Intersphincteric resection, open, with transanal colon pull-through and transverse coloplasty pouch

  • Universitätsklinik Lübeck

    Dr. Tilman Laubert

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  • Descending and sigmoid colon

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    • Splenic flexure attached to the diaphragm by the phrenicocolic ligament
    • Descending colon situated in secondary retroperitoneal position
    • Transition between descending and sigmoid colon in the left iliac gutter
    • Sigmoid colon situated intraperitoneally (→ sigmoid mesocolon)
    • Transition between sigmoid colon and rectum anterior to the 2nd/3rdsacral vertebra
  • Rectum

    The rectum is divided into thirds. The level of their borders is measured with the rigid endoscope and referenced to the anocutaneous line. Distal third at 0-6cm, middle third at 6-12cm, proximal third at 12-16cm

  • Fascia systems

    • The pelvic parietal fascia covers the pelvic wall with its vessels, autonomic nerves and plexus of the presacral veins/nerves
    • The rectosacral fascia and visceral pelvic fascia meet proximal to the anorectal transition
    • The visceral fasciae comprise the proper pelvic fascia (encasing the posterior and lateral mesorectum) and the anterior Denonvilliers fascia
  • Vessels

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    • Anastomoses between branches of the superior and inferior mesenteric artery (middle and left colic artery respectively) near the splenic flexure (anastomosis of Riolan).
    • Left hemicolon, sigmoid colon and upper rectum supplied by the inferior mesenteric artery and its branches: left colic artery, sigmoid arteries with Drummond marginal artery, superior rectal artery.
    • Proximal third of the rectum supplied by the superior rectal artery dividing posteriad into two terminal branches; middle third by the middle rectal artery (paired, each originating from the internal iliac artery); and the distal third by the inferior rectal artery (paired, each originating from the internal iliac artery). The middle rectal arteries course in the so-called lateral ligaments of the rectum and are divided in total mesorectal excision.
    • Venous blood from the left hemicolon flows via veins of the same name into the area drained by the portal vein.
    • Venous drainage of the proximal and middle third via the inferior mesenteric vein (draining into the portal vein), while venous blood from the distal third returns via the area drained by the inferior vena cava.
  • Lymphatic drainage

    • For all rectal segments along the course of the superior rectal artery and inferior mesenteric artery.
    • In the distal third also via lymphatics paralleling the middle rectal and internal iliac arteries to lymph nodes around the levator ani muscles and ischioanal fossa.
  • Topographical relations

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    Descending colon, retroperitoneum and rectum

    • Course of the descending colon from proximal to distal closely related to the spleen (splenic flexure), omental bursa (posteromedial to the splenic flexure), left kidney and pancreatic tail (proximal segment of descending colon).
    • Root of the sigmoid mesocolon from the left iliac gutter coursing mediad, crossing the common left iliac vessels, left ureter and left ovarian/testicular vessels.
    • Left ureter coursing on the psoas muscle, which it crosses from superolaterad to inferomediad.
  • Lateral rectal topography

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    In men, the Denonvilliers fascia covers the posterior wall of the bladder, the seminal vesicles and the posterior wall of the prostate.

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  • Indications

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  • Contraindications

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  • Preoperative diagnostic work-up

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  • Special preparation

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  • Informed consent

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  • Anesthesia

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  • Positioning

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  • Operating room setup

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  • Special instruments and fixation systems

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  • Postoperative management

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date of publication: 29.09.2009

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  • Skin incision and exposure

    34-7

    Longitudinal laparotomy.

  • Freeing the left colon

    34-8

    Free the left colon up to the middle of the transverse colon with release of the splenic flexure. Identify and dissect the inferior mesenteric vein, ligament of Treitz and the arterial blood supply.

  • Managing the inferior mesenteric vein

    34-9

    High ligation and suture ligation of the inferior mesenteric vein at the inferior aspect of the pancreas.

  • Managing the inferior mesenteric artery

    34-10

    After suture ligation of the inferior mesenteric artery close to its origin, divide the artery while sparing the superior hypogastric plexus.

  • Entering the lesser pelvis

    34-11

    After instituting Trendelenburg position, open the peritoneum at the base of the mesosigmoid and mesorectum on both sides from anteriorly to the promontory down to the pouch of Douglas, and then open the "holy plain" posterior to the mesorectum, respecting the layers and the hypogastric nerves.
    Perform this dissection akin to total mesenteric excision.

  • Mesorectal dissection

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    After identification of the ureters continue the posterior dissection within the lateral layer. Stretching the mesorectal boundary facilitates layered dissection along the mesorectal fascial sheath. Dissect the mesorectum posteriad on the fascia of Waldeyer down to the pelvic floor.

  • Anterior rectal dissection

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    Dissect both lateral ligaments and divide the ligament structures between the coccyx and rectum. Now incise the anterior peritoneal reflection between the bladder /uterus and rectum and dissect down to the Denonvilliers fascia. While staying within the correct layer carry the dissection down to the suprasphincteric/intersphincteric level. In men take particular care to respect the plexus of nerves and veins encasing the seminal vesicles. The inferior hypogastric plexus on the anterolateral pelvic floor must be spared.

    Tip: In women, dissection takes place in the retrovaginal space. In anterior cancer, partial resection of the posterior vaginal wall may be required.

  • Rectal palpation

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    Now palpate the rectum to assess if the dissection has been carried down deeply enough and how it relates to the tumor.

  • Exposing the puborectalis muscle

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    Exposure of the puborectalis muscle will also allow assessment if the dissection has been carried down deeply enough.

  • Mounting the Lone Star Retractor System™

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    Place the perianal hooks at the transition to the shiny skin of the anal canal, thereby opening up the anal funnel.

  • Submucosal injection for hemostasis

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  • Intersphincteric excision

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  • Delivering the resectate

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  • Pouch construction

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  • Preplacing the interrupted sutures for the anastomosis

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  • Pulling the oral stump through the lesser pelvis

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  • Completing and tying the interrupted sutures

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  • Removing the anal retractor

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  • Intraoperative complications

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  • Postoperative complications

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  • MVZ St. Marien Köln - Ärztliche Leiterin

    Edith Leisten

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  • Zusammenfassung der Literatur

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