The purpose of anterior rectal resection is resection of the rectosigmoid colon and reanastomosis of the colon and rectum.
Consequences of anterior rectal resection: After removal of the rectosigmoid colon, the physiological consequences are minimal.
If the patient has received a course on the pelvic area, then a temporary colostomy should be applied for 8-10 weeks before performing a low anastomosis. If irradiation of the pelvis was not performed, and careful bowel preparation was performed before the operation, then an unloading colostomy may not be performed.
Technique of anterior rectal resection
During the operation, the patient can be positioned in two positions. When performing a simple anterior resection with a low anastomosis of the rectosigmoid colon with the existing 10-12 cm of the patient's rectum, the patient can be operated on in the supine position.
If, after transection, less than 10 cm of the rectum remains, then it is necessary to change the position of the patient (modified position for stone section), exposing the perineum to use a device that performs an end-to-end anastomosis.
Progress of the operation
The abdomen and perineum should be prepared in advance. IN bladder a Foley catheter is inserted. The abdominal cavity is opened with a paramedian or midline incision.
The affected part of the rectosigmoid colon was identified. The segment of the colon that will be resected is determined. Two linear clamps are applied along the edges of the selected area. compresses the colonic vessels, producing small holes in the mesentery. It is advisable to preserve the left colic artery coming from the lower mesenteric artery. The remaining sections of the mesentery are cut with scissors. The colon segment with mesentery is removed.
During anterior resection of the rectum, it is necessary to perform sufficient mobilization descending department colon and even, if necessary, the splenic angle and transverse colon so that the colon reaches the rectum without tension. An anastomosis formed under tension will not heal well.
After mobilization of the descending colon is completed and it is brought without tension to the rectum, a Lembert suture is placed on the mesenteric edges with a synthetic absorbable thread.
A single-row suture is started with interrupted sutures using a 3/0 synthetic absorbable thread. Punctures are performed through the walls of the rectum and colon; the nodes are left inside the lumen. The formation of an anastomosis on the right and left along the circumference of the intestine continues. The last sutures must be applied using the “close-to-far” type with the walls screwed in.
The rectum is operated on for a variety of reasons, depending on which the appropriate technique is selected. Excision of the rectum is technically more difficult to perform than operations on other parts of the intestine. Undesirable consequences or complications appear more often due to high risk damage to nearby structures in a narrow space. Regardless of the type of resection used, preparation of the organ is necessary before surgery. To do this, several methods of cleansing the intestines are used: cleansing enemas, taking drugs that improve motility, diet.
Rectal surgery occurs only in severe cases.
When are surgeries needed?
Frequent reasons that necessitate operations on the rectal ampulla are:
- haemorrhoids;
- cracks in the mucous membrane of the anal canal.
Surgical intervention is necessary for the development of:
- cancer, polyposis, to prolong the patient’s life;
- - inflammation of hernial protrusions on the intestinal walls due to infection;
- pathological inflammation causing erosive damage or death of areas of the rectum;
- bleeding and intestinal blockages;
- Crohn's disease - chronic pathology transmural type;
- insufficient blood supply to the rectal part due to the presence of blood clots in the main arteries of the organ.
Also the reason surgical intervention may be explained:
- abdominal injuries of various types;
- complications after other attempts at intestinal restoration.
Types of resection
There are several ways:
- Anterior rectal resection. This method removes rectal cancer located at the top. To do this, an incision is made in the lower abdomen, part of the rectum and S-shaped section is removed. After excision, an anastomosis is created to connect the ends of the intestine.
- Lower anterior abdominal resection. The method is used when operating on the middle and lower part of the rectum. The entire rectum, mesentery, anal canal, and sphincter muscle are removed through the lower abdomen. This approach is often necessary for complete removal of cancer with warning possible relapse. Partial excision of the rectal ampulla involves the creation of an anastomosis between the bottom of the rectum and the anal canal. At the same time, the sphincter muscle is preserved, so there is no problem with fecal incontinence after the intervention.
- Abdominal perineal extirpation of the rectum. It is performed by making an incision in the abdomen and perineum near the anus. The rectal ampulla, anal canal, and sphincter muscles are completely excised. To ensure the normal passage of stool with emptying, a colostomy is formed. Previously, this operation was performed for any type of tumor in the rectum.
- Complete extirpation (excision) of an organ. This type of surgery is used for tumors located in the rectum no further than 50 mm from the anus. To make it easier for stool to pass after the intervention and to correct stool incontinence, an artificial stoma is created.
- Sphincter-sparing operations. The method avoids the need to create a channel for feces drainage. The operation is performed using the latest staplers.
