RU2157121C1 - Surgical method for treating malignant tumors of external female genital organs in cases when the anus is affected by the tumor process and in the cases of cloacogenic cancer - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves making bilateral inguinofemoral lymphadenectomy. The distal part of the rectum is mobilized 1 cm apart from the pelvic bottom. The serous and muscular membranes of the rectum are circularly cut. The mucous membrane is circularly separated towards the pelvic bottom muscles. Radical vulvectomy is carried out. The anus with surrounding tissues is included into the tissues to be removed in the zone 3 cm apart from the anus. The skin and fat tissues are cut to pelvic bottom muscles. Muscular and mucous layers of the rectum are identified. The mucous membrane is separated from musculofascial formations of the anal canal. The mucous membrane of the rectum is descended outward. The rectal mucous membrane lumen is clamped. The mucous membrane is excised in distal position with respect to the clamped zone. The mucous membrane is fixed on the skin wound lips. The clamped zone of the mucous membrane is removed in postoperative period. EFFECT: retained sphincter off the rectum. 5 dwg

Description

 The invention relates to medicine, namely to the section of oncology, and can be used for the surgical treatment of malignant tumors of the external genital organs in women with the involvement of the anus in the tumor process and in cloagenic cancer (the development of a tumor from the embryonic bud of the cloaca, localization between the posterior wall of the vagina and front wall of the rectum).

 The indicated involvement of the anus in the tumor process of the vulva complicates the situation so much that surgical treatment is considered impossible and the patient is recognized as incurable. This is due to the presence of pathogenic microflora of the contents of the intestine, infecting the surgical wound during resection of the rectum. The second important factor that impedes the operation when the anus is involved is the fact that the rectum is a functioning organ, and any surgical intervention significantly disrupts its function, causing incontinence (fecal and gas incontinence).

 Involvement in the tumor process of the anus leads to the need to abandon surgery. In these cases, treatment is limited to symptomatic therapy, condemning the patient to painful death from the progression of the oncological process.

 In the literature, we did not find a description of the case of surgical treatment of vulvar cancer with the involvement of the anus in the tumor process with a positive result. In the book of Ya.V. Bohman's "Malignant Tumors of the Vulva", Tashkent, Medicine, (1986, p. 58), the author cites a case of surgical treatment of a cloagenic tumor. In this case, the author performed posterior pelvic exentation with a good clinical result, the patient was observed for 6 years.

 The disadvantage of the described method is that the known method does not allow the operation of a weakened, age-related patient. Rear exententration is one of the most difficult and traumatic operations in oncological practice, for the application of which an unnatural anal opening is necessary, since it involves the removal of the rectum and its sphincters. As a result of this complex operation, the patient gets the opportunity to live, but subject to the presence of an unnatural anal opening. Such surgical tactics, in connection with the frequent refusals of patients from such operations and great complexity, did not find application in practical oncology.

 The use of surgical treatment with posterior exentration must be carried out simultaneously with inguinal-femoral lymphadenectomy and radical vulvectomy. Given the severity of the surgical trauma and the large volume of surgical intervention, we did not perform such operations, and we did not find descriptions in the literature of such combined operations.

 The objective of the present invention is to provide a surgical treatment method that allows performing surgical interventions with an invasive form of vulvar cancer involving the anus in the tumor process or with cloagenic tumors, which are known to be inoperable in the known methods, preserving the rectal sphincters, without imposing an unnatural anal opening, leading out operating wounds of the rectal mucosa, in order to prevent infection of the extensive wound of vulvectomy.

 This problem is solved in the created method for the surgical treatment of malignant tumors of the external genital organs in women with the involvement of the anus in the tumor process and cloagenic tumors. The method includes bilateral inguinal-femoral lymphadenectomy, radical vulvectomy, laparotomy, mobilization of the distal rectum, lowering the mobilized distal rectal mucosa through the muscular cylinder of the anal canal, cutting off the mucosa of the reduced rectum, fixing the proximal portion of the reduced rectal mucosa to the skin wound drainage of the surgical wound, closure of the entire surgical wound.

