1. Procedures Advanced Format: Abdominoperineal Resection

2. Definition/Purpose of Procedure Through combined abdominal and perineal incisions, the anus, rectum, and sigmoid colon are removed en bloc. Also called Miles Resection The proximal end of the bowel is exteriorized thru a separate stab wound as a colostomy. The distal end is pushed into the hollow of the sacrum and removed via perineum Performed to treat cancer of the lower rectum—and diseases are too low for use of EEA stapling devices

3. Pathophysiology Cancer of lower rectum: usually the lower third of the rectum, but may extend into the anal canal The sigmoid colon is the primary site of colon cancer and is the section of colon most susceptible to volvulus.

4. Abdominoperineal Resection

5. Surgical Intervention: Special Considerations Patient Factors –Requires the formation of a permanent colostomy in the abdominal wall for drainage of bowel contents –An indwelling foley catheter will be inserted and attached to closed drainage –Upper body thermia blanket Room Set-up –Organize the room for space! If 2 teams, one works at abdomen and one works on perineal portion (ABD: ST stands slightly behind assistant and must take special care not to contaminate! Perineal: ST Stands next to surgeon)

6. Surgical Intervention: Positioning Position during procedure: when performed as two simultaneous procedures, modified lithotomy Supplies and equipment –Probable Allen stirrups or “high impact knee-crutch stirrups” for positioning—can be adjusted for knee flexion and extension; Be sure to have additional padding (gel or foam) –Sequential Compression Devices Special considerations: high risk areas: cause pressure to back of knees and lower extremities and may jeopardize the popliteal vessels and nerves

7. Surgical Intervention: Draping/Incision Types of drapes (Depends on position) –Laparotomy and perineal: Under buttocks, folded towels, Lap T-sheet (cut hole for perineal exposure) Order of draping –Abdomen and perineal Special considerations: “clean” closure of abdomen requires regowning, regloving, redraping, and a new minor tray State/Describe incision: Abdominal midline

8. Surgical Intervention: Supplies Specific –Suture: Dexon and silk free ties; 3-0 chromic catgut (colostomy); closure: ) chromic catgut or Dexon –Medications on field (name & purpose) –Catheters & Drains NG tube, Penrose drains (large and med available), Hemovac

9. Surgical Intervention: Supplies cont’d Special –Hemoclip appliers –Extra glove and umbilical tape (for proximal end of specimen before passed thru perineal wound –Vessel loop or umbilical tapes for retraction –Marking pen for stoma site

10. Surgical Intervention: Instruments Specific (If done simultaneously, 2 separate instrument set ups) –Major laparotomy short set –Long instrument set and intestinal set –Rectal set –Possibly a separate minor set for closure

11. Surgical Intervention: Equipment Specific –ESU, Suction, Stirrups

12. Surgical Intervention: Overview of Procedure Steps The abdomen is entered The lesion is located and the bowel mobilized The colon is divided in an area proximal to the lesion A colostomy is performed and the abdomen is closed Through a perineal incision, the lower sigmoid colon, rectum, and anus are mobilized and removed The perineal incision is closed. Be sure to use multiple resources: concise but complete!

13. Surgical Intervention: Procedure Steps Cont’d Mobilization process: isolation of mesenteric tissue and omentum that caused diseased lymph nodes Double-clamp Divide tissue (cut using Metz scissors or ESU) Sections ligated Large blood vessels are clamped and ligated Dissection and mobilization to level of levator muscles in pelvic floor (2) clamps to proximal end of the mobilized area Bowel is divided, distal end placed in pelvis

14. Surgical Intervention: Procedure Steps Cont’d To reconstruct the pelvic floor, a portion of omentum may be sutured to it. Prepare colostomy site by incising small circle in abdomen w/skin knife. Deepened to inner abdomen with cautery. Specimen (small disk) is passed to STSR. Proximal end of bowel is brought through the circular incision and temporarily clamped in place while the abdominal incision is closed in layers.

15. Surgical Intervention: Procedure Steps Cont’d To create colostomy, surgeon everts edges of bowel stoma and sutures edges of skin using interrupted sutures of 3-0 chromic catgut on a fine cutting needle.

16. Surgical Intervention: Procedure Steps Cont’d Perineal portion: surgeon places heavy silk pursestring suture through the anus to occlude it and perineum is incised and deeped with ESU. Large bleeding vessels are double-clamped and ligated w/silk or Dexon Peans are used to grasp bowel attachments. Have sponge sticks and suction at all times during mobilization and dissection. Mobilization continues until surgeon reaches previously mobilized area

17. Heavy pursestring suture around anus to occlude it

18. Area of incision around the rectum

19. Surgical Intervention: Procedure Steps Cont’d The entire specimen is delivered through the perineal incision, then irrigates the wound Present trend is to obliterate the “dead space” with many interrupted sutures; achieve hemostasis One or two Penrose drains are placed in the wound, which is then closed with size 0 chromic catgut or Dexon. Skin is approximated with nonabsorbable suture.

20. Colon and Rectum are delivered through the perineal resection

21. Counts Initial: Sponges, sutures & blades, Instruments First closing Final closing –Sponges –Sutures and Blades –Instruments

22. Dressing, Casting, Immobilizers, Etc. Types & sizes –Abdominal incision and on colostomy:Bulky abdominal pad and gauze sponges –Perineal pad for rectal drainage possibly Type of tape or method of securing

23. Specimen & Care Identified as anus, rectum, and sigmoid colon Handled: Usually routine/in formalin Need a large container for storage and transport—formalin should cover specimen

24. References Alexander’s p. 385 Berry and Kohn p. 665 Fuller pp. 262-263 STST p. 425-426