1.rectal examination
Don’t be satisfied with finding the tumor or biopsy to determine the tumor, but also explore the tumor carefully! The center of the tumor is usually the primary location of the tumor with the deepest tissue infiltration. But the center of the ulcer on both sides is not necessarily the center of the tumor. For some reason, the ulcerated area expands faster in the posterior wall and relatively slower in the anterior wall.
The mobility of the mass has to be seen from two aspects. First, the mobility of the whole tumor indicates the extent and depth of tumor exenteration. Second, the mobility of the individual edges of the mass, which indicates the way and extent of mass expansion.
The location of the residual normal rectal mucosa can be used as a breakthrough point for surgical freeing!
The condition of the surrounding organs. There are significant differences with vaginal or prostate adhesions or invasion, and even more so during surgery.
The distance between the lower edge of the mass and the anus determines the way of reconstruction after excision. The commonly used hand measurement method has a large margin of error, and if possible, it is recommended to measure the distance between the lower edge of the mass and the dentate line. Method: The index finger of the right hand is held upward against the lower edge of the mass to straighten the rectal mucosa on one side. The left hand index finger is extended into the anal canal to the dentate line, and the two fingers are withdrawn together to measure the length! It is best to measure the front and back separately.
2. Incision selection
For patients with possible abdominal wall colostomy, the stoma location must be determined preoperatively together with the patient. Although it is cruel to the patient, an unreasonable stoma is even worse! One choice, one decision by the surgeon can have a huge impact on the patient’s life! Routinely use the right paramedian median or median around the umbilicus incision, even if there is absolute certainty to preserve the anus, do not easily choose the left side incision, in case of anastomotic fistula, in case of tumor recurrence! It is better to use continuous peritoneal suture to protect the skin after opening the abdomen. Don’t casually change the formed incision habit, just like a racer doesn’t casually change the racing car!
3. Abdominal exploration
Previously, the liver and spleen were first probed for metastatic nodes after opening the abdomen and the abdominal aorta for enlarged lymph nodes —– Now, these issues rely more on preoperative imaging!
Mass exploration is the focus. The tumor location, size, relationship to the peritoneal reflex, mobility, and lymph nodes need to be clarified to determine the surgical resection and scope. Determining if there are other tumors or polyps in the colon is also very important!
Originally, this process will not be a problem, but there is still a situation that is often mistaken: tumor at the junction of rectosigmoid colon or tumor at the lower end of sigmoid colon, which often has adhesions with the left pelvic cavity and will block the whole pelvic entrance when the tumor is large, so it is easy to mistake that the tumor is fixed with the pelvic wall and give up the resection.
4.Determine the operation method
For cases with enlarged lymph nodes adjacent to the abdominal aorta and its main branch arteries, extended radical surgery is required. Expanded radical surgery may seriously damage the pelvic autonomic nerves due to the large free resection area and cause serious urinary function and sexual dysfunction, therefore, expanded radical surgery must be functional expanded radical surgery at the same time!
Whether to preserve the anus can be initially determined by preoperative examination. However, the final decision during surgery is also based on the length of the preserved colon, local tumor invasion and lymph node metastasis, whether the surgical resection can be complete (under the naked eye), the risk of local recurrence after surgery, and the preservation of defecation function after surgery.
No matter how much the patient and family expects to preserve the anus, no matter what kind of guarantee you make to the patient before surgery, until the last moment, whether the anus can be preserved, or whether the anus should be preserved is still an unknown quantity! It is not the doctor, not the patient, not the family, and not the toolkit that really decides the way to operate, but the condition!
5.Free
In order to remove the rectum and tumor, many structures must be cut and separated. The specific structures are described in detail in the book, so I won’t go into them. When performing these operations specifically, the order, level, and technique are important.
I. Reasonable order
It should be that the operation in front does not adversely affect the operation behind, and it is better to facilitate the operation behind, or simplify the operation!
For example, adhesions between the sigmoid colon and the left peritoneum can affect the treatment of the superior rectal artery, the exposure of the presacral space, and the protection of the left ureter and genital vessels, and should be separated thoroughly first. Although it is possible to bypass the complex area of adhesions by separating from below the left page of the sigmoid mesentery, this can interfere with the exposure of the ureter and is detrimental to the closure of the peritoneal and mesenteric fissures of the pelvic floor.
