The Technique of Abdominoperineal Resection for Carcinoma of the Rectum*
The primary object of any operation for cancer of the rectum or rectosigmoid must be the eradication of the disease. The pathologic observation regarding the lymphatic spread which has been so well demonstrated by Miles makes it quite apparent that the combined abdominoperineal operation fulfils this purpose better than any other type of procedure so far devised.
Spinal anesthesia is preferable in performing this operation. Then the patient should be placed in the Trendelenburg position, which makes it easy to pack the intestines well out of the pelvis. This is an essential requirement because the operation necessitates deep pelvic dissection. A midline or left rectus incision is the next step and the liver is explored for metastasis. One nodule does not contraindícate operation. Multiple nodules do. The gland-bearing area is then examined, only, however, to note the extent of malignant invasion. Even extensive involvement of the nodes does not contraindicate operation. Finally the growth is inspected if it lies above the reflection of the pelvic peritoneum. If there are multiple small nodules on the peritoneum, operation is contraindicated unless the area which contains them can be resected widely.
If all these conditions favor going ahead with the operation, the sigmoid is then examined. Occasionally it is necessary to mobilize the sigmoid by cutting its peritoneal attachments on the lateral side (Fig. 1). The location of the inferior mesenteric artery is then determined and this vessel is ligated below the first sigmoid branch (Fig. 2). The Cameron light is very useful. . .