LP 2 Abdominoperineal Resection

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Transcript of LP 2 Abdominoperineal Resection

  • ProceduresAdvanced Format:

    Abdominoperineal Resection

  • Definition/Purpose of ProcedureThrough combined abdominal and perineal incisions, the anus, rectum, and sigmoid colon are removed en bloc.Also called Miles ResectionThe 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 perineumPerformed to treat cancer of the lower rectumand diseases are too low for use of EEA stapling devices

    MAVCC Info page 109

    See Alexanders p. 384: Fig 11-36use of EEA stapler to perform low anterior anastomosis

  • PathophysiologyCancer of lower rectum: usually the lower third of the rectum, but may extend into the anal canalThe sigmoid colon is the primary site of colon cancer and is the section of colon most susceptible to volvulus.

  • Abdominoperineal Resection

  • Surgical Intervention:Special Considerations

    Patient FactorsRequires the formation of a permanent colostomy in the abdominal wall for drainage of bowel contentsAn indwelling foley catheter will be inserted and attached to closed drainageUpper body thermia blanketRoom Set-upOrganize 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)

  • Surgical Intervention: PositioningPosition during procedure: when performed as two simultaneous procedures, modified lithotomySupplies and equipmentProbable 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 DevicesSpecial considerations: high risk areas: cause pressure to back of knees and lower extremities and may jeopardize the popliteal vessels and nerves

  • Surgical Intervention: Draping/IncisionTypes of drapes (Depends on position)Laparotomy and perineal: Under buttocks, folded towels, Lap T-sheet (cut hole for perineal exposure)Order of drapingAbdomen and perinealSpecial considerations: clean closure of abdomen requires regowning, regloving, redraping, and a new minor trayState/Describe incision: Abdominal midline

  • Surgical Intervention: SuppliesSpecificSuture: Dexon and silk free ties; 3-0 chromic catgut (colostomy); closure: ) chromic catgut or DexonMedications on field (name & purpose)Catheters & DrainsNG tube, Penrose drains (large and med available), Hemovac

  • Surgical Intervention: Supplies contdSpecialHemoclip appliersExtra glove and umbilical tape (for proximal end of specimen before passed thru perineal woundVessel loop or umbilical tapes for retractionMarking pen for stoma site

  • Surgical Intervention: InstrumentsSpecific (If done simultaneously, 2 separate instrument set ups)Major laparotomy short setLong instrument set and intestinal setRectal setPossibly a separate minor set for closure

    MAVCC Info p. 110What is generally on an Intestinal set? Tissue forceps, Intestinal forceps, Intestinal clamps, Anastomosis clamps, Pylorus clampsWhat is generally on a Rectal set? Speculum, rectal retractors, scopes, probes, crypt hooks, hemorrhoidal ligator, tissue forceps and grasping forceps, rectal scissors, biopsy forceps

  • Surgical Intervention: EquipmentSpecificESU, Suction, Stirrups

  • Surgical Intervention: Overview of Procedure StepsThe abdomen is enteredThe lesion is located and the bowel mobilizedThe colon is divided in an area proximal to the lesionA colostomy is performed and the abdomen is closedThrough a perineal incision, the lower sigmoid colon, rectum, and anus are mobilized and removedThe perineal incision is closed.

    Be sure to use multiple resources: concise but complete!