For example, ligature cutting off the superior rectal artery facilitates the finding, revealing and separation of the anterior sacral space, can prevent intraoperative spread of tumor cells, can reduce bleeding in the next step of freeing the rectum, and also allows 30 minutes to observe the blood flow of the reserved colon, it should be performed first and not at the final resection.
For example, the ureter is revealed first and then both sides of the rectum are freed. First the anterior sacral space on the front posterior side, then the pararectal space on the lateral posterior side, the peritoneum on both sides, the anterior rectal space, and finally the lateral ligament.
Make cards of all your operations, combine them, and see if your current order makes sense and if there is a more reasonable order!
6.Excision
I. Scope of resection and the bottom line of anal preservation As mentioned earlier, if it is appropriate to preserve the anus, total rectal mesenteric resection should be performed. This step, which guarantees a radical effect, seems to significantly increase the incidence of postoperative anastomotic fistula. The first reason that comes to mind is impaired distal rectal blood flow, which some believe is caused by the procedure itself and is an inevitable price to pay for the radical outcome! In fact, the main reason is some inadvertent and imperceptible injuries during the freeing, cutting and reconstruction of the rectum!
For example: excessive pulling of the rectum, blunt separation of the rectum immediately, electrocoagulation or suture hemostasis of the rectal surface, separation into the rectal muscle layer, pulling, twisting and excessive tissue compression of the stump closers, accidental injury during rectal irrigation, excessive topping of the anastomosis, double mechanical anastomosis off-center, and rough pushing out against the staple seat —–
Second, combined resection
Many abdominal primary surgeons simply free the mid-upper rectum slightly and leave it to the perineal operation, appearing very dashing! What structures are more appropriately left to the perineal group for operation and what structures must be completed via the abdomen which?
First of all, the lower end of the presacral space must be free transabdominally to the tip of the coccyx, otherwise the perineal group cannot enter the presacral space properly and smoothly, besides, freeing transabdominally to the tip of the coccyx is easy to do. It is better to free to the anal raphe on both sides, because the structures above the anal raphe are too far from the anus, and the transepithelial operation is bound to overstretch downward, which is very likely to cause injury to the lateral pelvic floor nerves. Anterior freeing to the base of the prostate or the posterior vaginal fornix is sufficient, and it is recommended to leave most of the prostate or posterior vaginal wall to be handled under direct vision by the perineal group.
The perineal incision can be made as a shuttle incision along the border of the perineal pigmentation, with the edge of the anal sphincter just below the incision. The perineal adipose tissue is very lax and usually does not need to be cut with an electric knife. Fingers can be used to separate, find, ligate, and cut the anal vessels that cross between them.
Generally, the anterior wall is separated under direct vision using the first side, then both sides, and finally turning out the rectum. The posterior side is first targeted at the tip of the tailbone, and after reaching the tip of the tailbone, do not rush to cut at the upper edge of the tailbone tip! Because of the downward pull on the anus, the caudal ligament is tightly attached to the posterior wall of the rectum, and cutting at this point will lead to a deeper anatomical level. Cutting directly into the posterior wall of the rectum is again very uncomfortable.
What to do? Stop pulling down the rectum and push up the rectum so that the caudal anal ligament is straightened up and away from the rectum and then cut off, allowing direct access to the anterior sacral space. Both sides of the anal raphe cut off face similar problems, but the solutions are different. When you pick up the anal raphe by hand, the biggest problem is that you can’t look straight at the tissue you want to cut, the assistant pulls the hook hard and it doesn’t work, reaching in two fingers doesn’t work, and you are worried about bleeding when you cut blindly! At this point, in fact, a small S-hook can easily solve the problem! Take the left side as an example: the operator’s left index finger reaches into the back of the left anal raphe and gently hooks it, and the assistant pulls the rectum to the right side with the hook, so that the anal raphe that needs to be cut is revealed between the top of the hook and the left index finger, and can be cut under direct vision. Then, the rectum is turned out and the anterior wall is freed from both sides to the middle under direct vision. Carefully and thoroughly stop bleeding during the freeing process. Bleeding from the surface of the prostate can be clamped and then electrocoagulated or fine-needle sutured, while bleeding from the vaginal wall can only be selected by fine-needle sutured.
