Laparoscopic Abdominoperineal Resection
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Transcript of Laparoscopic Abdominoperineal Resection
Cardinal Santos Medical Center Raphael E. Pascual GROUP VI
I. Definition/Purpose of the Procedure Through combined abdominal and perineal incisions, the anus, rectum, and sigmoid colon are removed. 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 thst are too low for use of EEA stapling devices
II. 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.
III. 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 thermal blanket
IV. Surgical InterventionPositioning Position during procedure: when performed as two simultaneous procedures, modified lithotomy Supplies and equipment Probable Allen stirrups or high impact knee-crutch stirrups for positioningcan 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
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
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.
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
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.
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.
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 doubleclamped 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
Heavy pursestring suture around anus to occlude it
Area of incision around the rectum
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.
Colon and Rectum are delivered through the perineal resection
Specimen & Care Identified as anus, rectum, and sigmoid colon Handled: Usually routine/in formalin Need a large container for storage and transportformalin should cover specimen
References Alexanders p. 385 Berry and Kohn p. 665 Fuller pp. 262-263 STST p. 425-426