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Perineal rectosigmoidectomy – Altemeier procedure
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Inserting the anal retractor and incising the rectal wall
After completely exposing the external prolapse attach the Lone Star retractor and expose the dentate line. Then a circular incision of the outer duplication of the rectal wall 1-2 cm above the dentate line is made under gentle traction at the tip of the prolapse with Allis clamps, so that the anastomosis is later proximal to the puborectal muscle.
Transect the outer duplication of the rectal wall
Step by step, transect the rectal wall with bipolar scissors. At each exposed part of this incision, grasp the caudal rectal wall and place Gambee sutures without tying them.
Note: Make the first full-thickness stitch of the absorbable multifilament suture from the submucosa to the inside and the return stitch from the inside to the outside. Put tension on the ends of the suture to open up the anal ring in circular fashion.
Opening the pouch of Douglas and transecting the lateral ligaments
Transecting the mesorectum
Pelvic floor repair
Next, dissect the posterior vaginal wall by retracting the preperitoneal fat of the Douglas pouch posteriad and expose the sling of the levator ani. Now stitch both limbs of the levator ani with a non-absorbable monofilament suture. Elevate the Douglas pouch by anchoring the peritoneum to the anterior wall of the sigmoid with the preplaced sutures. As a final step, adjoin both limbs of the levator ani in the midline anterior to the bowel and close the gap in the pelvic diaphragm with an anterior levatoroplasty.
- Anterior levatoroplasty is not mandatory but optional. Depending on the size of the defect, this may require several sutures.
Resecting the sigmoid
Now transect the sigmoid at a level where the colon is stretched while still ensuring a tension-free anastomosis in the next step. In doing so, open the lumen step by step, starting at 12 o'clock, and continue to place interrupted mattress sutures with the same suture material and technique as demonstrated in step 2.
- On the sigmoid stump, the initial stitch is full thickness from the outside in and from there it returns in the submucosal plane.
Now anastomose the sigmoid with the anal ring by tying together each of the different sutures, with the knots situated between the margins of the mucosa. For this, reposition the tractor outside the dentate line.
Finally, inspect the suture line with a speculum and an insert an Easy-Flow drain in the anal canal.
The Douglas pouch is clearly evident on the specimen, which may sometimes be up to 1/2 meter long. The rectum itself is extremely shortened and often measures only 5-6cm.
- The drain should reduce any pressure on the anastomosis and allow early detection of possible intraluminal bleeding.