Operative Flashcards
Lateral sphincterotomy for Anal fissure
- GA/spinal
- No muscle relaxation
- Lithotomy
- 15 ̊ head down
- PR and sigmoidoscopy
- Parks anal retractor to expose lateral canal
- Palpate inter-sphincteric groove in the 3 0’clock position
- Infiltration with 5ml LA with adrenaline in this position
- 1cm incision in the groove over lower edge internal sphincter
- I insert scissors into the submucosa, to separate it from the internal sphincter.
- I then open up inter-sphincteric space, to separate the internal and external sphincters
- I then clamp the isolated internal sphincter to be divided with artery clips for 30 secs, with one blade of the scissors either side of it, I divide the internal sphincter 1cm / or to the top of the fissure not above dentate line/ or the anal valves
- Prescribe stool softeners
Describe your pre-op preparation and procedure for Anterior resection.
Preparation:
Stoma siting by stoma therapist
X match blood
Bowel prep: Fleet enema
DVT: Clexane and SCD and Ab prophylaxis
Urinary catheter
Rectal washout
Shave
Prep perineum as well as abdomen
Drape
Position: Lloyd-Davis, yellow fins. Table based fixed retraction. Initially stand on right side, then left
NB anatomic points: Left ureter, spleen, IMV, duodenum, IMA, autonomic nerves
Procedure:
Main steps broadly are: 1. laparotomy 2. Colonic mobilisation 3. Identification of ureter and ligation of pedicles 4. TME dissection (low and ultralow) 5. Anastomosis 6. Ileostomy (where required)
1. Laparotomy
Midline incision, high if splenic flexure mobilisation
Full laparotomy: assess tumour, spread + other pathology
Pack away small bowel with usually 2 large packs and hold in place with a broad retractor.
2. Colonic mobilization
Using diathermy mobilise sigmoid colon and L colon up to and including the splenic flexure towards centre of wound from lateral peritoneal attachments. This is performed along the white line and is developed medially on the mesocolic fat until IMA is identified with the sympathetic fibers adherent or immediately posterior to it. This allows me to list the root of the mesocolon and IMA off the superior hypogastric plexus and hypogastric nerves.
Full mobilization of splenic flexure is performed by entering the lesser sac above the distal transverse colon and then carrying the dissection laterally until it meets with previous dissection plane
3. Identification of ureter and pedicle ligation
I now Identify + preserve gonadal vessels + Lt ureter which runs under the gonadal vessels and crosses the pelvic brim at bifurcation of the common iliac artery.
Incise right leaf peritoneum, identify Rt ureter if possible
Ligate IMA, staying close to the vessel as the Superior hypogastric plexus lies beneath it.
Twice with 2 2/0 vicryls ties, below origin of L colic artery usually about 1-2cm from Aorta.
Leave apex tie long,
Identify and follow IMV up, ligate, below duodeno-jejunal flexure and edge pancreas.
Select site for proximal anastomosis after check for length (down to distal pubic symphisis)
Skeletonise, and divide mesentery between Criles checking for marginal artery.
Divide Colon with GIA.
Reassess proximal colon for length.
Pack proximal bowel into upper abdo, hold with self-retainer
4. TME dissection
With traction on sigmoid, dissect caudad immediately behind IMA/SRA which leads dissection into pelvis in pre-sacral plane.
Identify the hypogastric nerves as I progress which can usually be felt + seen on S1
Continue TME dissection with diathermy behind rectum as far down as possible
To develop the retro-rectal space, carry dissection round laterally retracting with St Marks x2.
Retraction on bowel with folded swab
Again identify & preserve hypogastric nerves and ureters
Continue the dissection down to levator ani as rectum curves forward (or at least 5cm below tumour)
Incise peritoneal reflection of rectum anteriorly; enter plane between Denonvilliers fascia and seminal vesicles and prostate (or uterus + vagina) with the assistant using the St. Marks retractors for exposure.
Below the seminal vesicles dissect through Denonvilliers on to rectum, when below tumour
Complete lateral plane around rectum
Identify lateral ligaments, clip or diathermy
Need to go 5cm distal to tumour if recto-sigmoid or to where rectum bends acutely forward at coccyx onto levator ani if performing a Low anterior resection.
If a high anterior divide the mesorectum and ligate the Superior rectal vessels
Using TX 55mm or contour stapler on rectum
Apply right angle bowel clamp distal (>1cm) to tumour, above stapler if enough room
Rectal washout with betadine 5%, then fire stapler
Protect wound edges
Divide rectum with scissors above staples, excise specimen.
Check pelvic haemostasis.
5. Anastomosis
Again check enough length to avoid tension - to distal symphysis pubis level and pulsatile blood flow
Clean bowels end with betadine gauze
Size rectum with sizers - direct anastomosis or pouch
Purse string suture with 2/0 prolene
Insert anvil + tie prolene, keep ends long
Make sure bowel not twisted
Stapler introduced PR, positioned
Spike advanced through staple line
Assistant staple with Autosuture CEEA 31 or 33mm OR Ethicon ICS 29mm
(Ethicon 29mm = Autosuture 31mm internal diameter)
Check join with air insufflation: occlude proximal colon, leak test with saline in pelvis, air PR
Check doughnuts
Ensure NO TENSION + haemostasis
Covering spouting ileostomy if low (ensure proximal ileum spouts)
Washout, haemostasis
Blakes drains to pelvis
6. Ileostomy
Bring out ileostomy ensuring proper orientation - I perform this for all low and ultra-low anterior resections and in any other case where there may be danger to the anastomosis or the consequences of a leak justifies an ileostomy.
Close laparotomy - small bites
Mature ileostomy ensuring correct end is spouted.
Colo-anal:
if too low for stapler, use “lone star” anal retractor or sutures passing from anus to inner thigh
incise mucosa circumferentially with diathermy
At dentate line do hand sewn anastomosis
Pouch: fold back 6 cm length vicryl to anterior edge fire 80mm TLC or 75mm GIA up
