RU2175527C1 - Method for forming colostoma - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves sealing proximal loop with mechanical suture. Reservoir-holding mechanism is formed. Transplanted intestine loop is mobilized from mesenterium and appendages on the 20-25 mm long distance. Seromuscular layer is circularly separated 5-6 mm apart from the mechanical suture line. Seromuscular layer is separated on 14-16 mm long distance. Seromuscular layer is rolled as cuff. Transverse cuts of seromuscular layer tenia are spaced on the 9-10 cm long segment over the thin intestine cleared of appendages in chessboard order. Retroperitoneal pocket is built. Submucous membrane of the distal end of the pulled-out intestine is circumferentially attached above the muscular cuff to aponeurosis and skin. Internal opening peritoneum of the retroperitoneal canal is sutured in intestine circumference direction. Stoma lumen is opened. EFFECT: enhanced effectiveness in creating conditional reflex for evacuating from the stoma. 4 dwg

Description

 The invention relates to medicine, specifically to surgery, and relates to methods of forming a colostomy.

 Improving the method of unnatural anus remains an urgent problem in connection with the low level of quality of life of "colostomized" patients. To this end, many methods have been developed with colostomy, combining various mechanical devices designed for controlled control of the evacuation of components of the intestinal contents [1].

 Lack of reliability, difficulty in handling, foreign material origin of the mechanical elements of the "holding" colostomy, which can cause complications, starting from the rejection reaction, ending with necrosis of the removed intestine, limits their widespread use.

 The closest to the positive effect of the prototype [1] is a colostomy method with implantation of a magnetic locking device.

 The method is as follows (Fig. 1).

 After crossing and sealing with a mechanical suture of the lumen of the sigmoid colon, they begin to form a retroperitoneal canal. For this, two Billroth clamps are applied to the peritoneum, previously dissected to the left of the sigmoid colon. The first assistant with his left hand pulls the peritoneum, taken on the clamps, and flakes it to the intended projection of the hole for the formation of the stoma. To create a bed of a magnetic ring to the left on the anterior abdominal wall, retreating 5-6 cm upward from the anterior superior iliac spine and at least 4 cm lateral to the rectus abdominis muscle, form an opening in the anterior abdominal wall by circular excision of the skin with subcutaneous fatty tissue up to 2 cm in diameter and an additional linear incision up towards the costal arch up to 2-3 cm long. The aponeurosis of the external oblique muscle is dissected cruciformly up to 4-5 cm in length and 1-2 cm in the transverse direction. Having clamped the corners of the dissected aponeurosis, the internal oblique muscle is separated from the aponeurosis and an implant bed is created up to 3.0 cm in all directions around the perimeter of the aponeurosis. A magnetic ring is placed in the formed bed, which is fixed between the aponeurosis and the internal oblique muscle by interrupted sutures. At the end, the proximal loop of the crossed sigmoid colon is passed through the retroperitoneal canal into the formed hole on the anterior abdominal wall, where a flat colostomy is formed. The stoma clearance is opened after 24 hours.

 The fundamental disadvantage of all colostrum is the unpredictability of their emptying. As for the prototype, in this case, the patient can not predict the time of evacuation of intestinal contents and will have to open the shutter independently at the time set by him or his doctor. And since the time of emptying the colostomy is individual for each and depends on a number of points, including the time of ingestion and the nature of the food, the untimely evacuation of the contents accumulated in the colostomy will lead to the development of chronic colostasis. We must not forget about the constantly ongoing reaction of rejection of the allogeneic implant, the fragility and fragility of its parts, as well as the possibility of a banal loss to the patient of the shutter. The functioning of the colostomy requires a certain skill from the patient to use the shutter, therefore implantation of a magnetic device in mentally disabled patients is unacceptable. According to the authors of [1], failure to comply with their topography when implanting the device can cause not only great inconvenience and pain when the body is on the left side or the body is bent to the left, but the ring is shifted to form a pressure sore of the intestine. And finally, an equally important drawback that limits the widespread use of the model is the need to attract additional forces and means for the production of parts of a magnetic device.

The problem solved by the invention is the formation of the patient's conditioned reflex for emptying the stoma, similar to the urge to defecate, the continental ¹ function of the colostomy, increasing ease of use and simplifying the technology of the method. ( ¹ Continental function - the ability of the intestine to retain the components of intestinal contents).

