Perineal rectosigmoidectomy – Altemeier procedure

  • Universität Witten/Herdecke

    Prof. Dr. med. Gebhard Reiss

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  • Pelvic floor

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    (1) Rectogenital septum, (2) Rectal stalks (paraproctium), (3) Mesorectal fascia

    Acting as a "functional unit" the muscular pelvic floor closes off the inferior abdominal cavity and prevents the prolapse of intestines and pelvic organs. The structures of the pelvic floor support the intestinal and urogenital outlet system, with the muscular parts playing an essential functional role in retention and continence. Muscular overstretching and denervation may result in pelvic floor descent or the various forms of lesser pelvis organ prolapse. Women are affected far more frequently than men (ratio 9: 1).

    Usually, the development of pelvic floor deficiency is a multifactorial process. The number of vaginal deliveries, excessive pressing during defecation, obesity, and previous pelvic surgery are some of the most common causes of pelvic floor disorders.

  • Rectum

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    From a functional point of view, the rectum is a storage reservoir for feces preventing its continuous discharge. The rectum directly adjoins the sigmoid colon and resembles it in that it has an S-shaped anteroposterior and lateral curvature (sacral, anorectal and sacral flexure). Typically, the rectum is divided into three segments:

    1. Rectal ampulla (main reservoir, anterior to the sacrum)

    2. Anal canal (see below, sealing zone between the anorectal flexure and the cutaneous orifice)

    3. Between 1. and 2. an unspecified section which emerges perpendicularly from 1. and joins 2., also at right angles. Here, the mucosa presents with typical folds (Kohlrausch's folds).

    Posteriorly the rectum is related to the sacrum and coccyx, laterally to the internal iliac arteries and veins, regional lymph nodes, sacral plexus and parts of the autonomic nervous system, as well as both ureters and uterine adnexa. In the female, the uterus and vagina lie anteriorly, while in men this is true for the bladder and prostate/seminal vesicles. Inferiorly the rectum is related to the pelvic floor.

  • Anal canal

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    (1) Tunica muscularis, longitudinal sublayer, (2) Tunica muscularis, circular sublayer, (3) levator ani, (4) puborectalis, (5) external anal sphincter, deep part, (6) anal columns, (7) external anal sphincter, superficial part, (8) external anal sphincter, subcutaneous part, (9) Kohlrausch’s fold, (10) internal anal sphincter, (11) proctodeal gland, (12) corrugator cutis ani

    The interaction of three muscles in the lower rectum creates a sphincter mechanism:

    1. The internal anal sphincter represents a thickening of the last annular fibers of the smooth colon muscles and is innervated by the sympathetic nervous system.

    2. The levator ani, however, has voluntary innervation (sacral plexus) and includes the puborectalis arising from the symphysis pubis. Since the course of the puborectalis creates a sling (deficient anteriorly) around the rectum, the latter becomes angulated.

    3. The external anal sphincter is also a striated muscle and extends from the center of the perineum (centrum perinei, perineal body) to the coccyx. Its somatic innervation is supplied by the pudendal nerve. With its contraction it completely seals off the anal canal.

    The different innervation of the three muscles involved in the sphincter mechanism provides additional protection against failure and resulting incontinence.

    The mucosa of the anal canal is plicated into numerous longitudinal folds (anal columns) displaying a dense arterial (!) plexus with venous drainage. When the sphincter muscles contract, these plexuses fill up quickly distending the mucosa and pushing the folds against each other, thereby ensuring a gas-tight seal. Hemorrhoids and venous thromboses are well known vascular complications in this region.

    Defecation involves not only relaxation of the sphincter mechanisms (initiated by voluntary muscle action, drainage of the cavernous bodies) but also active abdominal press and intestinal peristalsis.

