RU2111706C1 - Method for forming smooth muscle sphincter in performing abdominoanal resection of the rectum - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out abdominoanal resection of the rectum with internal sphincter. The upper segments of the colon are mobilized and brought down into the anal duct retaining some excess of the mucosa. Flap with a limb is cut out from seromuscular layer of the colon brought down. The flap is wrapped around the distal portion of the colon brought down. Smooth muscle sphincter is produced. Its distal portion is sutured to the anal duct end along resection line. EFFECT: enhanced effectiveness of treatment; improved involuntary component of retention function.

Description

 The invention relates to surgery and oncology, when it is necessary to perform abdominal-anal resection of the rectum with the reduction of the overlying sections of the colon into the anal canal.

 There is a method of performing abdominal-anal resection of the rectum, in which before removal of the rectum, the sigmoid or overlying sections of the colon are mobilized for reduction into the anal canal. Next, the rectum is mobilized with the intersection and ligation of the medium-rectal vessels. From the perineum, a rectal wall above the dentate line is dissected transanally in a circular incision and the drug is removed. The prepared transplant from the overlying sections of the colon is brought down into the anal canal, where a colanal anastomosis is formed (Fedorov V.D. Rectum cancer, M., 1987, p. 158).

 This operation allows you to preserve the natural passage of intestinal contents without the formation of a colostomy on the anterior abdominal wall.

 This operation is used to localize the tumor at a distance of 7 - 12 cm from the edge of the anus. This is dictated by considerations of radicalism - the need to retreat distally from the tumor at least 4 cm.

 If the tumor is localized at a distance of 5-6 cm from the edge of the anus and lower, crippling abdominal-perineal extirpation of the rectum is usually performed with the removal of the rectal closure apparatus and the formation of a permanent terminal colostomy on the anterior abdominal wall.

 In cases where the tumor is located at a distance of 5-6 cm from the edge of the anus, abdominal-anal resection of the rectum with preservation of the closure apparatus can be performed and the overlying sections of the colon can be reduced to the anal canal, however, in this situation, to retreat the necessary distance from the lower edge of the tumor, surgeons are forced to resect the internal sphincter and hem the reduced intestine to the external sphincter of the anus. (Holdin S.A. Neoplasms of the rectum and sigmoid colon, L., 1977, p. 193 - 195, prototype method). However, in this case, there is no involuntary component of holding the intestinal contents, which leads to undesirable consequences in terms of functional results, such as: frequent multi-stage defecation; lack of a phase of involuntary holding of intestinal contents; lack of differentiation of various components of intestinal contents.

 A known method of forming a controlled perineal colostomy from a serous-muscular flap of the reduced intestine with abdominal-perineal extirpation of the rectum. This, of course, is a progressive operation, as it eliminates the formation of a colostomy on the anterior abdominal wall.

 The essence of the method is as follows.

 After crossing the main vessels, an intestinal transplant is prepared for releasing from the overlying sections of the colon. For this, after mobilization of the mesentery of the sigmoid colon for 15 cm, the wall of the reduced intestine is thoroughly freed from fatty suspensions. Typical rectal extirpation is performed. At the same time, front-side portions of the levator are distinguished from the perineum, they cross, the stumps are sutured with catgut, and the ends of the threads are not cut. The rectum with the closure apparatus is removed. Levator stumps are tied together and sutured to the posterior-lateral walls of the pelvis and the posterior wall of the reduced intestine, forming the pelvic floor. The prepared intestinal transplant is reduced to the perineal wound, where the perineal team makes a circular incision of the serous-muscular membrane of the intestinal wall. Next, the membrane is separated to the cutaneous edge of the perineal wound. Then, a spiral-shaped incision is made of the separated intestinal wall, forming a serous-muscle flap on the leg, which is wrapped around the distal part of the reduced intestine at the skin level, forming a smooth-muscle cuff, immersed in the pelvic cavity, and the distal part is sutured to the perianal skin. Excess mucous membrane is cut off. (The method of forming a controlled perineal colostomy, Auth. St. N 17807226 from 08/15/92).

 With all the advantages of this operation over classical extirpation of the rectum, it has a number of functional disadvantages. By forming a smooth muscle cuff, the involuntary component of holding the intestinal contents improves. An arbitrary component is absent due to the lack of striated muscles of the external sphincter of the anus.

 The aim of the proposed method is to improve the involuntary component of the function of holding intestinal contents.