- Transanal excision. The method involves eliminating the pathology through the anus, but preserving the functions of the sphincter. The affected area, located in the lower part of the rectum, is removed with special instruments. The incision line is sutured with two stitches. The operation is suitable for excision of small tumors with non-aggressive development and in the absence of metastases in the lymph nodes.
- Removing cracks. The method is more often used to cure hemorrhoids, chronic and acute cracking of the anal canal.
- Bougienage. The method involves forced expansion of the rectum with its pathological narrowing.
How long it will take to perform one type of operation or another depends on the severity of the case and the degree of tissue damage. IN postoperative period Definitely requires care and a special diet.
Complete removal
Removal of the rectum is called proctectomy. The procedure is complex and is used in extreme cases. Reasons for appointment:
- oncology;
- necrosis (death) of tissues;
- rectal prolapse or prolapse of the intestine without the ability to set the organ back and with ineffectiveness conservative methods treatment.
Proctectomy is carried out to areas with tissues unaffected by pathology with the removal of adjacent lymph nodes. If the pathogenic process is very widespread, you should get rid of the anal sphincter. To eliminate complications after resection of the sphincter muscle, such as fecal incontinence, a stoma is formed to drain the intestinal contents into a special portable colostomy bag. At the same time, the fatty tissue is excised from the affected intestine, which reduces the risk of relapse.
There are two ways to completely remove the rectum, such as:
- sphincter-preserving surgery of the anterior or transanal type;
- abdominal anal resection of the rectum with excision of the anus and surrounding muscle structures, which requires the creation of a permanent colostomy.
Under favorable circumstances, the operation will last up to 3 hours. If a colostomy is performed, nutrition after rectal surgery should provide the body with the necessary substances without creating problems with bowel movements.
The rectal ampulla can be removed by laparoscopic resection. Treatment with this method is minimally invasive, but requires specific equipment and highly qualified medical staff. To perform laparoscopic resection, small incisions are made in the abdominal wall. If there are appropriate conditions for carrying out and the required equipment, laparoscopic surgery gives a positive outcome, it can reduce rehabilitation time, reduce the incidence of complications, and quickly improve the well-being of operated patients. Therefore, laparoscopic surgery is one of the most popular methods.
Before any operation for complete resection of the rectum, bowel preparation is necessary. To do this, laxatives are used and enemas are given to completely empty the intestines. This will eliminate the risk of complications during surgical treatment.
Repairing cracks
The procedure is necessary for the surgical removal of any type of fissures in the anal canal. Appointed in the absence positive result conservative treatment methods. The objectives of the method are to remove the formed scar, which prevents the proper healing of an open crack. To do this, a fresh incision is made, which reverses the process into the acute phase. The problem is then cured with medication.
The operation should be performed under local or general anesthesia. The technique is selected by the doctor according to individual characteristics patient: availability hemorrhoids, individual tolerance to anesthesia, etc. For the operation, the following are used:
- scalpel;
- ultrasonic scalpel;
- electrocoagulator;
- laser.
The result does not depend on what instrument the doctor used to perform the operation. The procedure lasts on average 8 minutes. The time may vary depending on the type of anesthesia used. Longer operations are necessary in cases where the patient is diagnosed with hemorrhoids. In this case, resection anal fissure includes simultaneous removal of hemorrhoids. Special care promotes wound healing. Full recovery perhaps in 3-6 weeks.
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In this operation, the distal (or most) part is removed sigmoid colon, proximal half of the rectum with pararectal tissue and regional lymph nodes. The initial stages of mobilization are described above. After separation of the tissue and peritoneum, the iliac arteries and veins to the level of their bifurcations, as well as both ureters at the place of their intersection with the vessels, become visible. The loops are retracted to the right in the cranial direction small intestine. The sigmoid colon is brought into the wound and a lyre-shaped incision is made in the peritoneum in the area of the root of its mesentery. The sigmoid colon and proximal half of the rectum are mobilized. To avoid tension in the area of the future anastomosis, it is sometimes necessary to mobilize the entire left half of the colon.
After crossing the vessels of the sigmoid colon, as well as the superior rectal arteries and veins, the rectum is isolated within the fascia proper. The rectal resection line should be at least 4 cm below the lower edge of the tumor. At this point, the intestinal wall is freed from fatty tissue in an area approximately 2 cm wide. Sutures will subsequently be placed in this area. The border of the intersection of the sigmoid colon should be at least 8-10 cm proximal to the edge of the tumor. At the intersection, the wall of the sigmoid colon is also freed from the mesentery and omental segments. In this case, it is necessary to ensure good blood supply to the remaining section of the intestine.