  • Surgical Intervention: Procedure Steps ContdMobilization process: isolation of mesenteric tissue and omentum that caused diseased lymph nodesDouble-clampDivide tissue (cut using Metz scissors or ESU)Sections ligatedLarge blood vessels are clamped and ligatedDissection and mobilization to level of levator muscles in pelvic floor(2) clamps to proximal end of the mobilized areaBowel is divided, distal end placed in pelvis

    Fuller p. 262: Mobilization of the colon involves isolation of the mesenteric tissue and omentum that contain diseased lymph nodes. The surgeon frees the colon from its attachments by double-clamping the tissue with Mayo clamps. The tissue between the clamps is then divided with Metzenbaum scissors or a cautery pencil, and the sections are ligated with silk or Dexon ties. As mobilization continues, you will need longer instruments. Be sure to have ample supply of Pean clamps, long right angled clamps, and small sponge dissectors. Also need both smooth and toothed long tissue forceps. Large blood vessels are clamped with right-angled or Pean clamps and ligated with suture ligatures. You should have one or two suture ligatures ready at all times during the dissection.Dissection and mobilization are continued thru the pelvic floor to the level of the levator muscles. At this point, the abdominal dissection is halted, because the incision is too deep for the surgeon to comfortably and safely work. The surgeon now places 2 intestinal clamps across the bowel at the proximal end of the mobilized area. The bowel between the clamps is divided, and the distal end is placed in the pelvis. The proximal end of the divided bowel is then temporarily ligated with heavy silk suture. To reconstruct the pelvic floor, a portion of the omentum may be sutured to it.

  • Surgical Intervention: Procedure Steps ContdTo 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.

  • Surgical Intervention: Procedure Steps ContdTo 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.

  • Surgical Intervention: Procedure Steps ContdPerineal 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 DexonPeans 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

    Fuller p. 263

  • Heavy pursestring suture around anus to occlude it

  • Area of incision around the rectum

  • Surgical Intervention: Procedure Steps ContdThe entire specimen is delivered through the perineal incision, then irrigates the woundPresent trend is to obliterate the dead space with many interrupted sutures; achieve hemostasisOne 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

  • CountsInitial: Sponges, sutures & blades, Instruments First closingFinal closingSpongesSutures and BladesInstruments

  • Dressing, Casting, Immobilizers, Etc.Types & sizesAbdominal incision and on colostomy:Bulky abdominal pad and gauze spongesPerineal pad for rectal drainage possiblyType of tape or method of securing

  • Specimen & CareIdentified as anus, rectum, and sigmoid colon Handled: Usually routine/in formalinNeed a large container for storage and transportformalin should cover specimen

  • ReferencesAlexanders p. 385Berry and Kohn p. 665Fuller pp. 262-263STST p. 425-426

    MAVCC Info page 109

    See Alexanders p. 384: Fig 11-36use of EEA stapler to perform low anterior anastomosisMAVCC Info p. 110What is generally on an Intestinal set? Tissue forceps, Intestinal forceps, Intestinal clamps, Anastomosis clamps, Pylorus clampsWhat is generally on a Rectal set? Speculum, rectal retractors, scopes, probes, crypt hooks, hemorrhoidal ligator, tissue forceps and grasping forceps, rectal scissors, biopsy forceps Fuller p. 262: Mobilization of the colon involves isolation of the mesenteric tissue and omentum that contain diseased lymph nodes. The surgeon frees the colon from its attachments by double-clamping the tissue with Mayo clamps. The tissue between the clamps is then divided with Metzenbaum scissors or a cautery pencil, and the sections are ligated with silk or Dexon ties. As mobilization continues, you will need longer instruments. Be sure to have ample supply of Pean clamps, long right angled clamps, and small sponge dissectors. Also need both smooth and toothed long tissue forceps. Large blood vessels are clamped with right-angled or Pean clamps and ligated with suture ligatures. You should have one or two suture ligatures ready at all times during the dissection.Dissection and mobilization are continued thru the pelvic floor to the level of the levator muscles. At this point, the abdominal dissection is halted, because the incision is too deep for the surgeon to comfortably and safely work. The surgeon now places 2 intestinal clamps across the bowel at the proximal end of the mobilized area. The bowel between the clamps is divided, and the distal end is placed in the pelvis. The proximal end of the divided bowel is then temporarily ligated with heavy silk suture. To reconstruct the pelvic floor, a portion of the omentum may be sutured to it.Fuller p. 263