7.Reconstruction
I. In situ reconstruction
Most hospitals use instrumented anastomosis, and some economically underdeveloped areas still use manual anastomosis. Manual anastomosis can be difficult regardless of revealing, suturing and knotting, which is not conducive to completing a high quality single-layer anastomosis. The following recommendations will be of some help, but will not address the root of the problem Thoroughly remove the proximal colonic contents and disinfect the distal rectum after flushing to minimize contamination during the anastomosis. Use a cut-and-sew approach, and right-angle clamps at both ends should be oriented in the same direction.
The muscle and submucosal sutures alone require more gentle manipulation and finer suturing, and are not recommended without considerable skill and experience. Once the exposition is complete, incision, suturing, knot tying, and thread cutting are recommended to be done by one operator to provide a static, clear, stable, and reliable environment for the anastomosis. The bowel wall is incised no less than one-third at a time to avoid jagged cut edges or too much local tension. Sutures are straddled and each stitch is properly ligated, avoiding the use of sutures to lift the intestinal wall, and especially do not lift unknotted sutures. The tension-free principle was emphasized throughout the operation. After the posterior wall suture is completed, the remaining bowel wall is cut open and the anterior wall is anastomosed under direct vision. A one-half suture is used to evenly distribute the tension. After completion of the anterior and posterior wall sutures, two more corners are sutured so that all anastomoses are flat under direct vision and corner sutures under tension are avoided. If possible, an oblique anastomosis should be performed, i.e., the anastomosis of the anterior rectal wall is slightly distant from the dentate line and the posterior wall is slightly closer. This gives the anastomosis an oblique shape and reduces the risk of anastomotic stricture. The length of the posterior wall of the rectum, which has slightly poorer blood flow due to total mesenteric resection, is reduced, reducing the risk of anastomotic fistula. It conforms to the direction of rectal retroflexion and is more conducive to the preservation of rectal function.
Double instrumented anastomosis is recommended. The anastomosis is not difficult to operate after the distal purse string is closed, but the inner wall of the anastomosis is not flat enough, and the incidence of postoperative anastomotic edema is higher and recovery is slower. Do not pull the rectum excessively when closing the distal end with a double instrumented anastomosis, causing a false phase of distance. Do not cut off the rectum after mechanical closure when the tension is high; it should be cut off under direct vision without tension after removal of the closure. There are many issues to be noted during the instrumental anastomosis, and the key is to avoid secondary injury to the residual rectum.
II. Ectopic reconstruction
The combined abdominal perineal resection with abdominal wall artificial anus has been applied for a long time and the technology is mature, so we will not talk about it anymore. Although new theories and techniques continue to emerge for abdominal wall artificial anus, please remember that the patient has lost the natural anus and its delicate functions forever, and no artificial can replace it. Perhaps it would be more practical to think more about postoperative care.
8. Other
Lymph node dissection, extended dissection, and extended radical surgery with preservation of the autonomic nerve are relatively simple to say, but, in practice, extremely demanding. What is really needed is precise anatomical knowledge, fine and excellent basic skills, and trivial words will not help!
Once again, I would like to remind you that no matter what kind of teacher you have, what you can give is just a crutch, a direction, an encouragement and an expectation! The road still has to go step by step, the mountain still has to rely on their own one by one climb!
The site friend wuji1wrote:In the free rectal posterior wall cut Waldeyer’s fascia when revealing teaching difficulties, especially the male teaching obese patients, what is a good method?
A: Compared with women, the male pelvis is narrower and deeper, and if combined with obesity, revealing is indeed difficult!
1. By the way, the surgeon’s requirements for revealing vary greatly, some want full revealing, some want regional revealing, while some doctors only need partial revealing! Please appreciate the difference! In terms of completing the surgical operation alone, partial exposure is sufficient!
2, before freeing Waldeyer’s fascia, do not free the sides and front, so as not to affect the field of vision by bleeding from the trauma.
3.Sever the superior rectal artery first, and if necessary, sever the sigmoid colon and pull the rectum downward.
4.Pull the large S pull hook on the posterior wall of the rectum, which is more effective than pulling the intestinal canal by force.
5.Advance the whole line parallel to each other, avoid creating artificial difficulties by punching the hole in the center first and then unfolding the two wings!
6.Focus your attention on the separated gap!
7.Multiple people reveal, one person operates, providing static interface.