Extirpation of the rectum - removing it completely from the human body. It is used in the treatment of colorectal cancer. The operation is considered technically difficult due to the topography of the rectum, since it is located close to the walls of the pelvis and fascia of the sacrum. In addition, it is adjacent to the bladder, large blood vessels, and even the ureters, in men with a prostate, in women with a uterus, so there is always a risk of damage to the rectum when they are amputated. This is especially true for obesity and a narrow pelvis. The operation is used only if there is no result from other methods of treatment.
Indications for surgery
Extirpation of the rectum is carried out:
- in advanced cases of colorectal cancer;
- with tissue necrotization;
- with non-healing areas of the prolapsed rectum.
The choice of the type of operation is determined by the distance the tumor is from the anus. If it does not exceed 6-7 cm, BPE (abdominal perineal extirpation of the rectum) is used. It is also called the Kenya-Miles operation.
If the tumor is higher (but not higher than 10 cm), this makes it possible to carry out a sphincter-preserving operation - BPE with reduction of sigma.
Well, even with a tumor 10-12 cm higher than the anus, another 1 type of operation is performed with the sphincter (pulp) preserved - anterior and lower resection, Hartmann's surgery, etc.
Hartmann's operation
With this type of intervention, an abdominal incision is made along the anterior wall below the middle. The sigmoid and upper rectum secrete. Rectum is cut below the tumor. The stump is sutured. The affected area of the intestine is cut off and a stoma is placed in the left iliac region.
But more often than others, abdominal-perineal extirpation of the rectum is used, in 50-60% of all extirpations performed.
It is performed by a two-team method. Indications for WPT:
- rectal cancer in localization up to 6 cm from the anus;
- overgrown and large tumors involving pararectal fiber;
- cancer recurrence after sphincter-preserving operations.
In this case, the tumor level does not play a role. Contraindication can only be decompensation of the heart and liver.
The course of surgery for extirpation of the rectum
The affected area is excised to the border of healthy tissue. Pararectal fiber, regional lymph nodes, and some part of healthy tissue are removed from the gut as well. This is done to reduce tumor recurrence. With a large tumor, removal of the sphincter is required. In this case, an artificial outlet for stool is formed to empty the intestines - the stoma. It is attached to the receiver.
Extirpation of the rectum is the operation of choice, when deciding on the preservation of the sphincter or its removal, because the types of operations, respectively, are only two:
- Sphincter-preserving is anterior and inferior resection, transanal excision.
- With the removal of the sphincter - abdominal-perineal extirpation of the rectum (BPE), where instead of a sphincter a stoma is created; pelvic examination - removal of the bladder and genitals with the intestine, if they are affected.
Front resection
During this manipulation, only part of the affected intestine is removed through the abdominal wall. This technique is applicable for tumor localization at a distance of 10-12 cm from the anus. The method consists in the following: the upper part of the rectum and the lower part of the sigma are excised, and the remaining edges are stitched together. As a result, the intestines are slightly shortened.
Low anterior resection is used for middle or lower tumor levels. The affected areas of the intestine with the mesentery are removed. The remaining edge of the colon and straight stitch. With such an operation, the risk of relapse is minimal.
Transanal excision is successful in small non-aggressive tumors in the lower rectum ampoule. The affected area on the wall is removed, and the intestine is sutured.
Abdominal perineal extirpation of the rectum - Kenyu-Miles operation. The name is given for 2 ongoing mandatory sections - in the peritoneum and anus through the perineum. With it, the sphincter is replaced by a stoma. It is carried out with large tumors, a two-team method. Resection is carried out immediately from two sides - through the front wall of the abdomen and through the perineum.
Start of operation
The course of the operation during extirpation of the rectum:
- The patient is on his back, his legs are bent at the knees and hips, divorced and fixed to the stands. The coccyx protrudes beyond the edge of the table.
- First, catheterization of the bladder is performed: the catheter is attached to the thigh with a band-aid. It is connected to a rubber tube lowered into a jar, where urine is diverted during surgery.
- Anesthesia: endotracheal or spinal anesthesia.
Intra-abdominal extirpation
After the lower middle laparotomy, the abdominal cavity is examined and revised to establish operability. The table is tilted at an angle of 45 degrees to the left (Trendelenburg position) - this allows you to raise the pelvis above the head end. The small intestine is pushed up and to the right and laid with gauze napkins.
