ABDOMINOPERINEAL ABDOMINOPERINEAL RESECTIONRESECTION

Cardinal Santos Medical Center

Raphael E. PascualGROUP VI

I.I. Definition/PurposeDefinition/Purpose of the of the ProcedureProcedure

• 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. PathophysiologyII. 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 ConsiderationsIII. 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 InterventionIV. 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

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 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

• 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 transport—formalin should cover specimen

References

• Alexander’s p. 385

• Berry and Kohn p. 665

• Fuller pp. 262-263

• STST p. 425-426