perineal arc incision anoplasty

Perineal arc incision anusplasty for the surgical treatment of low rectal anus deformity. Congenital rectal anus deformity is the first in congenital digestive tract malformation. Due to the wide variety of malformations, and often combined with the deformity of other systems, the treatment is more complicated and the mortality rate is higher. In the early years, the operation was not well understood due to the anatomy of the control of bowel movements. The surgical results were not good, and the defecation dysfunction was often left after the operation. In recent years, due to the great progress in the study of rectal anus anatomy, combined with the appropriate surgical age and different surgical methods for different types of malformations, try to make the reconstructed anus close to normal anatomy and physiology. The surgical technique has been continuously updated, and the results have significantly improved the surgical results. At the same time, the cure rate has been further improved due to advances in pediatric surgical techniques and advances in neonatal surgery. Treatment of diseases: anal atresia Indication Perineal arc incision anusplasty is suitable for middle and low anal atresia. The sigmoid costomy is usually performed before surgery. The feature of this procedure is that the perineal arc incision is increased to facilitate the use of the external anal sphincter during surgery. Preoperative preparation 1. The position of the blind end of the rectum should be determined before surgery to determine which type of deformity it belongs to. 1 Photograph of inverted pelvic X-ray lateral film: Newborn swallowing air must reach the rectum for more than 12 hours, so the film should be taken 12 to 24 hours after birth, and the inversion time is more than 2 minutes. Anal crypt disposal lead type sign. At the moment of filming, choose the inhalation of the sick child. Attention should be paid to the X-ray projection angle when shooting, generally perpendicular to the film, and the illuminating point is the pubic symphysis so that important anatomical landmarks can be clearly displayed. This test result is often higher than the actual position of the rectal blind end, mainly because the rectal blind end is filled with sticky fetus, sometimes the gas is not easy to reach the apex, and the sick child is crying, the levator ani muscle contraction is large, and sometimes the rectum can be compressed. Blind end retraction. 2 In recent years, the application of B-ultrasound, CT and magnetic resonance imaging (MRI) has been helpful in determining the position of the blind end and estimating the state of the sphincter before surgery. 3 Some people also advocate the use of puncture and suction to determine the position of the blind end of the rectum. The specific method is to use a thick needle to puncture from the anal crypt, while sucking into the needle. Once the fetus is taken out, the depth of the needle is the distance between the blind end of the rectum and the skin. When puncture, it should be noted that the needle angle is inclined from the vertical line of the anus by 5° to 10° to prevent the needle from entering too deep and the needle is too strong to penetrate the bladder or other organs in the abdominal cavity. 2. Conduct a comprehensive physical examination to determine whether there are other system malformations. In particular, attention should be paid to whether congenital malformations such as congenital heart disease, esophageal atresia, and paralysis directly threaten the life of sick children. 3. The urethra should be preserved before surgery as a sign to separate the rectum during surgery to prevent damage to the urethra during free rectum. 4. Preoperative infusion to correct water and electrolyte disorders. For those who have no vomiting without digestive tract obstruction, it is not necessary to infusion. 5. Place the gastrointestinal decompression tube. 6. Prophylactic antibiotics. At the same time, vitamin K1110mg was given, intramuscular injection, 2/d to improve coagulation function. 7. Patients with combined fistula or colostomy should be cleaned before surgery to remove all feces. The blind end can be injected with 1% neomycin solution or metronidazole solution 12 hours before surgery. Surgical procedure 1. The incision takes the lithotomy position, and makes a transverse arc-shaped incision in the perineum. The curvature is forward, and the tip of the incision is located behind the pubis. The ends of the incision are at the same level of the ischial tuberosity. 2. Cut the skin and subcutaneous tissue, and bluntly separate. The external sphincter subcutaneous fibers were clamped with a vascular clamp. This muscle system forms part of the perineal body. The flap is reversed to the back. At this time, the pubic rectus muscle and the rectal blind end can be revealed by blunt dissection in the deep urethral direction with a vascular clamp. 3. Place a metal dilator in the abdomen sigmoid colostomy to the distal colon to reach the rectal blind end. Under the guidance of the dilator, carefully separate the tissue around the blind end of the rectum to free the distal end. Carefully separate the urethra under the guidance of the catheter and dilator, then make two support lines on the blind end of the rectum, and cut the blind end of the rectum longitudinally. If the blind end of the rectum is obviously dilated, sometimes it is necessary to make a tail in order to facilitate the dragging. Shape shaping. 4. The flap is reset, and a Ten shaped incision is made at the crypt of the anus. Attention should be paid to the skin at the general anal crypt. The wrinkles tend to be closer to the front of the real anus, so the gap is appropriately dislocated to the rear. 1cm can be. The "Ten" incision was cut into the skin, and the external sphincter subcutaneous ring was visible in the middle of the incision. At this point, the hemostatic forceps are carefully separated from the middle of the muscle ring, and the blind end of the rectum is pulled out through the hole. The intestinal muscle layer and the external sphincter subcutaneous ring are fixed intermittently, and finally the whole layer of the intestine is intermittently sutured with the skin. When there is a rectal urethral fistula, it is repaired, and the catheter is indwelled for 1 week after repair. complication Anal stenosis For common complications. Part of the reason is the local wound infection, cracking after anal angioplasty, and then the formation of scars, such as failure to adhere to anal expansion, the incidence is higher. In addition, if the tension is too large after the rectum is pulled out, the rectum is retracted after the operation, and the wound is split, resulting in severe stenosis of the anus. When there is a slight stenosis, it can be treated with dilatation; but in case of severe stenosis, if the anus is not effective, it is feasible to perform partial "Z" reshaping or partial resection of the scar, and insert the flap; if the rectal blind end is severely retracted, it can be elective. Interventional perineal analplasty. 2. Anal incontinence Due to the unclear anatomical relationship during the operation, the muscle complex was damaged during the operation. It may also be secondary to anal stenosis leading to stenosis and incontinence. Incontinence due to sphincter injury is feasible for perineal anal sphincter angioplasty, or other external sphincter replacement surgery. If the anal stenosis is caused, local scar removal and anal angioplasty are feasible. 3. Rectal mucosal eversion If the anal caliber is too large or the mucous membrane remains too long, the disease can be complicated. The valgus mucus secretes mucus and contaminates the underwear, often causing bleeding and ulceration due to friction. In the case of this complication, the valgus mucosa can be surgically resected when the child is slightly older. If the anal caliber is not suitable (or large or too small), an anastomosis should be performed. 4. Intra-rectal infection During the operation, there is fecal overflow, contaminating the surgical field, or due to incomplete hemostasis during the operation, forming blood and causing infection. Poor drainage after surgery is also a factor in infection. Postoperative antibiotics should be routinely used to prevent infection, such as existing infections, in addition to increasing the amount of antibiotics, timely drainage if necessary.

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