Editing Abdominoperineal resection


Abdominoperineal resection aka Miles procedure

== Pre-op ==

* Mark colostomy site

== Prep ==

* GA, IV Abx, IDC, TEDS/SCDS
* Lloyd-Davies position
* DRE to confirm distance of     cancer from AV

== '''Technique:''' ==

=== '''Abdominal     resection - supine - laparoscopic''' ===

** IMA divided
** Descending colon mobilised      and divided above the rectosigmoid junction, but with enough length to      reach pubis (enough length for stoma)
** Rectum dissected according      to TME principles to the level of levator ani.
** Colostomy created and      abdomen closed.

=== '''Perineal     resection - change to prone''' ===

** Close anus with purse-string      suture to prevent leakage
** Mark landmarks: ischial      tuberosities, coccyx, perineal body
** Elliptical or circular      incision made around anus, which is then resected an bloc with the      sphincter, and aiming to excise up to ischial      tuberosities/coccyx/perineal body. Careful not to cone the dissection.
** Continue circumferential      dissection, but posterior is easiest - less important structures
*** Lateral: deepen to expose       ischiorectal fossa and coccyx, with self-retainer for help. Ischiorectal       fossa tissue should be areolar and avascular, except for branches of       inferior rectal artery crossing to anus.
*** Posterior: through the       anococcygeal ligament in front of presacral fascia, until the abdominal       plane of dissection is reached
*** Anterior: deepen incision       anteriorly through perineal body. Stay behind the line of transverse       perineal muscles, and aim towards the sacral promontory.. If       bulbospongiosus is seen, you are too far anterior. Dissecting between       anus and urethra/anus and prostate in men, or anus and vagina in women.       Constantly feeling for position of IDC.
** Take a rim of levator muscle      and join abdominal dissection
* Specimen removed through the     pelvic incision
* Fill empty space of pelvis     with omentum
* Close pelvic floor and skin
* Perineal defect can also be     closed with rectus abdominis flap or gracilis muscle flap or IGAM flap     (inferior gluteal artery myocutaneous flap)

[[Category:Colorectal]]