Extraperitoneal Part Research Articles

Staged surgical treatment of wounds of the extra-abdominal rectum

AIM: to improve the algorithm and results of surgical treatment of combat wounds of the rectum. PATIENTS AND METHODS: thirty-one patients with combat injuries of the rectum were included in the cohort. RESULTS: twenty-seven (87.1 %) patients were discharged in satisfactory condition, 4 (12,9 %) patients died. Sepsis developed in all four patients: in two of them sepsis was on the background of necrotising fasciitis and one had peritonitis. Endoscopic control revealed 10 wounds of the extraperitoneal part of the rectum undiagnosed at the 1st and 2nd stages of medical care. Surgical care included all four main components: diverting stoma, distal washout (mechanical cleansing of the rectum to clear water), suturing of the lesion through perineal access, drainage or tamponisation of the presacral space was done in 20 (64.5 %) patients. Endoluminal VAC therapy was used in 12 patients. In 11 of them, VAC treatment was successful with complete healing of rectal wall wounds. CONCLUSION: the four-component treatment approach is the optimal option for wounds of the extraperitoneal part of the rectum. Diverting stoma and distal bowel washout prevents severe infection. Endoluminal VAC therapy, in some cases, can be used as an alternative to presacral drainage and suturing of the rectal wall lesion.

Peritoneal dialysis catheter placement technique

Correct implantation of a peritoneal dialysis (PD) catheter, among many factors, is the main aspect of the success of this method of renal replacement therapy and the avoidance of complications associated with dialysis access and its mechanical function. There are many types of peritoneal catheters: a simple Tenckhoff catheter, a catheter with a coiled spiral-shaped intraperitoneal part of the coli type, a catheter with a curved extraperitoneal part of the swan-neck type, a self-positioning catheter, a pre-bridge catheter. The article describes implantation techniques for peritoneal dialysis (PD) catheters in renal replacement therapy. Complications associated with Tenckoff's catheter still cause significant morbidity and mortality, necessitating the transition to hemodialysis (HD) treatment.

Spontaneous and uncomplicated anal elimination of a hip pin—a case report

In 2005 a 78-year-old woman was admitted with an undisplaced proximal femoral fracture and was operated with osteosynthesis by 2 hip pins (Smith and Nephew, Tuttlingen, Germany). Postoperatively, she was allowed full weight bearing and left hospital 14 days later. At first follow-up, 8 weeks after surgery, the patient walked with an ambulatory device and admitted that she had some pain. The radiographs showed a displaced fracture (Figure 1A-C). The patient was informed about possible prognosis outcome, but she was satisfied with the progress thus far and refused any kind of further treatment at this point. Figure 1. A. Undislocated primary fracture. B. The day after surgery, showing dislocation. C. Two months postoperatively. D. Six years postoperatively. Follow-ups at 5 and 8 months revealed further displacement of an unhealed fracture. The patient was still not motivated to have further treatment, and no additional follow-up was planned. In June 2011, the patient felt moderate anal discomfort. During defecation the following day, she experienced pain and needed aid from her home-based nurse to extract a foreign body which slipped into the toilet bowl with a metallic sound. With suspicions about the origin of the screw, it was presented to the patient’s GP and she was admitted to our outpatient clinic for further investigation. The patient was completely asymptomatic in the abdomen, and her anal discomfort had disappeared. The radiograph (Figure 1D) revealed only 1 remaining hip pin and the screw presented to us was confirmed to be identical to the missing distal screw implanted in the patient’s left hip 6 years earlier. The fracture was greatly displaced, with no sign of healing and the remaining screw was still in situ; it was displaced, but without any major migration. The skin showed no recent scars or signs of perforation. To avoid further complications, including pelvic migration, the remaining screw was easily removed percutaneously under local anesthesia. In order to reveal any possible intrapelvic damage, and at the same time hoping to track the pathway of the migrated screw, we performed a CT scan (Figure 2A-C) with 3D reconstructions (Figure 3A and B). The CT scans left no doubt regarding the pathway of the screw. The femoral head was perforated with a canal similar to the diameter of the screw and there was a crater in the pelvic bone located in line with the perforation through the femoral head. There was no sign of bowel perforation, but some scar tissue was located between the rectum and the crater surrounding the pelvic perforation. The location of the scar tissue and the pelvic bone perforation indicated a migration into the extraperitoneal part of the colon. Figure 2. CT scans showing the canal through which the hip pin had migrated through the femoral head and the pelvic bone before entering the abdomen. Figure 3. CT reconstruction (3D) of the entry hole through the pelvic bone, identifying the entry point of the screw to the abdomen before entering the rectum on its way to defecation.