Sigma is excised above the tumor by 15 cm. A cap or glove is put on the bowel stump and bandaged. Then the descending (proximal) section of the sigma is sutured to the parietal peritoneum, forming a colostomy (unnatural anus for subsequent excretion of feces). A stoma is formed along the oblique incision of the left abdominal wall.
A hand is introduced into the presacral space and it separates the rectum from the sacral fascia.
The hand should be folded boat-like, with a spatula. This is done without sharp objects because it can easily damage the pelvic fascia with veins, and then bleeding can occur.
With scissors, tupferomerectum in front is separated from the wall of the bladder, then in men - from the prostate, in women - from the vagina and uterus. At the desired level of resection, the colon is cut, the stump is ligated.
To prevent infection, put on a stump cap or a rubber sterile glove. The connection is tightly bandaged with thread.
The lower distal end of the intestine is lowered into the pelvis and the peritoneum is sutured above it. The incision on the abdominal wall is stitched in layers.
Crotch stage
The perineal incision begins. First, a circular tissue incision is made around the anus, then the rectum with the remains of the sigma is removed + the surrounding tissue.
The crotch and anus is tightly sutured. The anus is sutured with silk ligatures.
After this, the rectum is mobilized from below, i.e., in the perineum. The lumen of the intestine is sealed - for this they retreat from the anus 3-4 cm, the skin is cut along the oval, subcutaneous tissue with it. The skin edges of the intestine are sutured with additional silk knotted sutures, which are tied on a cloth moistened with furagin solution. The entire abdominal cavity and pelvis are also washed (2 l of a 0.1% solution of furagin).
The laparotomy incision is sutured in layers, leaving a place for antibiotic administration in the corners. A rubber tube is left for drainage in the sacral space. On day 3, it is connected to a low-power vacuum suction in the chamber. Suction leads to a rapid decay of the cavity. The drainage tube is removed only for 5-6 days.
Sutures are removed on the 10th day. The appearance of bleeding, increased bleeding, or the attachment of an infection require the use of tampons and a rubber drainage tube. Seams at the same time, even rare ones, do not impose.
Releasing operation
Abdominal-anal extirpation of the rectum with sigma reduction and sphincter retention - laparotomy. It can be done when the tumor is above 7 cm from the sphincter. At a distance of 5-6 cm from the upper border of the tumor, the intestine is ligated, then the level of a healthy sigma section is determined - this is the reduced intestine. In a straightened form, it should freely reach the inguinal ligament. Its color and pulsation of blood vessels should not be disturbed.
According to the level of normal blood circulation, black ligatures are placed for identification. If these conditions do not exist, Kenyu-Miles surgery is performed, in which the mobilized sigma is placed in the small pelvis and the parietal peritoneum is sutured. The wound of the abdominal wall is covered with a large wet towel.
Laparoscopic method
BPE today is the only substantiated operation of the lower intestinal ampoule from the position of oncoradicalism. But she also has disadvantages:
- major postoperative injury;
- it is difficult to fully distinguish between abdominal organs and fiber;
- frequent purulent wound infections.
Therefore, new methods of approach to such operations have been developed. Endosurgeons proposed to perform the abdominal stage of BPT in a laparoscopic manner. This has several advantages:
- morbidity decreases markedly;
- complications of purulent processes are reduced at times;
- the patient’s stay in the department is reduced, and rehabilitation is accelerated.
With laparoscopic abdominal-perineal extirpation of the rectum, a certain amount of air is pumped into the abdominal cavity. Then only a few small incisions are made in the anterior abdominal wall. A laparoscope with a camera equipped with a backlight is introduced through one of them. And through other incisions, surgical instruments are introduced.
What is a stoma
Extirpation of the rectum with the formation of a stoma is a surgically created hole in the front wall of the abdomen, to which the capacity of the colostomy receiver is attached. Earlier feces were held back by the sphincter.
This hole is formed from the free end of the intestine. Stoma is temporary and permanent.
Temporary is needed only for the period of postoperative regeneration of the rectum. After healing, the stoma closes again surgically after a few months. A stoma becomes permanent with BPE if the tumor was in the lower rectal ampoule.
