. A manual of operative surgery . tdisadvantages during the later stages of the operation, andconsiderably embarrasses the work of the anaesthetist. The operation is carried out in three stages :— (1) The exposure and separation of the bowel. (2) The removal of the bowel. (3) The treatment of the divided ends of the bowel. (1) Exposure and Separation of the Bowel.—When the patientis in position the bowel may be finally irrigated with 1 in 5,000perchloride of mercury solution, and dried with iodoform gauze,a light plug of which may be allowed to remain in the gut. chap, xxxiv] EXCISION OF THE R
. A manual of operative surgery . tdisadvantages during the later stages of the operation, andconsiderably embarrasses the work of the anaesthetist. The operation is carried out in three stages :— (1) The exposure and separation of the bowel. (2) The removal of the bowel. (3) The treatment of the divided ends of the bowel. (1) Exposure and Separation of the Bowel.—When the patientis in position the bowel may be finally irrigated with 1 in 5,000perchloride of mercury solution, and dried with iodoform gauze,a light plug of which may be allowed to remain in the gut. chap, xxxiv] EXCISION OF THE RECTUM 75i An incision is made in the median line from the posterioredge of the anus to the centre of the sacrum. The knife passesto the bone at once. The soft parts on the left side of thewound are detached en masse, and drawn outwards. They in-clude part of the gluteus maximus. The left side of the sacrumis thus bared and brought well into view. The sacro-sciaticligaments attached to this left border are divided, as are also. FIG. 193.—DIAGRAM OF RECTUM FROM BEHIND. [After Hartmann.) P p, Level of reflexion of peritoneum ; L, Upper edge of levator ani. The dotted line acrossthe last piece of the sacrum indicates the best level for excision of the bone. the ligamentous attachments on both sides of the coccyx. Thecoccyx is now freed on all sides from its muscular attachments,and is left bare. The soft parts in the hollow of the lower partof the sacrum are detached with a rugine. They include thesacra media vessels and the venous plexus which lies in frontof the sacrum. The coccyx is now removed entire. Should sufficient space to reach the diseased segment ofthe rectum not be provided, a portion of the left side of thesacrum is removed. Bardenheuer takes away the whole lower 752 OPERATIONS UPON THE RECTUM [part ii part of the bone as far as the third sacral foramina, whilstanother surgeon advocated a still higher resection {see Fig. 193).The higher the division the greater
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