Procedures

Advanced Format:
Abdominoperineal Resection

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 rectumand
diseases are too low for use of EEA stapling devices

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.

Abdominoperineal
Resection

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)

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
positioningcan 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

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

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

Surgical Intervention: Supplies contd

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

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

Surgical Intervention: Equipment

Specific
ESU, Suction, Stirrups

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!

Surgical Intervention: Procedure Steps

Contd
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

Surgical Intervention: Procedure Steps

Contd
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.

Surgical Intervention: Procedure Steps

Contd
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.

Surgical Intervention: Procedure Steps

Contd
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

Heavy pursestring suture around

anus to occlude it

Area of incision around the rectum

Surgical Intervention: Procedure Steps

Contd
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.

Colon and Rectum are delivered

through the perineal resection

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

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

Specimen & Care

Identified as anus, rectum, and sigmoid
colon
Handled: Usually routine/in formalin
Need a large container for storage and
transportformalin should cover specimen

References

Alexanders p. 385
Berry and Kohn p. 665
Fuller pp. 262-263
STST p. 425-426