Abdominoperineal Resection Miles
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cuplacuwedivenshcaative ultrasonography can be performed. The upper ab-dominal contents should be gently palpated and then theintestines inspected. After palpating the stomach and du-odenum, the small bowel should be palpated and in-spected from the ligament of Treitz to the ileocecal valve.
From the University of Texas Southwestern Medical Center at Dallas, Dallas,TX.
Address reprint requests to Clifford L. Simmang, MD, MS, FACS, FASCRS,532
24This is to identify concomitant pathology that may needattention at the time of this operation. The colon is thenpalpated throughout, as are the retroperitoneal structures.
3 Harry Hines Blvd., Dallas, TX 75390-9156.2004 Elsevier Inc. All rights reserved.
lifford L. Simmang, MD, MS, FACS, FAS
ver the past few decades there have been significantadvances in adjuvant therapy for malignant condi-
ns of the anus and low rectum, as well as medicalerapy for inflammatory bowel disease involving the rec-m and anal canal. Many of these advances have allowedhincter-sparing operations and in some cases, the pos-ility to delay or avoid surgery. In 2003, it is predicted
at there will be 42,000 new cases of rectal cancer and00 cases of anal cancer.1 Although the possibility ofhincter sparing surgery following neoadjuvant therapyher with a low double stapled anastomosis or an inter-hincteric dissection and hand sewn coloanal anastomo-may be possible in many patients with cancer of the
rectum, when the sphincter complex is involved,hincter sparing operations are not possible. In addition,spite significant advances in medical therapy for in-mmatory bowel disease, abdominoperineal excision isuired for most patients undergoing surgery for Crohns
octitis and is occasionally selected as the operative proce-re of choice by a few patients with ulcerative colitis.Indications for abdominoperineal resection includeose patients with a malignancy involving the sphinctermplex,2 patients with Crohns proctitis and anal dis-se,3 patients with ulcerative colitis preferring to have ama or those patients with any of the above conditionso already suffer with incontinence and would be debil-ted by a low anterior, coloanal, or ileal pouch analastomosis. These patients have a superior quality of lifeth their stool evacuation from either an ileostomy or alostomy into a contained bag allowing them the free-m to live a normal life.Preoperative preparation and education of the patientimportant before creating a stoma. An Enterostomalerapist (ET) should visit with the patient and discussat a stoma is and what appliances are available andw they would function. The ET nurse will then performeoperative stoma siting. The stoma should be siteday from creases and in a location that the patient can. It is preferable to mark more than one location in the0 Operative TechniqueS
ssibility that the bowel may not easily reach the pre-red location and an alternative site should be marked.In preparation for an abdominoperineal resection, pa-nts undergo a standard bowel preparation with me-anical evacuation of the large bowel often using alanced electrolyte solution (GoLytely, Braintree Lab-atories, Braintree, MA) along with an antibiotic prophy-is. We use a combination of neomycin 1 g and metro-azole 1 g at 1 PM, 2 PM, and 9 PM the evening before
rgery. Bowel preparation is performed at home and thetients arrive to the hospital before their planned oper-ve procedure. Before the start of the operation, addi-nal antibiotic prophylaxis is given intravenously. Al-ough many antibiotic regimens are appropriate, we usefotetan (Astra-Zeneca, Wilmington, DE) 2 g before sur-ry and 1 g at 12 and 24 hours later. After the perioperativesing of antibiotics, further antibiotics are not used.In the operative room the patient is positioned in adified lithotomy position (Fig 1). The rectum is pre-
red by insertion of a 32 French Malecot catheter fol-ed by lavage with normal saline solution. Once clear,
ll strength Betadine solution is instilled within the rec-m for its tumorocidal properties. The Malecot cathetery be left as a drainage tube for evacuation of residual
lonic contents during the operation and to prevent ac-mulation of residual stool in the rectum during thelvic or perineal dissection. Alternatively, some sur-ons prefer to encircle the anal canal with a suture such as1 Prolene to occlude the anal orifice. If the procedure isrformed for anal cancer, this often is not possible.Most commonly, a midline incision is created andrves around the umbilicus opposite the side of thenned stoma. If a colostomy is planned the incision will