 A new technical result is achieved by the method of forming a colostomy, including sealing the proximal loop with a mechanical suture, creating a retroperitoneal canal and an opening in the anterior abdominal wall in the direction of the planned projection of the stoma and forming an extroperitoneal reservoir-holding mechanism: the proximal loop of the crossed intestine is parietally mobilized from the mesentery and pendants for 20 -25 mm, retreating 5-6 mm from the line of the mechanical suture, produce a circular dissection of the serous-muscular layer of the intestine, releasing the edge of the serous-muscular membrane that has been circulated is separated from the submucosa throughout 14-16 mm, wrapped in the shape of a cuff and fixed with interrupted sutures, serosomyotomy of the adductor loop is carried out over 9-10 cm by applying transverse intestinal tenies on free or previously removed from suspensions dissections of the serous muscle layer every 3 cm so that on each subsequent tenia the incisions are staggered in relation to the dissections of the previous tennia, then the peritoneum, races sectioned laterally from the intestine, exfoliate in the direction of the opening in the anterior abdominal wall, the leading intestine is passed through the formed retroperitoneal canal, the exposed submucous membrane of the distal end of the excreted intestine is fixed directly above the muscle cuff around the circumference to the aponeurosis and the skin, the peritoneum of the innerperitoneal opening is sutured around the circumference of the intestine interrupted sutures, at the same time open the lumen of the stoma.

 New in the invention is that they form an extroperitoneal reservoir-retaining mechanism: the proximal loop of the crossed intestine is mobilized parietally from the mesentery and pendants for 20–25 mm, retreating 5–6 mm from the line of the mechanical suture; circular dissection of the serous-muscular layer of the intestine is performed, freed the edge of the serous-muscular membrane is circularly separated from the submucosal base for 14-16 mm, wrapped in the shape of a cuff and fixed with interrupted sutures, serosomyotomy of the adductor loop is carried out on zhenii 9-10 cm by applying a pre-free or released from the suspension portions teny bowel transection sero-muscular layer every 3 cm in such a manner that on each successive tenii notches are staggered with respect to the previous tenii dissection.

 Then the peritoneum, dissected laterally from the intestine, is peeled off in the direction of the hole in the anterior abdominal wall, the leading intestine is passed through the formed retroperitoneal canal, the exposed submucous membrane of the distal end of the excreted intestine is fixed directly above the muscle cuff around the circumference to the aponeurosis and the skin, the peritoneum of the innerperitoneal canal opening is sutured around the intestinal circumference with interrupted sutures, the stoma lumen is simultaneously opened.

 In the literature analyzed by the authors, this combination of distinctive features was not found, and this combination does not follow explicitly for a specialist from the prior art. This technical solution can be used in clinical practice. Thus, this method meets the criteria of the invention - "novelty", "inventive step", "industrially applicable".

 The method is as follows (Fig. 2).

 The proximal loop of the crossed intestine, previously sealed with a mechanical suture, is parietally mobilized from the mesentery and pendants for 20–25 mm. Having retreated 5-6 mm from the line of the mechanical suture, a circular dissection of the serous-muscular layer of the intestine is performed. The liberated edge of the serous-muscular membrane is circularly separated from the submucosa over a length of 14-16 mm, wrapped in the shape of a cuff and fixed with interrupted sutures. Carry out a serosomyotomy of the lead loop for 9-10 cm. For this, 3 cross sections of the serous-muscular layer every 3 cm are performed on the muscle bands (thenia) of the intestine in free or previously freed from the suspensions portions so that on each subsequent tenion of the incision were staggered in relation to the dissections of the previous muscle tape. At the planned point, the stomas form a hole in the anterior abdominal wall. To do this, excise the skin with the underlying fiber in a circular incision, dissect the aponeurosis and exfoliate the muscles.

 Then the peritoneum, dissected laterally from the intestine, is peeled off with two fingers in the direction of the formed hole in the anterior abdominal wall. The treated stump of the adducting intestine is passed through the formed retroperitoneal canal. The integrity of the parietal peritoneum in the area of the internal opening of the retroperitoneal canal is restored with interrupted sutures, fixing it around the circumference of the colon. The exposed submucosa of the distal end of the excreted intestine is fixed directly above the formed muscle cuff around the circumference to the aponeurosis and the skin of the anterior abdominal wall. At the same time, the stoma lumen is opened.

