Under this method may be included certain operations for small
epitheliomas low down in the rectum done through the anus. The patient
having been properly prepared, the sphincter is thoroughly dilated; a
circular incision through the entire wall of the gut is made, and the
segment is caught with traction forceps and dragged by an assistant
while the operator frees, by scissors and blunt dissection, to a point
at least one-half inch above the cancer. The free end of the gut is then
tied with strong tape, as the temptation is very great to put your
finger in the bowel as a guide, and thereby invite infection. A deep
dorsal incision is then made, going down to the right of the coccyx
through the post-rectal tissue. The hand is then placed in the sacral
fossa and the structures lifted out into the pelvis, after which this
space is thoroughly packed with gauze to control the bleeding and hold
the structures out of the fossa. The edges of the wound, including each
half of the sphincter which has been cut posteriorly, are held by flat
retractors, while the operator proceeds to dissect the anterior portion
of the rectum loose from its attachments. A sound should be held in the
urethra in men and an assistant's finger in the vagina in women to
prevent wounding these organs. After the gut has been dissected out well
above the tumor, it is caught by clamps and cut off below these.
Bleeding is controlled by ligatures and equal parts of hot water and
alcohol. This newly-exposed gut is then sterilized by pure carbolic acid
and alcohol, or may be seared with cautery. Sometimes the peritoneum can
be stripped off from the rectum and its cavity need not be opened; it is
better, however, to open the cavity at once when the growth extends
above this point. The peritoneum is incised, cut loose from its
attachments close to the rectum, back to the mesorectum, which should be
cut close to the sacrum, in order to avoid the inferior mesenteric
artery. When the gut has been loosened sufficiently above the tumor, it
may be still fastened by two lateral peritoneal reflections, which are
the lateral rectal ligaments, and should be cut at once. The gut is then
brought down and sutured to the anus, and the operator should proceed to
close the peritoneum and restore the planes of the pelvic floor down to
the levator ani by fine catgut sutures. After this has been
accomplished, the anus, which is now well outside the operative field,
should be reopened, the gauze removed, and the gut flushed with a
solution of bichloride or peroxide of hydrogen. Quenu advises that in
amputating each layer should be cut separately, in order to avoid
hemorrhage, but there appears to be no advantage in this; in fact, we
are more likely to meet with deficient blood supply, causing subsequent
sloughing of the gut, than with hemorrhage. The posterior and anterior
portions of the perineal wound are packed with gauze and left open to
assure drainage, and the parts are covered with aseptic pads, held in
position by a well-fitting "T" bandage. A large drainage tube is passed
well up into the rectum, its lower end extending outside of the
dressings, in order to convey the discharges and gases beyond the
operative wound.