Plate 72
###### Figure 21

The margins of the peritoneum are mobilized in order to close the peritoneal floor securely. The peritoneum is grasped with toothed forceps and mobilized by the surgeon's hand or by blunt gauze dissection (Figure 15). The peritoneum in the pouch of Douglas is mobilized as widely as possible to facilitate closing the pelvic floor. The location of the ureters is reaffirmed from time to time to avoid their accidental ligation or injury. In females the uterus and adnexa may be used, if necessary, to close the new pelvic floor. At times it may be possible to close the pelvic floor in a straight line, but, more frequently, a radial type of closure is necessary to avoid undue tension on the suture line (Figure 16). All raw surfaces should be covered whenever possible. The omentum is placed over the peritoneal closure (Figure 17). Some make no attempt to close the peritoneum and rely on muscular closure.

When the patient's anatomy permits, a pedicled omental flap based on the left or right gastroepiploic artery can be created and laid into the pelvic defect. When enough omentum is available, this both fills the volume of the pelvis and covers the raw surfaces of the dissection. Some surgeons prefer to anchor the sigmoid to the lateral parietal peritoneum in order to close the left lumbar gutter and to avoid the possibility of an internal hernia. Whenever possible, these sutures should include the fat tabs or mesentery to avoid possible perforation of the bowel.

The omentum is returned to the region of the new pelvic floor and the table is leveled. The colostomy is created through a separate 3-cm (1¼ in.) opening selected and marked prior to surgery. In general, it is midway between the umbilicus and the left anterior superior spine (Figure 18). As this colostomy will be a permanent one, it is wise to choose the site in consultation with the enterostomal therapist. The adhesive ring of the colostomy bag must conform to the contour of the abdomen and must be secure when the patient is standing, bending, or sitting. After excision of the circle of skin, a two-finger-sized opening ...

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