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Intersphincteric resection, open, with transanal colon pull-through and transverse coloplasty pouch - general and visceral surgery
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Skin incision and exposure
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Freeing the left colon
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Managing the inferior mesenteric vein
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Managing the inferior mesenteric artery
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Entering the lesser pelvis
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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Anterior rectal dissection
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.
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Rectal palpation
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Exposing the puborectalis muscle
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Mounting the Lone Star Retractor System™
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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