 The creation of a smooth muscle pulp from a circularly separated serous-muscle layer, wrapped in the form of a cuff at the distal end of the excreted intestine, allows the patient to retain feces and intestinal gas. As for the technique of its formation, the location of the circular dissection at a distance of 5-6 mm from the line of the mechanical suture is due to tissue ischemia in the compression zone of the stapler. Narrowing the length of the parietal mobilization of the intestine less than 20 mm is not enough for the formation of muscle pulp, while the expansion of more than 25 mm can cause circulatory disorders in the wall. For the same reasons, it is undesirable to exceed or decrease the set length (14-16 mm) of the cuff separation. The staggered arrangement of oblique cross sections of longitudinal muscle tapes (teni) contributes to an increase in reservoir properties due to the expansion of the haustra throughout the retroperitoneal segment of the withdrawn loop (9-10 cm). The volume of the reservoir, formed as a result of serosomyotomy of the longitudinal muscles of the intestine, is sufficient to reduce the frequency of emptying the stoma to 1-2 times a day. The subjective effect - the urge - a feeling of readiness for bowel movement, which appears in the near future, is the result of a combination of retaining and reservoir properties of the structure, allowing most of the "colostomized" patients not to use a colostomy bag (clinical example).

 The mechanism of this phenomenon is hidden in the accumulation of intestinal contents in the retroperitoneal stoma site - the reservoir, its expansion and involuntary overstretching of the parietal peritoneum, which, in turn, is a sensitive receptor zone, which causes the patient to feel ready to empty (Fig. 3). The existence of such kind of subjective sensations, which naturally occur at a certain time on average 1-2 times a day, contributes to the formation in the distant period of the reflex arc of the conditioned reflex to empty the stoma, somewhat reminiscent of the conditioned reflex to defecation.

 The retroperitoneal location of the stoma intestine prevents the formation of an adhesion process between its reservoir-retaining part and the intestinal loops, which deforms the lumen, impairing the motility and continental properties of the removed loop. Prevention of complications such as the formation of a parocolostomy hernia, retraction, evagination, stoma invagination, pinching of the loop of the small intestine is also the result of a technically correctly formed extroperitoneal colostomy. A flat colostomy from the submucosal layer allows to achieve the maximum cosmetic effect. The simplicity and effectiveness of the design and the non-use of allogeneic materials to improve the continental properties of the colostomy do not limit its widespread clinical use.

 An extroperitoneal reservoir-retaining colostomy method has been developed and introduced into the clinic in patients with colorectal cancer.

Clinical example
In the direction from the clinic on July 3, 1999, patient S., 53 years old, was hospitalized in a clinic with suspected colorectal cancer. In the course of studying the medical history of the disease, it was revealed that already in the last 1.5-2 months, the patient has noticed an alternation of diarrhea and constipation with the inconstant appearance of impurities of red blood or dark clots in the feces.

; тромб. 348,3; лейк 8,7•10⁹/л; п 6%; с 52%; э 4%; л 35%; м 3%; СОЭ 40 мм в час.Examination:
General blood test (July 4, 1999)
Hb 83 g / l. ; erythritol. 2.3 • 10 ¹² / l; col. pokl 0.8; retic.

; thrombus. 348.3; lake 8.7 • 10 ⁹ / l; n 6%; with 52%; e 4%; l 35%; m 3%; ESR 40 mm per hour.

Ultrasound of the abdominal cavity (07/04/99)
Conclusion: indirect signs of chronic pancreatitis. There are no regional and distant metastases.

Colonoscopy (07/05/99)
At a distance of 5-6 cm from the anus, a circular tumor is determined, stenosing the intestinal lumen up to 1-1.5 cm. Due to bleeding and rigidity of the stricture walls, it is not possible to determine the proximal boundaries of the tumor. Biopsy.

 Conclusion: highly differentiated adenocarcinoma.

Irrigoscopy (07/08/99)
With some delay in the spread of contrast medium at the level of the lower ampullar part of the rectum, a barium suspension filled the colon. At a distance of 5-6 cm from the anus, a filling defect is determined, circularly narrowing the intestinal lumen for 3-4 cm. Emptying is uneven. A persistent depot of barium suspension at the level of concentric narrowing of the lower ampullar region with uneven and rigid contours.