Rectum separation in patients with cervical cancer for treatment planning in primary chemo-radiation

PurposeTo proof feasibility of hydrogel application in patients with advanced cervical cancer undergoing chemo-radiation in order to reduce rectal toxicity from external beam radiation as well as brachytherapy.Material and methodsUnder transrectal sonographic guidance five patients with proven cervical cancer underwent hydro gel (20 cc) instillation into the tip of rectovaginal septum adherent to posterior part of the visible cervical tumor. Five days after this procedure all patients underwent T2 weighted transversal and sagittal MRI for brachytherapy planning. MRI protocol included T2 weighted fast spin echo (FSE) imaging in sagittal, coronal and para-axial orientation using an 1.5 Tesla MRI. Separation of anterior rectal wall and cervix was documented.ResultsHydrogel application was uneventful in all patients and no toxicity was reported. Separation ranged from 7 to 26 mm in width (median 10 mm). The length of the separation varied between 18 and 38 mm (median 32 mm). In all patients displacement was seen in the posterior vaginal fornix, and/or at the deepest part of uterine cervix depending on the extension of the cul-de-sac in correlation to the posterior wall of the uterus. In patients with bulky tumor and/or deep (vaginal) extend of peritoneal cavity tumour was seen mainly cranial from the rectovaginal space and therefore above the hydrogeI application. Only in the extra-peritoneal (lower) part of the cervix a good separation could be achieved between the rectum and cervix.ConclusionHydrgel instillation in patients with cervial cancer undergoing chemoradiation is safe and feasible. Because of the loose tissue of the cul-de-sac and its intra- and extraperitoneal part, hydrogel instillation of 20 cc did not result in a sufficient separation of the cervix from anterior wall.

Endoscopic full-thickness resection of the stomach

Endoluminal endoscopic resections of the gastrointestinal (GI) tract have had increasing significance in recent years. Except for the extraperitoneal part of the rectum, endoscopic resections are restricted to the mucosal and submucosal layer to preserve the integrity of the GI tract wall. The SurgAssist is the first flexible stapling device consisting of a 2,000-mm-long flexible shaft and a stapling magazine that can be positioned intraluminally and used with a remote control. To prove the principle, we investigated the endoluminal application of an endoscopically assisted and intraluminally visualized full-thickness resection of the gastric wall in a pilot study of three pigs and a series of three human exenterates. Full-thickness resection of the gastric wall in pigs can be performed with the SurgAssist flexible stapling device from an endoluminal access. However, due to the small lumen of the esophagus, the simultaneous transesophageal introduction of the stapler shaft and gastroscope is not possible in pigs. The same procedure in three human exenterates showed that the simultaneous introduction of the flexible stapler and a standard gastroscope could be achieved without damaging the esophageal wall. Full-thickness resections of up to 4 x 4 cm were carried out with the use of two or three stapler magazines. The resulting sutures were found to be airtight upon endoscopic inflation of the stomach. The clinical use of the SurgAssist intraluminal stapling device for endoscopic full-thickness resection of the gastric wall seems applicable for lesions in suitable locations of the stomach. Gastrointestinal stroma tumors and T1 tumors of the lower gastric corpus and antrum region are possible indications.

Ventral Bladder Hernia Following Tubal Ligation

While involvement of the bladder in inguinal hernias is relatively common (1% to 10% incidence), reports of midline bladder hernias are rare.1–3 Such hernias are classified according to the relationship of the hernia to the peritoneum. The more common paraperitoneal bladder hernia involves the extraperitoneal part of the bladder that lies along the medial aspect of the hernial sac. In the intraperitoneal form the bladder is completely covered by peritoneum. The least common extraperitoneal form has no peritoneal covering.3 To our knowledge we report the first case of ventral bladder hernia following tubal ligation. CASE REPORT A 64-year-old female presented with a right lower quadrant mass 2 years in duration, and recent onset of dysuria and chills. Pressure on the mass caused suprapubic discomfort and an urge to urinate. History was significant for breast cancer, recurrent urinary tract infection and a tubal ligation 10 years previously. On physical examination the patient was obese and a 10 cm. mass was palpated in the right lower quadrant 2 cm. from the midline. The mass was believed to be protruding through the fascia of the abdominal wall and was nonreducible and tender on palpation. There was a well healed 2 cm. infraumbilical midline incision consistent with tubal ligation. There were no peritoneal signs, no inguinal or femoral hernias, and bowel sounds were present. Urinalysis revealed pyuria, bacteriuria and positive nitrites. Urine cultures yielded Escherichia coli. The patient was treated with ciprofloxacin for 5 days, which relieved the irritative voiding symptoms. Computerized tomography (CT) of the abdomen and pelvis showed a ventral abdominal wall hernia in the right lower quadrant that contained bladder (fig. 1). Cystography confirmed these findings (fig. 2). Ventral bladder hernia repair was performed through a Pfannenstiel incision. The abdominal wall fascial defect was identified and the bladder hernia was dissected off of the surrounding tissue. Attempts were made to reduce the bladder hernia without success and, thus, it was necessary to excise the segment of herniated bladder at the level of the fascial defect. The bladder was then mobilized from the abdominal wall fascial defect and closed, and the abdominal wall fascial defect was repaired. A layer of perivesical fat was left over the bladder suture line. A suprapubic tube was left indwelling for 10 days to drain the bladder. DISCUSSION

Transanal full-thickness excision of rectal tumours: should the defect be sutured? a randomized controlled trial.