  • Blood supply

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    Three main arteries supply the rectum with blood:

    • Superior rectal artery (from the inferior mesenteric artery) via the sigmoid mesocolon (Caution: Transection of this artery at the level of the sigmoid colon results in ischemia of the upper rectum!)
    • Medial rectal artery (from the internal iliac artery), coursing craniad of the levator ani
    • Inferior rectal artery (from the internal pudendal artery) inferior to the levator ani.

    Venous drainage is via the venous rectal plexus underneath the mucosa of the rectum. The superior rectal vein drains the blood of the upper rectum via the inferior mesenteric vein into the liver, while the medial and inferior rectal veins drain the blood of the middle and lower rectum via the internal iliac vein into the lower vena cava (portocaval anastomosis).

    Lymphatic drainage of the rectum parallels the rectal blood vessels: The large cluster of inferior mesenteric lymph nodes forms a separate group at the upper rectum (superior rectal lymph nodes); the internal iliac lymph nodes filter lymph from the middle rectum (from the pararectal lymph nodes) and the superficial inguinal lymph nodes from the lower anal region, anus and perineal skin.

  • Perineum

    The perineum includes the region inferior to the pelvic diaphragm (genitourinary and anal region) and is delimited:

    • Craniad by the fascia of the inferior pelvic diaphragm
    • Anteriorly by the symphysis pubis
    • Laterally by the ischium
    • Posteriorly by the inferior edge of the gluteus maximus.

    The posterior perineum corresponds to the anal region and is known in the nomenclature as ischioanal fossa, while the anterior perineum corresponds to the pubic region and can itself be divided into three segments lying on top of each other:

    • At the most superficial level a subcutaneous perineal pouch (Colles space) (between the stratum membranosum telae subcutaneae perinei = Colles fascia and the perineal fascia)
    • A superficial perineal pouch between the perineal fascia and perineal membrane (Buck),
    • And a deep perineal pouch superior to the perineal membrane.

    Below the skin the posterior ischioanal fossa consists mainly of fatty tissue and numerous vessels/nerves (branches of the inferior rectal and internal pudendal artery and the pudendal nerve to the anal region). At the transition to the sacral region, a space lined with epithelium may develop in the gluteal fold and form a sinus between the tip of the coccyx and the anal verge. It may be encapsulated like a cyst (dermoid cyst) or have an external orifice (pilonidal sinus).

    The anterior superficial perineal space comprises the superficial muscles of the perineum and the blood vessels and nerves to the external genitals (perineal artery and artery of bulb of vestibule, as well as branches of the pudendal nerve to the labia/clitoris and scrotum respectively).

    The deep anterior perineal space is less clearly delimited, merges with the ischioanal fossa posteriorly and comprises the deep perineal muscles and other deep vessels/nerves.

  • Ev. Amalie Sieveking-Krankenhaus

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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: 06.07.2014
  • Ev. Amalie Sieveking-Krankenhaus

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  • Inserting the anal retractor and incising the rectal wall

    154-7

    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

    154-8

    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

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    The herniated Douglas pouch presents on the anterior circumference of the inner intestinal loop, is opened and at the same time armored with sutures of a different color. Under digital control, transect the lateral ligaments with their pathways between ligatures.

  • Transecting the mesorectum

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    Finish dissection of the thickened elongated mesorectum/mesosigmoid, which is then transected between ligatures at the level of the superior resection margin.

  • Pelvic floor repair

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    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.

    Note: 

    • Anterior levatoroplasty is not mandatory but optional. Depending on the size of the defect, this may require several sutures.
  • Resecting the sigmoid

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    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.

    Note: 

    • On the sigmoid stump, the initial stitch is full thickness from the outside in and from there it returns in the submucosal plane.
  • Anastomosis; specimen

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    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.

    Note: 

    • The drain should reduce any pressure on the anastomosis and allow early detection of possible intraluminal bleeding.
  • Ev. Amalie Sieveking-Krankenhaus

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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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  • Literature summary

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  • Ongoing trials on this topic

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  • References on this topic

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  • Reviews

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  • Guidelines

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