 In the created method, mucosal resection is performed in the volume of the distal rectum with hemming of the resected distal rectum to the edges of the perineal skin wound, removing the back wall of the vagina from its lumen and fixing it to the edges of the skin wound. The vaginal wall, which is widely turned out and removed from the entrance of the vagina, is stitched with the edges of the skin wound of the vulvectomy and posteriorly with the resected and reduced rectal mucosa.

 The method will be further presented based on the drawings.

 In FIG. 1 shows a section line of the skin.

 In FIG. 2 shows the beginning of a single-stage inguinal-femoral lymphadenectomy.

 In FIG. Figure 3 shows the wound of laparotomy in the separation of the serous-muscular layer of the rectum from the rectal mucosa above the pelvic floor.

 Scheme of the sagittal section of the anal canal during reduction of the rectal mucosa and cut-off of the skin and subcutaneous fat with subcutaneous anal muscle.

 Scheme of the sagital section of the anal canal after cutting off the entire preparation, including tissues of the anal region. In FIG. Figure 4 shows a wound defect in the perineum after cutting off the drug (without clamping the rectal mucosa).

 In accordance with the invention, the method is as follows: the patient is placed in a position on the back, the patient's legs are deployed and slightly bent at the knees. Under general intubation anesthesia, two teams of surgeons simultaneously perform an inguinal-femoral lymphadenectomy on both sides (see Fig. 2). The skin is dissected by a cut connecting the two anteroposterior iliac spines, extending 3-4 cm above the fold. The second incision extends from the anteroposterior awns down the front and inner thighs of the right and left, dropping down towards the perineum. Thus, the incisions in the inguinal regions have the form of two triangles facing their base to the vulva (see Fig. 1). The separation of the skin flap with fiber begins at the apex of the triangle, both on the right and on the left (see Fig. 2). This incision allows you to remove tissue lying from the pubis to the front-upper edge of the spinous process of the ilium. The pre-pubic fiber is removed. An inguinal-femoral lymphadenectomy is performed. At the same time, the same operation of the inguinal-femoral lymphadenectomy is performed by the second team of surgeons on the other hand. After performing inguinal-femoral lymphadenectomy, the patient is transferred to the lithotomy position. The operation is continued by two teams of surgeons, one team performs a laparotomy, the second - a vulvectomy.

 The first team, having performed the median laparotomy, after the revision of the pelvic organs and retroperitoneal space, performs the operation of lowering the rectum, the sigmoid and rectum are mobilized for this by opening the pelvic peritoneum, and the mesentery is separated from the surrounding tissues and vessels. Directly above the bottom of the pelvis, the serous-muscular layer is dissected circularly around the entire circumference of the intestine and dissected from the mucosa, using soft clamps to capture the serous-muscular layer of the intestine, and separate it from the mucous layer towards the anus (see Fig. 3). The department is carried out in a blunt way, with the development of bleeding, hemostasis is performed. When approaching the anus, the operation through the laparotomy wound ceases, the area of operation is plugged.

 At the same time, the second team of surgeons performs an operation in the perineum. Directly vulvectomy is performed in two sections. The first is a continuation of the incision made with inguinal-femoral lymphadenectomy, which goes from the inner surface of the thigh towards the anus, widely covering the base of the labia majora at a distance of at least 3 cm from them, continuing downward and widely passing around the anus. The same incision is repeated on the other hand. Both sections converge below the anus by 2 - 3 cm.

 An internal incision of a vulvectomy is performed, walking along the line of entry of the vagina, starting from the urethra and ending in the posterior commissure. The depth of the incision reaches the muscles of the pelvic floor. M. Bulbo-cavernosus, m. Perinei superficialis are removed and the remaining trigonum uro-genitale and musculus perinei profundus are exposed. The vaginal tube is separated from the surrounding tissue to a depth of 3 cm around the circumference. If there is an infiltration of the posterior wall of the vagina in the area of the posterior commissure, then it is necessary to remove the tumor by widely excising the posterior wall of the vagina.

