Procedures

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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

• 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

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.

Abdominoperineal Resection

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)

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

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

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

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

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

Surgical Intervention: Equipment

• Specific– ESU, Suction, Stirrups

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!

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

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.

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.

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

Heavy pursestring suture around anus to occlude it

Area of incision around the rectum

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.

Colon and Rectum are delivered through the perineal resection

Counts

• Initial: Sponges, sutures & blades, Instruments

• First closing

• Final closing– Sponges

– Sutures and Blades

– Instruments

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

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

References

• Alexander’s p. 385

• Berry and Kohn p. 665

• Fuller pp. 262-263

• STST p. 425-426