 Conclusion: a tumor of the lower ampulla of the rectum.

 After preliminary mechanical cleaning of the colon under general anesthesia on July 12, 1999, the patient underwent lower middle laparotomy. When revising the abdominal organs, data for the regional and distant spread of the tumor process were not found. Given the low localization of the cancerous tumor, it was decided to perform abdominal-perineal extirpation of the rectum with the formation of an extroperitoneal reservoir-retaining colostomy. At the base of the sigmoid colon, the peritoneum is dissected from both sides by a lyre-shaped incision. Distal to the discharge of the left colon artery, the inferior mesenteric artery is bandaged. The sigmoid colon is mobilized from the mesenteric vessels for 5 cm before entering the small pelvis. The latter is crossed between previously applied mechanical sutures. The distal loop of the crossed intestine is isolated with a rubber glove.

 To form a reservoir-retaining colostomy, the end of the proximal loop of the sigmoid colon is mobilized parietally from the mesentery and pendants for 24 mm. 5 mm away from the line of the mechanical suture, a circular dissection of the serous-muscular layer of the intestine was performed. The liberated edge of the serous-muscular membrane is circularly separated from the submucosa for 15 mm, wrapped in the shape of a cuff and fixed with interrupted sutures. A serosomyotomy of the adducting loop was performed over 10 cm. For this purpose, 3 cross sections of the serous-muscular layer were made on the intestinal muscle tapes (tenia) every 3 cm on the areas that were free or previously freed from the pendants so that the incisions were placed on each subsequent tenus staggered in relation to the dissections of the previous muscle tape.

 At the planned point of the stoma, a hole is formed on the anterior abdominal wall. For this, the skin with the underlying fiber is excised in a circular incision, the aponeurosis is dissected, and the muscles are stratified. The peritoneum, dissected laterally to the sigmoid colon, is peeled off with two fingers in the direction of the opening in the anterior abdominal wall. The treated stump of the adducting intestine is drawn through the formed retroperitoneal canal. The integrity of the parietal peritoneum in the region of the inner opening of the retroperitoneal canal has been restored by interrupted sutures, fixing it around the circumference of the sigmoid colon. The exposed submucous membrane of the distal end of the excreted intestine is fixed directly above the formed muscle cuff around the circumference to the aponeurosis and the skin of the anterior abdominal wall. At the same time, the stoma lumen was opened.

 Extirpation of the rectum began with dissection of the fascial membrane at the base of the mesentery of the distal loop of the crossed sigmoid colon. The posterior semicircle of the rectum between its own fascia and the anterior fascia of the sacrum to the coccyx is highlighted in a sharp way. When isolating the lateral walls of the rectum, single lymph nodes with a diameter of 0.8-1.0 cm were found. The latter are mobilized with the surrounding tissue to the anal canal with suturing and intersection of the middle rectal arteries.

 Simultaneously with the allocation of the anterior semicircle of the intestine, the side of the perineum, the anus is sutured and excised with two bordering incisions. After crossing and ligation of the posterolateral portions of the levators, the anterior semicircle of the rectum is separated from the posterior wall of the vagina. The anterolateral portions of the levators were dissected and the remaining fixed sections of the rectum were mobilized. The intestine is removed through the perineal wound. Hemostasis. Recovery of the pelvic peritoneum, layer-by-layer suturing of the abdominal cavity. Remediation and drainage of the pelvic cavity with the removal of drainage tubes through contrapertures to the perineum. Sealing of the perineal wound with interrupted sutures.

 The drug: removed 24 cm of the rectum with pararectal tissue and lymph nodes. At 5 cm from the anus throughout the entire (4 cm) lower ampullar region, a circular tumor with decay sites is determined, which infiltrates the wall of the rectum.

Diagnosis: cancer of the lower ampulla of the rectum T ₃ N ₁ M ₀ P ₃ G ₁
In the postoperative period, flow-washing rinsing of the pelvic cavity was carried out for 3 days through the installed drainage tubes on the perineum, which were removed on the 4th day. Detachable by stoma for 3 days. Healing of laparotomic and perineal wounds by primary intention, sutures were removed on the 8th day. The patient was discharged on 21 days in satisfactory condition under the supervision of an oncologist at the clinic.