 At the final stage of separation, the entire preparation, consisting of vulva, pubic fiber, fiber with lymph nodes and fascia of the inguinal-femoral areas, superficial muscles of the pelvic floor, large vestibular glands, cavernous clitoris, rests only on the tissues surrounding the rectal mucosa and on the mucosa itself rectum. Dissecting the tissues around the anus, remove the tissue of the sciatic-rectal fossa, approach the rectum, identify the mucous membrane and muscle layers. Cross the muscle layer of the rectum. Carefully separate the muscle and mucous layer from each other circularly around the entire circumference and in the direction into the depths of the pelvis. Outward traction of the whole drug reduces the rectal mucosa through the stretched anal canal outward (see diagram of Fig. 4). The rectal mucosa is clamped and cut off below the terminal at a distance of 3-4 cm from the external sphincter (see diagram of Fig. 4). Thus, the entire drug is separated by a single block (see Fig. 5). The clemented portion of the rectum is fixed with four sutures to the external sphincter. The resected distal section of the cleared rectum is stitched with the edges of the perineal skin wound.

 For the purpose of hemostasis and to weaken the tension of the edges of the wound, immersed catgut sutures are applied. The wound surface is covered from above by the skin of the abdomen. The defect under the symphysis is restored due to the longitudinal displacement and stitching of the edges of the skin of the abdomen and upper inner thigh surfaces. The vaginal mucosa, separated in the lower third, is tightened and sutured to the edges of the skin wound. This reduces the tension of the skin flap and, most importantly, the surgical scar is displaced outward from the entrance to the vagina, which ensures further painless intercourse.

 The drawings and diagrams depict in detail the progress of the proposed surgical treatment. After considering the drawings, you can understand the essence of the proposed method.

 Further, the foregoing will be supported by examples of a specific embodiment of the proposed method.

Example 1
Patient Kriksina N.I., 45 years old.

 Medical history N 1909, 1996

 Received with a diagnosis of C-r vulvae, T4 N1 M0, 2 C. gr.

 Tumor localization: the tumor involved posterior adhesion, an enlarged metastatic lymph node was determined in the inguinal region on the right. Given the young age of the patient and the absence of pronounced extragenital pathology, it was decided to perform surgery in the amount of expanded vulvectomy with inguinal-femoral lymphadenectomy and removal of the anus.

 The patient underwent a double-brigade extended vulvectomy with resection of the anus.

 After bilateral inguinal-femoral lymphadenectomy, a median laparotomy was performed, and the rectus muscle was separated from the surrounding tissues. Above the pelvic floor, the serous-muscular layer of the rectum is cut off, and the mucous membrane of the rectum is separated from the muscular-serous layer towards the anus.

 The second team of surgeons performs a radical vulvectomy with excision of the skin around the anus and separation of the mucosa from the serous-muscular layer. Outward traction of the entire block of tissues, which rests on the rectal mucosa, reduces the rectal mucosa and fixes it to the external sphincter with four sutures. A clamp is applied to the rectal mucosa and cut off. The region of drainage is drained with a thin silicone tube located circularly under the skin suture, which is fixed to the sphincter and the vagina wide inverted.

 The sutures were removed on the 12-14th day of the postoperative period, wound healing proceeds in the anus in the secondary tension with daily sanitization.

 PIP - N 15353 - 57 Squamous keratinizing cancer.

 On the 28th day of the postoperative period, the patient was discharged home.

Example 2
Patient Zvereva K.I., 47 years old.

 Case history N 5390. Diagnosis: C-r vulvae, T-4 N-2 M-0, CL 2.

 Localization: the tumor involved the base of the labia majora and infiltrated the posterior commissure.

 An extended vulvectomy was performed. During the removal of the tumor, a rectum resection was performed.

 After bilateral inguinal-femoral lymphadenectomy, a median laparotomy was performed, the rectus muscle was separated from the surrounding tissues, the sero-muscular layer of the rectum was cut off above the pelvic floor and the rectal mucosa was separated from the muscular-serous layer towards the anus.

