A. Huber A.H.C.v. Hochstetter M. Allgower Transsphincteric Surgery of the Rectum Topographical Anatomy and Operation Technique With 31 Figures, Most in Color, in 58 Separate Illustrations Springer-Verlag Berlin Heidelberg NewY ork Tokyo 1984 PD Dr. med. Andreas Huber Chirurgische Klinik, Kantonsspital, CH-6004 Luzern Prof. Dr. Arthur H.C. von Hochstetter Leiter der Abteilung fur topographische und klinische Anatomie, Departement fUr Chirurgie, Kantonsspital, CH-4031 Basel formerly: Professor of Anatomy at the University of Western Ontario, London, Ontario, Canada Prof. Dr. Martin Allgower Departement fUr Chirurgie, Kantonsspitai, CH-4031 Basel Translator: Terry C. Telger, 3054 Vaughan Avenue, Marina, CA 93933/USA Title of the original German edition: Transsphinktere Rektumchirurgie © Springer-Verlag Berlin Heidelberg New York Tokyo 1983 ISBN 3-540-12583-3 / 0-387-12583-3 ISBN-13: 978-3-642-69472-1 e-ISBN-13: 978-3-642-69470-7 DOl: 10.1007/978-3-642-69470-7 Library of Congress Cataloging in Publication Data. Huber, Andreas. Trans sphincteric surgery of the rectum. Translation of: Transsphinktere Rektumchirurgie. Bibliography: p. Includes index. 1. Rectum-Surgery. 2. Anus-Surgery. I. Hochstetter, A.H.C.v. (Arthur H.c.), 1918 -. II. Allg6wer, M. (Martin), 1917 -. Ill. Title. (ONLM: 1. Rectum-Surgery. WI 650 H877t) R0544.H813 1984 617'.555 83-20268 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re use of illustrations, broadcasting, reproduction by photocopying machine or simi lar means, and storage in data banks. Under § 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to 'Verwer tungsgesellschaft Wort', Munich. © Springer-Verlag Berlin Heidelberg 1984 Softcover reprint of the hardcover I st edition 1984 The use of registered names, trademarks, etc. in the publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. 2124/3140-543210 Foreword More than a century ago, Cripps successfully employed the direct and complete division of the anal sphincters as a means of approaching the lower rectum and anal canal, and reported on a series of 36 patients who had been treated in that fashion. Cripps was pleasantly surprised to find good fecal continence in over two-thirds of the patients during later follow-ups, despite the fact that the divided sphincters had not been repaired. The transsphincteric procedure was largely forgotten in subsequent years, however, and only the parasacral proctotomy of Kraske, which spared the anal sphincters, can be said to have gained an established place in the" surgical armamentarium. " It remained for York Mason to redirect the attention of the surgical community to the great potential of the trans sphincteric approach and the excellent continence that can be achieved through adequate repair of the divided sphincters. Having recognized the outstanding practical value of this procedure, we felt it necessary to define more precisely the anatomical prerequisites that would ensure minimum operative bleeding, and to bring the procedure more in line with current knowledge of normal continence and defecation. Dr. A. Huber, in consultation with the director of the Institute for Clinical Anatomy of our surgical department, Prof. A. von Hochstetter, did many months of dissection work on fresh anatomic preparations in an effort to explore and refine the various aspects of the trans sphincteric ap proach. During this time his discoveries were repeatedly tested for clinical relevance in patients suffering from rectal disease. The present, short monograph details the experi ence and insights that have been gained from this process. The major indications for the transsphincteric, "open book" procedure are benign but refractory rectal diseases such as recto vaginal fistulae, benign ulcers, villous ad enomas, marked rectal prolapses, and selected cases of marked rectocele. In the latter condition in particular, it is advantageous to combine an extensive sleeve resection of the rectum with reefing of the puborectalis sling to modify VI Foreword the anorectal angle. If adequate ventilation is maintained in the prone patient, the 2- to 3-hour operation is remarkably well tolerated even by aged individuals. In the case of rectal malignancies, the procedure should be limited to growths which have not spread beyond the rectal wall (DICC T1N2No or Dukes Type A). But the "sacred cow" of a 5-cm distal wall clearance may at last be dispensed with. The fate of a rectal carcinoma hinges on its pararectal spread, and a safety margin of 2 cm is gener ally sufficient for wall resections. Thus, small growths less than 3 cm in diameter that are confined to the bowel wall may be removed by a sphincter-conserving resection up to 5 cm from the anocutaneous junction, relying upon frozen tissue sections to monitor the adequacy of the resection. We personally are very pleased with this addition to our surgical arsenal and hope that it will be equally useful and successful in other hands. Basel, September 1983 Martin Allgower Table of Contents Part I. Transsphincteric Surgery of the Rectum 1 1. Significance 3 2. Definition 4 3. Indications 4 4. Preoperative Preparation 5 5. Postoperative Care 5 6. Follow-up Examinations 5 7. Complications 6 8. Remarks on Continence 6 Part II. Topographical Anatomy 11 Foundamentals and Methods 13 Part III. Operative Technique 41 Part IV. Results and Discussion 59 1. Carcinomas of the Rectum 61 2. Benign and Premalignant Tumors of the Rectum 67 3. Rectal Prolapse 68 4. Fistulae and Strictures 72 5. Traumatic Lesions 74 6. Malformations 76 Bibliography 79 Subject Index 81 Part I Transsphincteric Surgery of the Rectum 1. Significance Surgical removal of diseased tissue from the lower rectum, or the resection of this bowel segment, calls for a highly refined operating technique. This is due mainly to the close proximity and attachments that the lower rectum has with the pelvic floor muscles and the anal sphincters. Together, the rectum, pelvic floor and sphincters comprise an organ system whose function is to ensure normal defecation and anal continence. The challenge to the surgeon is to cure disease in this hard-to-reach area without destroying fecal continence. Transsphincteric exposure of the rectum is a technique which is compatible with this goal. Applied selectively, this procedure offers an excellent chance of a cure without forcing the patient to accept a "preternatural anus." The idea of a transsphincteric approach to the rectum is not new. Various authors had already outlined its basic features by the latter part of the 19th