Stapling devices (UKL, UO or analogues) are applied to the remaining segments of the intestine, and two crushing clamps are applied to the removed segments. The abdominal cavity is isolated with tampons and napkins. The intestinal wall is cut with a scalpel. The cut surface is treated with an antiseptic. The part of the intestine affected by the tumor is removed in one block with the fiber and regional lymph nodes located in it.
The crossed ends of the sigmoid and rectum are brought closer together, and an end-to-end interintestinal anastomosis is performed. It should be taken into account that the diameters of the anastomosed intestinal lumens may not always coincide. In these cases, the intestine with a wider lumen (usually the rectum) is anastomosed, stitching it strictly cross section with perpendicular sutures, and the intestine with a narrower lumen - in an oblique section. As a rule, double-row sutures are required. First, separate interrupted sutures are applied to the posterior semicircle of the anastomosis. Then the intestinal lumen is crossed below the applied hardware suture, the section of the mucous membrane is treated with an antiseptic and an internal row of sutures is applied through all layers of the intestinal wall.
In this case, separate synthetic sutures with knots into the intestinal lumen, a continuous wrapping suture made of absorbable material, and also a screw-in furrier's suture are used. The choice of suture type does not have a significant impact on the outcome of the operation. It is important that the edges of the mucous membrane are well aligned. After suturing the intestinal lumen, separate seromuscular sutures are placed on the anterior semicircle of the anastomosis.
IN Lately The use of a mechanical suture for anterior resection of the rectum is becoming increasingly popular. The technique of hardware colorectal anastomosis described by M. Ravitcli and F. Steichem (1982) has become very common. Despite the existing individual warnings about the dangers of a mechanical suture, a mechanical suture is currently preferable to a manual suture when performing anterior resection of the rectum. Behind last years Improved devices appeared and the anastomotic technique became much simpler. Early studies suggesting that the recurrence rate increases with the use of hardware sutures have not been confirmed. So N.Wolmark et.al. (1986) compared the results of manual and mechanical suture in radical rectal resections for cancer. At the same time, no statistically significant difference was revealed in the frequency of relapses, the time of their appearance and the survival of patients.
Regardless of the method of anastomosis, the operation ends with thorough hemostasis and washing of the pelvic cavity with an antiseptic solution. A long clamp is inserted presacrally through a separate skin incision above the coccyx. Use it to grab the drainage tube and pull it out. The internal end of the drain should be placed distal to the anastomosis. The layers of the parietal peritoneum are sutured with separate sutures, thus placing the anastomosis in the pelvic cavity retroperitoneally. The issue of applying a decompression transversostomy or transanal insertion of a decompression probe is decided individually.
V. D. Ivanova, A. V. Kolsanov, S.S. Chaplygin, P.P. Yunusov, A.A. Dubinin, I.A. Bardovsky, S. N. Larionova
With a disease such as rectal cancer, surgery is often the only method of saving the patient’s life. To do this, the part of the organ affected by the tumor, the surrounding fatty tissue and regional lymph nodes are removed. Removing some volumes of healthy tissue helps reduce the risk of relapse.
Surgeries for colorectal cancer can be performed different ways, it all depends on the stage and prevalence pathological process. For small tumors, local excision is possible; for large tumors, extensive resection is indicated. It is possible to perform operations that do not require the formation of a permanent colostomy.
These include transanal excision and anterior resection. If the sphincters cannot be preserved, abdominal-perineal extirpation is performed, which requires the creation of a permanent colostomy.
Types of operations for rectal cancer
In anterior resection, an incision is made abdominal wall, through which the upper parts of the rectum and the lower parts of the sigmoid are removed. The ends are sutured and an anastomosis is formed. Low anterior resection is used when the lower and middle part of the organ is affected.
As in the previous case, an incision is made in the lower abdomen, but large amounts of tissue must be removed. The entire rectum, mesentery, and anal sphincter muscles are removed. Total mesorectumectomy is the main method of treating cancer of this location.
Recurrence of a tumor after such an intervention is extremely rare. After resection of the rectum, its lower section is sutured to the end of the colon. In this case, a permanent stoma is not formed; the operation is considered sphincter-preserving.
However, there is a need to create a temporary ileostomy, which promotes normal healing of the anastomosis.
Perineal extirpation is an operation for rectal cancer that was once very popular. During surgical intervention 2 incisions are made: one in the abdominal wall, the second near the anus. Extirpation implies complete removal rectum, anal canal and sphincter muscles.
Important! The intestines lose their inherent functions, so a permanent colostomy is created to remove feces.