 This goal is achieved by the fact that before the rectum is removed, the overlying sections of the colon are mobilized sufficiently long to form a smooth muscle cuff, and after resection of the rectum and internal sphincter, the graft is lowered into the anal canal, where a smooth muscle sphincter is formed from the wall of the reduced intestine, and is sutured to the external sphincter , forming a coloanal anastomosis with leaving an excess of the mucous membrane.

 The method is as follows.

 Under anesthesia, a lower middle laparotomy is performed. During the audit establish the ability to perform this operation. A lyre-shaped incision is made in the pelvic peritoneum. Then study the vascular pattern of the mesentery of the sigmoid colon, evaluating the adequacy of blood supply to the reduced transplant. At the slightest doubt in the adequacy of blood supply or in the absence of a sufficient length of the sigmoid colon, the left half and the left bend of the colon are mobilized. This aspect seems to us extremely important, since insufficient nutrition of the marginal segment of the intestinal transplant can lead to necrosis and the development of purulent complications in the pelvic cavity, not to mention the functional results.

 Next, the selected area of the intestine for 15 cm is carefully freed from the adipose tissue of the mesentery and pendants. The sigmoid colon in the distal part of the liberated area is crossed by an NLCA or FMS apparatus. Synchronously, two teams of surgeons (from the perineum with resection of the internal sphincter) produce the mobilization of the rectum in the fascial-fat case with the intersection and ligation of the medium-rectal vessels. The drug is removed.

 Next, the prepared intestinal transplant is lowered into the anal canal, the pelvic part of the peritoneum is restored from the side of the abdominal cavity and the laparotomy wound is sutured. In the distal part of the reduced intestine, the serous-muscular layer of the intestinal wall to the mucosa is dissected in a circular section. Separate the layer in the oral direction to the level of the external sphincter. The separated layer is helically dissected. Thus, a serous-muscle flap is formed on the feeding leg. It is wrapped around the reduced intestine in the immediate vicinity of the external sphincter so that each subsequent turn fits into the previous one. The coils are fixed among themselves with rare catgut sutures. As a result, a smooth muscle cuff is formed around the distal part of the reduced intestine, which is immersed in the pelvic cavity, and its caudal end is fixed to the proximal part of the external sphincter by separate catgut ligatures, forming a colanal anastomosis. The excess mucous membrane is partially cut off, leaving a segment of about 3-4 cm to isolate the anastomotic line from contamination with intestinal contents on the first day after surgery. Subsequently, it is completely cut off.

 Example. Patient L. 56 years old, medical history N 1283-94, was in the center for colorectal cancer at a distance of 6 cm from the edge of the anus. 04/03/94, the Patient was operated on as planned. An abdominal-anal resection of the rectum was performed with resection of the internal sphincter by lowering the sigmoid colon into the anal canal and the formation of a smooth muscle sphincter from the serous-muscular flap of the reduced intestine. The postoperative period was uneventful. Independent stool for 9 days. Excess mucosa is cut off for 10 days. after operation. By the time of discharge, the patient freely retains all components of the intestinal contents, clearly differentiates feces and gases. Daily stool 2 to 3 times a day.

 Example. Patient G., 48 years old, was in the clinic with a diagnosis of cancer of the rectum 5 cm from the edge of the anus. The medical history N 2009-94, 07.06.94, the Patient was operated on as planned. An abdominal-anal resection of the rectum and internal sphincter was performed with mobilization and reduction of the left parts of the colon into the anal canal by the formation of a smooth muscle sphincter from the serous-muscle flap of the reduced intestine. The postoperative period was uneventful. Independent stool for 6 days. Excess mucosa is cut off for 8 days. By the time of discharge, it clearly differentiated gas and gases, retained all components of the intestinal contents.

 Thus, in comparison with the prototype, the method has the following advantages: significantly increases the functional results of abdominal-anal resection of the rectum with resection of the internal sphincter due to the improvement of the involuntary component of the holding function; significantly expands oncological indications for performing sphincter-preserving operations by including in this group of patients with localization of a rectal tumor at a distance of 5 - 6 cm from the edge of the anus.

Claims (1)

 A method for creating a smooth muscle sphincter during abdominal-anal resection of the rectum, including resection of the rectum with an internal sphincter, mobilization and lowering of the overlying parts of the colon into the anal canal, leaving an excess of mucous membrane, characterized in that, in order to improve the involuntary component of the holding function, from the sero-muscular layer of the reduced intestine, a flap is cut out on the leg, which is wrapped around the distal part of the reduced intestine, forming a smooth muscle sphincter, the distal part of which horn is sutured to the edge of the anal canal along the line of resection and an excess of the mucous membrane is left.