What is the extralevator method
According to the standard technique of abdominal-perineal extirpation of the rectum during the operation, the rectum is separated by the mesorectal fascia to the levators, and then the intestine is isolated from the levators to the anus.
When a tumor grows into the muscle wall of the intestine, this pathway is very likely to lead to perforation of the intestine at the site of the tumor.
Since 2007, a modification of the WPT - eBPE operation has begun to be applied, which means the extralevator WPT. Instead of a circular section of the anus, a cylindrical WPT was proposed. The idea of the operation is that it is not necessary to “unpack” the intestine with the tumor from the levators, but it is better to remove it together with the levators, cutting them off from the place of attachment - this is the extralevator abdominal-perineal extirpation of the rectum. The patient during this manipulation is on his stomach. With this technique, the risk of bowel perforation decreases sharply from 23% to 4%.
Condition after surgery
Rehabilitation of the body begins even before the patient is withdrawn to the ward, in the intensive care unit. The patient gradually moves away from anesthesia.
The staff ensures that no bleeding occurs. Pain and discomfort in the wound area are relieved by analgesics.
For 2 days the doctor allows you to sit in bed. A long stay in a horizontal state only harms.
In the wound for several days there is drainage for the outflow of the collecting transudate. All drugs are administered only with droppers.
Complications after extirpation
Most often, bleeding, damage to adjacent organs, hernia of the midline of the abdomen, non-healing of sutures, thrombosis, ischuria. Ishuria - the impossibility of self-emptying the bladder, despite its overcrowding due to trauma to the nerve endings responsible for the work of the urea.
Among other complications:
- suppuration of the suture;
- re-growth of the tumor;
- infection of the abdominal cavity.
The incidence of adverse effects of abdominal-perineal extirpation of the rectum is 10-15%.
Operation Failures
This phenomenon also occurs on the part of some patients. The origin of the fear of the operation is psychological - the patient is ashamed that he will always have a colostomy receiver. He will not be able to control bowel movements himself. But we are talking about extending life, and the choice is made by the patient himself. The cost of extended extirpation of the rectum in Moscow ranges from 31 to 70 thousand rubles in various leading clinics. The percentage of 5-year survival after surgery is 30-40%.
Additional treatments
To at least slightly reduce the risk of tumor return and increase the effectiveness of rectal extirpation surgery, treatment methods are supplemented by radiation or chemotherapy. They are prescribed before or after surgery. According to the reviews of the patients themselves, such a complex reduces the frequency of relapses.
Chemotherapy
Chemotherapy is the use of special complexes of drugs that are prescribed to cancer patients. The disadvantage of this method is that chemistry acts on sick and healthy cells, causing side effects. Atypical cells are destroyed, the growth of metastases and the tumor itself is also reduced, but the well-being suffers noticeably. Although the progression of the tumor slows down.
There are 2 types of chemotherapy: adjuvant and neoadjuvant.
In the first case, this is the destruction of the tumor with the poison of cytostatics, and it is carried out for prophylactic purposes after surgery. In the second, drugs are prescribed to reduce the size of the tumor before surgery.
As the main treatment, chemotherapy is used when surgery is not possible. The procedure is the intravenous infusion of whole cocktails of drugs that kill atypical cells.
Radiation therapy
According to official studies, the recurrence rate after surgery is from 20 to 50%. To prevent this, apply another method of treatment - radiation therapy. As a treatment using x-rays or electron beams - sources of ionizing radiation.
The essence of the method is that radiation is more harmful for cancer cells than for healthy ones. In atypical cells, mutations unfavorable for them occur, leading them to death. The course can last 4-5 weeks. If it turned out to be ineffective, they finish the treatment altogether and do not use other methods.
Complications of additional methods
These additional methods are aggressive. Therefore, they themselves can give complications:
- dyspeptic symptoms in the form of constipation or diarrhea;
- persistent vomiting and nausea;
- weakness and dizziness;
- burns may occur at the site of exposure to the rays;
- increased urge to the toilet.
After the end of the course of treatment, this symptomatology gradually disappears.
Electrostatic Cancer Treatment
This is a completely new method of treatment, still little known. Russian scientists have developed a device that acts on tumor cells with an electrostatic field. The positive effect for the patient is proven by numerous tests and studies.
To identify diseases in the initial stages, medical examinations should be regularly performed. Early diagnosis will help to avoid many problems in treatment.