rve to the right of the umbilicus and if an ileostomyre planned it would then curve to the left. The fascia isided along the linea alba and the peritoneal cavity is
tered. On entering the peritoneal cavity explorationould be performed. In patients with malignant disease,reful palpation of the liver is important and intraoper-s in General Surgery, Vol 5, No 4 (December), 2003: pp 240-256
Mobilization is begun by incising the lateral peritonealattlowcotifiretnatudisancourwivecadolevtinthth
Once the major arterial trunk is divided this defines the
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241Abdominoperineal ResectionLithotomy positioning. The operative position for a synchroen accomplished with the use of adjustable stirrups to allow fovation of the lower extremities assists in promoting venous duential compression devices are also used for prophylaxis no
shion to prevent nerve injury. The patients position must be ina blanket, may be placed underneath the patients buttocks teration. Once in position, the anal canal may be closed with aabdominoperineal resection is low lithotomy. This is mostntle flex at the knees and elevation of the lower extremities.ge, which may reduce the incidence of venous thrombosis.ly for venous thromboembolism, but also as an additional
ted for appropriate padding. A soft roll, which may be a sheetin elevation and exposure for the perineal portion of the
y suture to prevent perineal contamination.achments just above the white line of Toldt. This al-s entry into an areolar fusion plane (Fig 2). As the
lon is further mobilized, a second fusion plane is iden-ed and dissection continues in this plane allowing theroperitoneal structures to remain posterior. The go-dal vessels are seen and identified first (Fig 2). The nextbular structure is the ureter and it is important in allsections of the left colon to clearly identify the ureterd avoid injury. Following mobilization of the sigmoidlon this can be carried superiorly and the splenic flex-e mobilized. Once lateral mobilization is complete, andow is created underneath the superior hemorrhoidalssels at the level of the sacrum (Fig 2). The peritoneumn be opened distally to allow enlargement of this win-w. The peritoneum is then incised proximally at thisel just below the superior hemorrhoidal vessel. Con-uing in this plane superiorly will lead to the origin of
e inferior mesenteric artery (IMA). Once encountered,e IMA is ligated near its origin from the aorta.Adjacent is the inferior mesenteric vein, which is thenided between clamps. Although I prefer to divide theA near its origin (Fig 3), some surgeons will divide theA after the take off of the left ascending colic artery.
though no oncologic benefit has been demonstratedm a high ligation of the IMA, a high ligation does
ovide a significant increase in the mobility of the colon.
proximal margin of resection. The mesentery is divided tothe colon, which will be near the junction of the descendingand sigmoid colon. The colon is then divided with a linearcutting stapling device, which allows separation and pre-vents spillage or contamination of colonic contents (Fig 3).
Once the colon is divided, attention is directed towardthe pelvic dissection. This is begun in the posterior plane.Continuing to mobilize the rectum in the avascular em-bryonic fusion plane will allow a total mesorectal excisionto be performed using a nerve sparing technique as thehypogastric nerves can be readily identified during thisdissection (Fig 4). There will be branches given off as thenerves traverse the pelvis, but the main trunk should beidentified and preserved during the main dissection (Fig4). A deep pelvic St. Marks type retractor is very usefulfor getting lift on the rectum and allowing this areolartissue plane to become readily visible. Dissection of therectum should be performed sharply under vision. I pre-fer to use electrocautery as it does aid in hemostasis espe-cially in the area of the lateral stalks (Fig 5). As progressdissecting the posterior rectum continues and tethering isnoted from the lateral peritoneal reflection, this should beincised and divided. This will allow for further mobilitywith the rectum. Sharp dissection will allow sharp divi-sion of Waldeyers fascia. Blunt pelvic dissection by slid-ing the operators hand behind the rectum has led to a
242 Clifford L. Simmangher incidence of rectal perforation because of the ad-rence of Waldeyers fascia. Sharp dissection and divi-n will decrease this complication. Circumferential dis-tion is now performed by incising