 Four months later, on November 24, 1999, patient S., 53 years old, was hospitalized in the clinic for follow-up examination and study of the functional results of the formation of an extroperitoneal reservoir-holding colostomy. She does not complain, she is satisfied with the results of treatment, considers herself socially rehabilitated. Continental colostomy function is satisfactory. The patient had a subjective sensation of readiness for bowel movement - a urge to defecate, in connection with which the patient does not use a colostomy bag. Ostomy is emptied no more than 1-2 times a day with stool, with a preceding urge. Against the background of intestinal gas incontinence, the patient did not observe the leakage of the liquid part of the intestinal contents. During the survey, data for the generalization of the main process were not found. The patient was discharged in satisfactory condition under the supervision of an oncologist at the clinic.

Examination:
Complete blood count (3.12.99 g)
Hb 138 g / l; red blood cells 4.6 • 10 ¹² / l; col. indicator 0.91; white blood cells 4.8 • 10 ⁹ / l; the wand. 1; segment. 47; e. 2; lymphocytes 42; monocytes 8; ESR 15 mm per hour.

 Biochemical blood test (12/12/99) General. protein 62 g / l; glucose 3.7 mmol / l; total bilirubin 7.9 mmol / l; creatinine 56 mmol / l; cholesterol 3.5 mmol / l; AsAT 0.2 μmol / L; AlAT 0.36 μmol / L.

Coagulogram (11/25/99)
IPT 97%; fibrinogen 3.772 g / l; et.test neg.

Bacteriological examination of feces (11/30/99)
Microbiological signs of dysbiosis - the content of Escherichia coli with reduced enzymatic properties is increased.

ECG (11/25/99)
Sinus rhythm, heart rate of 63 per minute, the electrical axis of the heart is deflected to the left, signs of left ventricular myocardial hypertrophy.

Ultrasound examination of the colostomy (11/25/99)
In the area of the distal part of the removed loop of the colon, a reservoir is located in the form of an increase in the clearance of 89x63 mm.

X-ray of a colostomy (12/01/99)
By introducing 200 ml of contrast medium through the stoma, the colon is filled for 30 cm. The retaining function of the pulp is satisfactory: after removal of the probe, as well as in the position of the patient on the abdomen, barium leakage from the stoma is not observed on the left or right side. In the area of the distal part of the extracted loop, an accumulation of contrast is noted, where the extension of the 10x6 cm loop is determined in the form of a reservoir (Fig. 4).

 Thus, the simplicity and effectiveness of the proposed method, which is able to form a stable conditioned reflex in the patient in the form of a urge to empty the stoma, which ensures the retention of intestinal contents and does not require any special care skills from it, can improve the "quality" of life and the results of medical and social and labor rehabilitation of "colostomized" patients.

Literature
1. Fedorov V.D., Odaryuk T.S., Rivkin V.L. and other Colorectal cancer. - Ed. V. D. Fedorova. - 2nd ed., Revised. and add. - M .: Medicine, 1987, S. 155-161.

Claims (1)

 A method for forming a colostomy, including sealing the proximal loop with a mechanical suture, creating a retroperitoneal canal and an opening in the anterior abdominal wall in the direction of the projected stoma projection, characterized in that a reservoir-retaining mechanism is formed: the proximal loop of the crossed intestine is parietally mobilized from the mesentery and pendants for 20 - 25 mm, retreating 5-6 mm from the line of the mechanical suture, produce a circular dissection of the serous-muscular layer of the intestine, the freed edge of the serous-muscular membrane of the circus they are brightly separated from the submucosa over a length of 14–16 mm, wrapped in the shape of a cuff and fixed with interrupted sutures, serosomyotomy of the adducting loop is performed over a length of 9–10 cm by applying cross sections of the serous-muscular layer through free or previously freed from suspensions of the intestinal tract every 3 cm so that on each succeeding tenia the incisions are staggered in relation to the dissections of the previous tennia, then the peritoneum, dissected laterally from the intestine, is peeled off the direction of the hole in the anterior abdominal wall, the leading intestine is passed through the formed retroperitoneal canal, the exposed submucosa of the distal end of the excreted intestine is fixed directly above the muscle cuff around the circumference to the aponeurosis and the skin, the peritoneum of the innerperitoneal canal opening is sutured around the circumference of the intestine with interrupted sutures, while the stoma is opened .

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