Since Babcock’s first rectal drag-out resection in 1932, it has been modified several times by Bacon (1945), Black (1948) and others. The abdominal operations including freeing the rectum to the anal raphe are the same as the anterior resection. In contrast, the extent of resection and treatment of the anal side varies depending on the procedure (Figure 7-26), with the common denominator being that the colon and anal canal are left to heal on their own without anastomosis. This type of surgery can be complicated by complications such as distal colon necrosis, anal canal and sphincter injury, and is now mostly replaced by low anterior resection with anastomosis. The method is still necessary to learn and develop as a part of the history of rectal cancer surgery development.
(I) Modified Bacon procedure
In 1950, Ravitch improved Bacon’s operation by preserving the anal levator and internal anal sphincter and removing the skin in the dentate area, thus improving bowel control and reducing infection. The indications for this surgery are rectal cancer 4-6 cm from the anal verge, small tumor, and early stage cancer with good differentiation.
Surgical steps.
1) The abdominal incision and the freeing of sigmoid colon and rectum are the same as the anterior resection, but the rectum should be free to the plane of anal raphe, and the rectum should be ligated with thick silk thread above this plane.
2) If the sigmoid colon is short, the lateral peritoneum of the descending colon should be cut, and if necessary, the splenic flexure should be freed so that the sigmoid colon can be dragged to the anus without tension.
3) Lift the sigmoid colon and ligate it with a thick wire at 4-5 cm above the tumor.
4) Dilate the anus to 4 to 5 fingers and flush the recto-anal canal. The anal canal is pulled away in all directions with 4 towel clamps on the perineum, and the skin of the anal canal is circumferentially cut at about 2 to 3 cm below the dentate line.
5) Below the plane of the anal raphe, the rectal mucosa several subanal canal was separated, and then the vascular forceps were extended through the anus to clamp the rectal wall at the ligature and turned outward, and the rectal mucosa and muscle layer were circumferentially cut with an electric knife at the plane of the anal raphe.
6) Pull out the cancer and rectum from the anus, pay attention not to twist them and not to put too much tension on them, cut off the intestinal canal at the upper edge of the tumor 10-15 cm and ensure that the broken end of the sigmoid colon is exposed outside the anus 3-4 cm, and suture the side wall of the dragged out intestinal canal to the skin around the anus with 3-0 absorbable thread while cutting. The severed end was thoroughly hemostatic, covered with iodoform gauze and dressing wrapped.
7) About 2 weeks after the operation, the pulled-out colon and the anal canal wound adhesions heal, and the pulled-out colon below the dentate line is removed with an electric knife under epidural anesthesia for anoplasty.
The advantage of this procedure is that the rectum is resected at a very low position, and a high degree of radicality can be maintained.
This procedure can be complicated by
①Infection: Since the colon has to pass through a section of the stripped anal canal, fluid accumulation between the anal canal and the colon is prone to infection. Methods to avoid this: thorough hemostasis and unobstructed drainage.
② Drag out the intestinal tube necrosis: mostly due to excessive force when dragging the colon outward, the vascular damage or thrombosis. It can also be caused by contraction of the anal sphincter and compression of the intestinal canal.
①Severing part of the anal sphincter, which has adverse effects on preserving anal function.
② Pre-operative epidural cannulation, within the first 3 d after surgery, give analgesic, such as morphine hydrochloride 2 mg dissolved in saline 2 ml, every 6-10 h via cannula injection after surgery anal function is good. If the intestinal canal necrosis reaches the pelvic cavity, it should be operated again.
(③The healing part is easy to be stenosed, and anal dilation should be started 2 weeks after stage II surgery, 1~2 times a day, and the number of dilation should be gradually reduced when there is no stenosis.
(B) Rectal transabdominal resection and anal canal pull-out resection
This procedure is a modification of Bacon’s procedure by Zhou Xigeng et al. A circular incision is made 1 to 2 mm distal to the dentate line, through the proximal edge of the anal canal skin and submucosal muscle layer, deep to the internal dilator muscle, and dissected by peeling upward until above the plane of the anal levator muscle. Then the rectum above the levator muscle was circumferentially cut from inside to outside and then the rectum was pulled out. The pulled out bowel is then removed 10-14 days after surgery.
This procedure also preserves the anal levator muscle and its underlying tissues, avoids damage to the anal nerve, and provides more satisfactory postoperative anal function with bowel control.
(C) Transabdominal rectal resection preserving anal colonic extraction
This procedure was reported by Jinnai Jounosuke in Japan in 1961. The indications are the same as those for the modified Bacon operation, which is performed in two stages.
1.Phase I surgery This stage is performed to remove rectal cancer and pull out the colon. The abdominal operation is the same as the former resection operation, and it is decided that the splenic flexure of the colon needs to be free when performing this operation, and the downward freeing should reach the level of the dentate line, that is, freeing above the anal raphe. A large right-angle clamp is used to hold the intestinal canal about 2 to 3 cm above the dentate line.
The anal canal is fully dilated by an assistant from the perineum and can be inserted smoothly with 4 to 6 fingers of the operator. The rectal canal lumen is repeatedly flushed with water and then wiped with chlorhexidine solution or 75% ethanol. Then a second large rectal forceps is placed below the large rectal forceps, where the rectum is severed along the second large rectal forceps down, rather at the level of the dentate line or 1. 0 cm above it.
The rectal dissection was stopped by electrocoagulation, and the hole was poked from the anterolateral aspect of the caudal tip, and 2 latex tubes were left in the presacral area for drainage. Then, the descending colon was examined for blood flow and cut in the lower 1/3 of the sigmoid colon. The specimen was removed, and the proximal intestinal lumen was left in latex tubes and then sutured closed. The pelvic cavity was flushed with plenty of distilled water and then the colon was pulled out from the anus. The extra-anal retained intestinal segment should be 5-6 cm. The pulled-out intestine was fixed with 3 to 4 stitches by suturing the perianal skin.
2.Second-stage surgery The pulled-out intestine is excised 2-3 weeks after the first-stage surgery, and the pulled-out intestine is cut off at the level of the broken end of the dentate line. Compared with Bacon’s operation and Black’s operation, this operation simplifies the operation, less bleeding, no anastomotic leakage, and faster and better recovery of anal function after the operation, and most cases can recover anal function within 1 year.
(IV) Evaluation
Direct drag-out proctocolectomy, although not as effective as anal preservation with anastomosis, is an economical procedure without anastomotic leakage, and is still used in many hospitals. Regarding the problem of more frequent bowel movements, if one practices lifting the anus 500 times a day, the ability to control the bowel can be significantly improved.