PURPOSE: It is generally recommended that the defect, after full thickness total wall excision of a tumour located in the extraperitoneal part of the rectum, should be sutured. There is a lack of controlled studies however, supporting this approach. The aim of this study was to compare the results obtained in patients after peranal local excision of rectal tumours whose defect were sutured with those that were not. METHODS: 44 patients were prospectively randomized to group A: The defect is closed; Group B: Defect left un-sutured. Pre-operative test were digital examination, proctoscopy and endorectal ultrasound. Local full-thickness excision was performed mainly with the Transanal Endoscopic Microsurgery (TEM) equipment, but for cases near the anal verge a Parks' retractor was used. Data recorded were operation time, blood loss, hospital stay and early and late complications. The first postoperative assessment was planned at 1 month and then every three months until 18 months of follow-up. Result for 40 patients (21 from group A; 19 from group B) were analysed. There were no differences between groups regarding age, sex, location of the tumour and specimen's size. RESULTS: The intra-operative loss of blood was 22 ml for group A and 39 ml for B, the difference was not significant. The mean operation time was slighter longer for group A (93 min) than for group B (77 min) but not statistically significant. For both group the mean hospital stay was of 4[2-7] days. No differences in early or late complications could be demonstrated. CONCLUSION: The present study suggests that there is no difference between these two practices in terms of intra-operative results and outcome.

Transanal endoscopic microsurgery (TEM)

Summary. In the period from July 1983 to June 1991, 321 operations were performed using the technique of transanal endoscopic microsurgery (TEM). The most proximal tumours resected were in the lower sigmoid up to 25cm from the anal verge. The complication rate requiring surgical intervention was 6.5% and the recurrence rate after polypectomy was 5%. Of 44 patients with pT1 low-risk tumours, one developed a recurrence as did two of the three patients with pT1 high-risk tumours. Using the technique of TEM, segmental resections with end-to-end anastomosis are possible in the extraperitoneal part of the rectum.

Prognostic staging of extraperitoneal rectal cancer.

In 375 patients who had curative resection for cancer of the rectum below the peritoneal reflection, prognosis was evaluated according to four currently used staging systems, i.e., Dukes' system, the modified TNM system described by the American Joint Committee for Cancer Staging, The Australian Clinicopathological Staging System, and The Astler-Coller Staging System. Dukes' Staging System, which originally was described for use in rectal cancer, gives as good a prognostic separation as any of the other staging systems, some of which include serosal involvement as a staging criteria, which cannot be used for cancer of the extraperitoneal part of the rectum. It is furthermore demonstrated that an important prognostic separation can be obtained by dividing the B group of Dukes' Staging System into tumors that reach the surface of the muscularis propria and those with demonstrable invasion of extrarectal structures, the latter having as bad a prognosis as Dukes' C tumors.

Endometriosis in the groin

Recently we found one case of endometriosis in the extraperitoneal part of the round ligament (EERL). We found 30 cases previously described in the literature. A comparison showed that 90% were right-sided and often associated with an inguinal hernia. Fertility seemed to be below normal. In four of the cases a laporotomy was done. All had intraperitoneal endometriosis. In cases of EERL and claimed sterility therefore, the presence of intraperitoneal endometriosis should also be considered.

Functional anatomy of the anorectal sphincter

Sensory component, reflexes and motor components are responsible for anorectal continence. The most important factors are the extraperitoneal part of the rectum, the M.m. sphincter ani internus and externus, the levator ani muscles and the corpus cavernosum recti. The diagnostic of anal incontinence is usually evident from history and physical examination. Additionally intraluminal pressure recordings and electrical measurements are helpful.

Prenatal perforation of the extraperitoneal part of the rectum, associated with a developmental defect of the pelvic floor: M.R.Q. Davies, S. Cywes, and H. Rode. Z Kinderchir 39:271–273, (August), 1984

Prenatal perforation of the extraperitoneal part of the rectum, associated with a developmental defect of the pelvic floor: M.R.Q. Davies, S. Cywes, and H. Rode. Z Kinderchir 39:271–273, (August), 1984

Computed tomography of extraperitoneal spaces.

For years the extraperitoneal part of the abdomen has been considered a difficult area for anatomic definition, clinical evaluation, and radiologic diagnosis. Traditional methods that may provide direct or indirect evidence of disease processes originating in this region have included retroperitoneal pneumography, gastrointestinal barium contrast studies, excretory urography, lymphangiography, and

The management of injuries to the extraperitoneal part of the rectum: With reference to the use of streptokinase and streptodornase and air-vent suction

The management of injuries to the extraperitoneal part of the rectum: With reference to the use of streptokinase and streptodornase and air-vent suction