Currently, doctors rarely use surgical interventions of this type, giving preference to sphincter-preserving ones. The use of modern equipment simplifies the operation. Removal malignant tumors small sizes can be performed through the anal canal.
It is impossible to do without abdominal-perineal extirpation for large widespread neoplasms growing into the muscles of the pelvic floor and anal sphincter. The number of operations performed under this scheme decreases annually.
In most cases, anterior resection successfully replaces extirpation. This does not affect the patient's life expectancy or the risk of relapse. There is no need to create a permanent colostomy, which would lead to disability of the patient.
Transanal tumor removal is performed on early stages rectal cancer. As with other sphincter-sparing operations, a permanent colostomy is not created. During the operation, only the part of the intestinal wall affected by the tumor is removed.
The instruments are inserted through the anal canal, which makes the intervention less traumatic. After removing the affected tissue, the defect is repaired using several sutures. It is impossible to remove regional lymph nodes with such a surgical intervention; it is not used at stages 3-4 of cancer.
Consult your doctor! If the surrounding tissue contains even a small number of atypical cells, the tumor will certainly reappear. Transanal removal is indicated only for early stages of non-aggressive forms of cancer.
Some patients try to avoid surgery due to fears associated with the inability to control bowel movements. Surgery to remove rectal cancer is the only effective way treatment, so you can’t refuse it.
Minimally invasive procedures - laser or electrical destruction, radiation and chemotherapy - are auxiliary methods, they do not contribute to healing.
Complications of the operation
The surgeon may encounter some difficulties when performing the operation. The rectum is located in a narrow space, surrounded by organs genitourinary system, lateral walls of the pelvis and spine.
Extirpation of this organ is a difficult process to perform. Its main complications can be considered incomplete removal of the tumor, damage to nerve endings and nearby organs. After surgery, urinary incontinence, erectile dysfunction, and internal bleeding may occur.
In most clinics, surgical interventions are performed blindly; the surgeon separates the intestine from the surrounding tissue by touch. This is considered the main reason for the spread cancer cells throughout the body.
Application endoscopic equipment, which allows operations under video control, solves this problem.
Life after surgery
The quality of a person’s life after surgical treatment of rectal cancer depends entirely on the chosen method. The formation of a permanent colostomy affects not only the physical, but also the emotional condition patient.
That is why oncologists try to choose sphincter-preserving interventions, in which the anal canal is connected to the upper rectum by anastomosis. However, if it is not possible to do without removing the stoma to the anterior abdominal wall, reconstructive surgery must be postponed until the condition stabilizes.
The course of the rehabilitation period depends on the nature of the surgical intervention. At emergency operations performed for internal bleeding, perforation of walls or blockage of the intestine recovery period takes longer than planned ones.
Recurrence of the disease most often occurs in the first 5 years after completion of treatment.
Timely detection of cancer cells is facilitated by long-term follow-up after surgery. It is necessary for diagnosing and eliminating functional disorders.
You will have to visit an oncologist at least once every 3 months for the first 2 years and every six months for the next 3 years. 5 years after the operation, you can undergo examination once a year. The patient's medical examination plan includes an ultrasound examination of the organs. abdominal cavity and regional lymph nodes, blood serum analysis for the content of SA and CEA.
If tumor markers increase or other pathological changes in the body, CT and MRI are necessary.
Regular visits to the doctor are needed not only for monitoring physical condition. Oncological diseases negatively affect the psycho-emotional mood, contribute to the development depressive disorders and anxious thoughts.
The doctor must instill in the patient confidence in a successful outcome. When a permanent colostomy is formed, a person needs measures aimed at social adaptation.
Carrying out the operation
The operation is performed under general anesthesia. The surgeon performs a dissection of the anterior abdominal wall and performs an inspection of the intestine. Then the segment of the rectum along with the tumor is removed, and part of the sigmoid and rectum is sutured with a double-row suture. As a result of the operation, natural bowel movements and the sphincter are preserved.
Postoperative period
The length of hospital stay can be about 5-10 days. Immediately after the operation, the patient is admitted to the department intensive care for a few days. During this period, nutrition is administered intravenously, and the rectum is regularly washed with antiseptics. You also need to follow a diet in the first months after surgery.
Creating a connection between the sigmoid and rectum deep in the pelvis is technically difficult. This operation requires excellent qualifications of the surgeon and appropriate equipment of the clinic. The scientific and practical surgery center has all the necessary equipment. Specially selected surgical equipment, comfortable hospital and intensive care rooms, maximize the positive attitude of patients and their rapid recovery after the intervention.