 The second team of surgeons performs a radical vulvectomy with excision of the skin around the anus and separation of the mucosa from the serous-muscular layer. Outward traction of the entire block of tissues, which rests on the rectal mucosa, reduces the rectal mucosa and fixes it to the external sphincter with four sutures. A clamp is applied to the rectal mucosa and cut off. The anus area is drained with a thin silicone tube located circularly around it. By subcutaneous sutures, the rectal mucosa is fixed to the sphincter and the vagina wide inverted. Wound healing in the perineum proceeded by secondary intention, the sutures were removed on the 11th day. The patient does not observe incontinence phenomena. Complaints of violation of the act of defecation does not show.

 The duration of the operation is 6 hours 30 minutes.

 PIP-1041-48 data: Squamous keratinizing cancer.

 The patient was discharged on the 39th day.

Example 3
Patient Bakharovskaya I.S., 51 years old.

 Medical history N 2375, 1997

 Diagnosis: C-r vulvae T-4 N-1 M-0, 2 cells column

 Tumor localization: posterior commissure with infiltration of the right labia majora.

 Given the absence of pronounced extragenital diseases, the patient underwent extended vulvectomy with bilateral inguinal-femoral lymphadenectomy and resection of the rectum. After bilateral inguinal-femoral lymphadenectomy, a median laparotomy was performed, and the rectus muscle was separated from the surrounding tissues. Above the pelvic floor, the serous-muscular layer of the rectum is cut off and toward the anus the rectal mucosa is separated from the muscular-serous layer.

 The second team of surgeons performs a radical vulvectomy with excision of the skin around the anus and separation of the mucosa from the serous-muscular layer. Outward traction of the entire block of tissues, which rests on the rectal mucosa, reduces the rectal mucosa and fixes it to the external sphincter with four sutures. A clamp is applied to the rectal mucosa and cut off. The anus region is drained with a thin circular circular silicone tube. The edges of the skin wound are sutured with a saphenous suture, the edge of the mucous membrane is fixed to the sphincter and the vagina wide inverted.

 Sutures are removed on the 11-12th day, healing by first intention. In addition to the anus, in the area of the anus, healing proceeded by secondary intention with the formation of paropractitis. Local ointment treatment and baths were performed. By the 41st day of the postoperative course, the patient was discharged home.

 The patient complained of violation of the act of defecation did not show.

 P.G.I. - N 18723 - 39: squamous non-keratinized cancer.

 Thus, the proposed method provides the possibility of surgical treatment in cases of more extensive lesions of the surrounding tissues of the vulva and in cloagenic cancer.

Claims (1)

 A method for the surgical treatment of malignant tumors of the external genital organs in women with the involvement of the anus in the tumor process and cloagenic cancer, including surgery by two teams simultaneously, at the first stage, two teams perform bilateral inguinal-femoral lymphadenectomy, characterized in that at the second stage one team of surgeons performs median laparotomy, mobilizes the distal rectum at a distance of 1 cm from the pelvic floor, circularly dissects the serous and muscle membranes of the rectum, separates the rectal mucosa from the muscle layer, circularly throughout the circumference towards the anus, the second team of surgeons performs a radical vulvectomy, including the anus with surrounding tissues at a distance of 3 cm from the volume of tissue removed, cuts the skin and fatty tissue to the depth of the pelvic floor muscles , separates the underlying tissues from the muscles of the pelvic floor, identifies the muscle and mucous layers of the rectum, exfoliates the mucosa of the rectum from the muscle-fascial formations of the anal canal, reduces the mucosa of the rectum to the outside, fixes it to the external sphincter, closes the lumen of the rectal mucosa and cuts off distally to the cleared area, the surgical wound of the vulvectomy is drained, the rectal mucosa is fixed with sutures to the edges of the skin wound of the perineum and posterior wall of the vagina, the first team of surgeons sews up the laparotomy wound, the second team sews up the wound on the 7th - 9th day of the postoperative period, the cleared section of the rectal mucosa is cut off.

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