Procedure Steps Cont’d • Perineal portion: surgeon places heavy silk pursestring suture through the anus to occlude it and perineum is incised and deeped with ESU. • Large bleeding vessels are double-clamped and ligated w/silk or Dexon • Peans are used to grasp bowel attachments. • Have sponge sticks and suction at all times during mobilization and dissection. • Mobilization continues until surgeon reaches previously mobilized area

  17. Heavy pursestring suture around anus to occlude it

  18. Area of incision around the rectum

  19. Surgical Intervention: Procedure Steps Cont’d • The entire specimen is delivered through the perineal incision, then irrigates the wound • Present trend is to obliterate the “dead space” with many interrupted sutures; achieve hemostasis • One or two Penrose drains are placed in the wound, which is then closed with size 0 chromic catgut or Dexon. • Skin is approximated with nonabsorbable suture.

  20. Colon and Rectum are delivered through the perineal resection

  21. Counts • Initial: Sponges, sutures & blades, Instruments • First closing • Final closing • Sponges • Sutures and Blades • Instruments

  22. Dressing, Casting, Immobilizers, Etc. • Types & sizes • Abdominal incision and on colostomy:Bulky abdominal pad and gauze sponges • Perineal pad for rectal drainage possibly • Type of tape or method of securing

  23. Specimen & Care • Identified as anus, rectum, and sigmoid colon • Handled: Usually routine/in formalin • Need a large container for storage and transport—formalin should cover specimen

  24. References • Alexander’s p. 385 • Berry and Kohn p. 665 • Fuller pp. 262-263 • STST p. 425-426

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