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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    Longitudinal laparotomy.

  • Freeing the left colon

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    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

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

  • Managing the inferior mesenteric artery

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    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

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    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

  • Intersphincteric excision

  • Delivering the resectate

  • Pouch construction

  • Preplacing the interrupted sutures for the anastomosis

  • Pulling the oral stump through the lesser pelvis

  • Completing and tying the interrupted sutures

  • Removing the anal retractor