Exteriorisation of the Specimen

Once the rectum has been divided, a mini-laparoto-my is performed. The mini-laparotomy can be either a Pfannestiel incision or a supra-umbilical midline incision. The Pfannestiel incision has better cosmetic results but cannot be easily extended in case a wider access is needed for some reason, whereas midline laparotomy is very easy to extend, so we recommend the latter for those who are at the beginning of their experience. The laparotomy must be protected to prevent contamination or insemination by neoplastic cells during the extraction of the specimen (Fig. 22). The proximal portion of the colon is resected extra-corporeally and the anvil for the circular stapler is

Fig. 21. The rectum is stapled
Fig. 23. Anastomosis

positioned. The laparotomy is closed, pneumoperi-toneum restored and an end-to-end straight anastomosis is performed (Fig. 23). The anastomotic rings are checked to make sure they are complete through 360°; a pneumatic test is performed, submerging the anastomosis in water and insufflating air through the anus. Two perianastomotic drains are positioned (Fig. 24). Before removing the trocars, it is important to check for bleeding from the insertion sites.

If a handsewn anastomosis is planned, a transanal standard mucosectomy is performed after positioning a Lone Star retractor. The specimen is removed through the minilaparotomy and a pull-through handsewn anastomosis is performed. For Miles procedures, a standard perineal dissection is performed

Fig. 24. The abdomen after anterior resection

and the specimen is removed through the colostomy site or through the perineum.

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