Century. In 1875 Verneuil and Kocher described a posterior exposure of the rectum which required a coccygectomy, and in 1885 Kraske recommended that partial resection of the left ala of the sacrum be added to this procedure. In 1876 Cripps published an essay on the transsphincteric approach to the rectum and reported on 36 patients whose rectal tumors had been removed by that technique. It is interesting to note that, although Cripps made no attempt to suture the divided sphincters, 23 of the 36 patients regained full fecal continence following surgery. Although numerous references were made to this procedure in subsequent years (Bevan 1917; David 1943; Larkin 1959; Oh and Kark 1972), a great many surgeons were reluctant to adopt it, apparently in the belief that division of the levator ani and sphincters would result in permanent anal incontinence. More recently, Mason (1974) published an account of his left parasacral transsphincteric exposure and the excellent results he achieved with it. Since that report, we have been practicing the Mason technique of trans sphincteric rectal surgery at the Kantonsspital Basel, Switzerland, and have obtained equally good results. We feel that the transsphincteric approach will assume an increasingly impor tant place in the anorectal surgery of the future. Given the strict criteria for patient selection, however, it is unlikely that this operation will become routine, at least in the general surgical hospital. Moreover, the pelvis and pelvic floor possess a highly complex and variable anatomy. For example, we have observed large individual differences in the mass and arrangement of the levator ani muscle, as well as in the "perirectal space," which frequently contains a large amount of fat permeated with delicate blood vessels that are highly prone to injury. In the literature on trans sphincteric rectal surgery, anatomical aspects usually are discussed only in highly simplified terms, and questions relating to anatomical details such as the innervation of the pelvic floor frequently go unanswered. In an effort to fill this gap, we have created a combined surgical and anatomical atlas in which a special section has been devoted to the topographic anatomy of the anorectal region. 4 Transsphincteric Surgery of the Rectum 2. Definition Transsphincteric surgery of the rectum refers to procedures in which exposure of the terminal bowel segment is gained through a posterior division of the pelvic floor, possibly combined with an anal sphincterotomy. During the operation the patient is prone with the legs slightly abducted and the hip and knee joints flexed 90° (the Heidelberg position). Through a left parasacral incision, the pelvic floor is opened, and, if necessary, the sphincters are divided so that the distal portion of the rectum and anal canal can be visualized. At the conclusion of the procedure the pelvic floor and sphincters are anatomically repaired so that normal defecation and continence are preserved. 3. Indications Disease The following diseases of the rectum and anal canal are considered to be indica tions for transsphincteric surgery: - Early, low-sited rectal malignancies which are not amenable to a low anterior resection. - Benign and premalignant tumors which cannot be radically removed by the trans anal route. - Rectal prolapse with incontinence. - Rectal fistulae and strictures which cannot be managed by any other method. - Lesions of the pelvic floor and sphincters. - Malformations. Indications are discussed in greater detail in Part IV. Localization The site of the lesion is another important criterion for patient selection. The transsphincteric approach is best suited for lesions located between 4 and 12 cm from the anal verge. Complete division of the sphincters extends the operative field caudally to the pectinate line. Under favorable circumstances, cranial por tions of the rectosigmoid located up to 30 cm from the anal verge can be reached by the transsphincteric route. If this approach does not allow adequate cranial mobilization (which is unlikely with careful preoperative planning), then a laparo tomy will also be required. Turning the patient to the supine position and back to the Heidelberg position is somewhat cumbersome but should not cause serious difficulties if proper precautions are taken. Preoperative Preparation - Postoperative Care - Follow-up Examinations 5 Patients The Heidelberg position is surprisingly well tolerated even by aged and debilitated patients. Assuming that anesthesia is correctly administered, there need be no hesitation in selecting these patients for transsphincteric surgery. The operation lasts about 21/2 hours on the average and apparently is less stressful than a laparotomy, for example. 4. PreoperatiYe Preparation As in any surgical procedure, patient selection, preoperative preparation and post operative care have a critical bearing on the success of the operation. Preoperative preparations include the thorough cleansing of the cQlorectum, preferably by an intestinal lavage of the type generally recommended for colonic surgery. If the passage of fecal matter is significantly impaired by rectal disease, then a three-stage procedure employing a temporary colostomy is advised. We administer prophylactic antibiotics shortly before and during the operation. This is an effective means of preventing infection, provided sufficiently high serum levels are present at the time of operation. An operating table must be made available which allows the patient to be placed in the Heidelberg position. The table setup, the Heidelberg position, and preparation of the operative field are described in Part III. 5. PostoperatiYe Care The trans sphincteric operation is excellently tolerated, and early ambulation is encouraged. Oral nutrition may be started as soon as bowel motility has resumed - usually on about the second postoperative day. Enemas are to be avoided, but mineral oil preparations may be given orally to aid bowel movements. 6. Follow-up Examinations Regular follow-up examinations should be scheduled for the purpose of monitor ing surgical wound healing and testing for continence. Examinations for healing are especially important following the removal of malignant growths and may be conducted as a part of general oncologic aftercare. While the bowel lumen is accessible to inspection through a proctoscope, computerized tomography is the best technique for evaluating the pararectal space, allowing the very early detection of recurrent growths and local metastases.