RU2144790C1 - Method for forming colonic reservoir in abdominoperineal rectum extirpation - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing rectum extirpation. Superior regions of colon are mobilized and brought down into the perineum wound. S-shaped colonic reservoir is created. A graft with pedicle is cut from discharging end of the reservoir by applying spiral- shaped incision. Smooth muscle sphincter is created. The aboral part is sutured to perineal skin boundary. EFFECT: enhanced functional results.

Description

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

 A known method of forming a controlled perineal colostomy from a serous-muscle 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 over 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, the levator stumps are connected 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. The excess mucous membrane is cut off (Method for the formation of controlled perineal colostomy. Copyright certificate N 17807226 from 08/15/92) - the prototype method.

 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. This is exacerbated by the lack of accumulative function of the rectum and, as a consequence, frequent multistage defecation, which forces patients to devote most of their time to hygienic procedures.

 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. From the distal part of the lower intestine, a large intestinal reservoir is formed with two loops in the form of the letter J. Next, the rectum is mobilized with the intersection and ligation of the medium-rectal vessels. From the perineum, above the dentate line, a circular incision of the intestinal wall is made and the drug is removed. The prepared graft is lowered into the anal canal, where a colanal anastomosis is formed by suturing the top of the reservoir to the upper edge of the anal canal. Next, a preventive ileostomy is formed, which is closed 1-2 months after the intervention (Lazorthes F. et all. 1986).

 This operation is used to localize the tumor in the mid-ampullar part of the rectum and allows you to correct the lack of reservoir function of the reduced intestine.

 The aim of the proposed method is to improve the cumulative function of the reduced intestine during abdominal-perineal rectal extirpation with the reduction of the colon into the perineal wound.

 The goal is achieved in that before the rectum is removed, the overlying sections of the colon are mobilized of sufficient length, from which the large intestine reservoir and smooth muscle cuff are formed, after removal of the intestine with the tumor, the graft is reduced to the perineal wound, where a controlled perineal stoma is formed with the excess mucous membrane remaining. A preventive ileostomy forms in the left iliac region.

 The method is as follows. Under anesthesia, the lower median laparotomy is performed. A lyre-shaped incision is made in the pelvic peritoneum. 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. Retreating from the distal edge of the stump of the sigmoid colon of 5-6 cm, the intestine folds in the shape of the letter S, is fixed with holders in such a way that the length of the outlet segment is at least 5-6 cm. The wall of the conjugated segments of the intestine is dissected by two horseshoe-shaped cuts. The tank knees are sewn together with a single-row seam. Check for leaks. In the distal part of the outlet knee, the serous-muscular layer of the intestinal wall to the mucosa is dissected in a circular incision. 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 distal part of the tank, so that each subsequent turn fits into the previous one. The coils are fixed among themselves with rare catgut sutures.

 Synchronously, two teams of surgeons (from the perineum with the intersection of the levator) mobilize the rectum in the fascial - fat case with the intersection and ligation of the middle rectal vessels. The drug is removed.

 Further, the pelvic floor is formed from the perineum by stitching the legs of the levator with catgut sutures. The prepared intestinal transplant is reduced to the perineal wound, where the distal part of the smooth muscle cuff is sutured to the edge of the skin, leaving an excess of mucous membrane 3-4 cm long. The pelvic peritoneum is restored from the side of the abdominal cavity, an ileostomy is formed according to Tornoboll and the laparotomy wound is sutured.

 Example: Patient H., 50 years old, medical history N 1283 - 95, was in the center for colorectal cancer at a distance of 4 cm from the edge of the anus. August 27, 1995, the patient was operated on as planned. Peritoneal perineal extirpation of the rectum was carried out with the mobilization of the left parts of the colon, the formation of an S-shaped colonic reservoir and smooth muscle cuff in the area of the perineum of the colostomy. Thornball ileostomy. The postoperative period was uneventful. Independent stool for 9 days. The excess mucosa is cut off on the 6th day after the operation. 2.5 months after the operation, intraperitoneal closure of the ileostomy was performed without complications. By the time of discharge, the patient freely holds solid and liquid feces. Stool daily 2-3 times a day.

 Example: Patient Z. 42 years old was in a clinic with a diagnosis of rectal cancer 5 cm from the edge of the anus. The medical history N 2009-95 09.10.95, the patient was operated on as planned. Peritoneal perineal extirpation of the rectum was performed with the formation of an S-shaped colonic reservoir and smooth muscle cuff in the area of the perineal colostomy. Thornball ileostomy. The postoperative period was uneventful. Excess mucosa is cut off on the 8th day. The closure of the ileostomy was made 2 months after the operation. By the time of discharge retained all the components of the intestinal contents. Chair daily 1 time per day.

Thus, in comparison with the prototype method has the following advantage:
- significantly increases the functional results of the abdominal-perineal extirpation of the rectum with the removal of the colon into the perineal wound due to the restoration of the reservoir capacity of the reduced intestine, thereby improving the quality of life of this category of patients.

Sources of information
1. Odarok T. S. et al. Method for the formation of a controlled perineum colostomy. Copyright certificate N 17807226. 1992

 2. Lazorthes F., Fages P., Chiotasso P., Lemory S., Bloom E. - Resection of the rectum with construction of a colonic reservoir and coloanal anastomosis for carcinoma of the reectum. - Br. j. surg. 1986; 73: 136-138.

Claims (1)

 A method of creating a large intestinal reservoir during abdominal-perineal extirpation of the rectum, including extirpation of the rectum, mobilization and lowering of the overlying parts of the colon into the perineal wound, characterized in that, in order to restore the accumulative function of the reduced intestine from its distal part, S- shaped colonic reservoir, and a flap on the leg is cut out from the outlet segment of the reservoir by a spiral-shaped incision, a smooth muscle sphincter is formed, the aboral part of which is sutured to edge of perianal skin.