RU2177267C1 - Method for creating interintestinal anastomosis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting out a flap on vascular feeding pedicle from the greater omentum. The flap is brought close to anastomosis zone after resecting intestine behind its loops. Flap edges are attached to inferior mesocolon surface using separate interrupted sutures along the lateral surface of mesocolon root. Round window which diameter is equal to the corresponding diameter of afferent intestinal loop, is created in distal portion of the flap. The window is put over loop end. Anastomosis is created. Flap window is moved to the suture line. Internal edge of the window is arranged all over the anastomosis perimeter. Another version involves bringing the flap to the anastomosis zone by perforating the mesocolon in a zone having no blood vessels. EFFECT: reduced risk of postoperative complications. 11 cl

Description

 The invention relates to medicine, namely to abdominal surgery.

 A known method of forming an intestinal anastomosis I.S. Kuznetsov (I. Kuznetsov. Anastomosis application method. USSR author's certificate N 489503, class A 61 B 17/00, 1974), including preliminary opening of the lumen of the anastomosed segments of the intestinal loops in the thickness of the serous-muscular membrane with subsequent application of 3-4 rows corrugating seams. When tensioning and tying the ends of each seam together, the formation of a serous-muscular-mucous roller is achieved, which is a duplication of the edges of the wound due to the concentration of muscle fibers. Then, pulp is formed from serous-muscular-mucous membranes by applying invaginating sutures at the ends of the incision until the serous-muscular-mucous roller is closed, then organs are anastomosed using two-story sutures.

 However, studies by many authors have shown that between the loops of the intestinal anastomosis, due to the biological permeability of the latter, a closed infected space is formed with a high probability of incidence, which leads to serious complications: inconsistency of sutures, anastomositis, cicatricial narrowing of the anastomosis.

 As the closest analogue, a method for the formation of an intestinal anastomosis was adopted (A. Zaporozhets. Postoperative peritonitis. - Minsk: Science and technology. 1974. - P. 148-149).

 The method consists in the formation of an inter-intestinal anastomosis. Then, a flap on the feeding leg is cut from a large omentum, it is brought to the zone of the formed anastomosis, which is enveloped from one plane of the mesentery of the intestine to another (Fig. 1-3). At the same time, the middle of the flap width is placed along the suture line, and the edges at a distance of 2-3 cm on both sides of the suture line are sutured to the intestinal wall with 3-4 interrupted ketkut sutures (Fig. 2).

 However, the known method has several significant disadvantages. A large omentum flap on the vascular pedicle, fixed to the intestinal anastomosis, creates an artificial cord in the abdominal cavity with many windows along its front and rear contours, which contributes to the development of adhesive intestinal obstruction, the frequency of complications increases significantly in patients with general peritonitis. Between the stitched flap of the omentum and intestinal anastomosis due to the biological permeability of the latter, a closed infected space is also formed with a high probability of developing serious complications. The method does not allow to envelop the mesenteric part of the anastomosis with a flap along the suture line, which does not exclude the development of suture failure in this zone.

 In addition, the method has limited functionality, it cannot be used when forming anastomoses of complex configuration: "end to side", "side to end", "side to side", because does not allow them to be reliably strengthened.

 The objective of the invention is to provide a more reliable method of forming an intestinal anastomosis, which has wider functionality and allows to reduce the likelihood of postoperative complications.

 To solve the problem, a group of inventions is proposed, united by a single inventive concept.

 The problem is solved as follows.

 Option 1.

 In the method of forming an intestinal anastomosis, including cutting a flap on the feeding leg from the greater omentum, bringing it to the anastomosis zone and suturing to the intestinal wall, the flap is brought to the anastomotic zone after resection of the intestine behind its loops by fixing separate nodal sutures of its edges along the lateral surface of the root mesentery to the lower surface of the mesocolon, in the distal part of the flap, retreating from its edges by 2-3 cm, form a rounded window with a diameter corresponding to the outer diameter of the leading loop of the intestine, at the end which they put on, then anastomosis is imposed with double-row interrupted sutures, with the first internal mucus-muscular-serous imposed with catgut, and the second, external, serous-serous, with non-absorbable suture material, the threads of which are left uncut, after which the flap window is moved to the seam line so so that its inner edge is located around the entire perimeter of the anastomosis, and suspended from the seam line by the left threads.

 Option 2

 In the method of forming an intestinal anastomosis, including cutting a flap on the feeding leg from the greater omentum, bringing it to the anastomosis zone and hanging it on the intestinal wall, the flap is brought to the anastomotic zone after resection of the intestine behind its loops by perforating the mesentery in the avascular zone, followed by fixation with separate nodal sutures of its edges to the edges of the mesentery-formed windows, in the distal part of the flap, departing from its edges by 2-3 cm, form a rounded window with an inner diameter corresponding to the outer diameter at the leading loop of the intestine, on the end of which it is put on, then anastomosis is applied with double-row interrupted sutures, with the first, internal mucous-muscular-serous, being applied with catgut, and the second, external - serous-serous - with non-absorbable suture materials, the threads of which are left uncut, after whereby the flap window is moved to the seam line so that its inner edge is located around the entire perimeter of the anastomosis, and is sutured to the seam line by the left threads.

 Using the invention allows to obtain the following technical result.

 The method allows to increase the reliability and physical strength of the anastomosis, its tightness along the entire perimeter, to improve the blood supply to the anastomotic loops along the suture line. The risk of developing postoperative complications is minimized: inconsistency of sutures, anastomositis, cicatricial narrowing of anastomosis, development of adhesive obstruction.

 The method can be used in the formation of any variant of the anastomosis and in any part of the abdominal cavity, while sheltering the line of sutures along the entire perimeter of the anastomosis, including the mesenteric edge.

 The technical result is achieved by forming in the distal part of the flap a large omentum of a rounded window and suturing its inner edge with a second row of serous-muscular sutures along the perimeter of the anastomosis, which helps to strengthen it, increasing physical and biological integrity.

 The method of summing up the omentum flap on the vascular pedicle to the intestinal anastomosis - both transmesenteric and para-mesenteric, eliminates the formation of an artificial cord in the abdominal cavity and the development of adhesive obstruction.

 The method is as follows (Fig. 4-9). Produce a laparotomy. After revision of the abdominal cavity, the volume of intestinal resection and the nature of the formation of the intestinal anastomosis are determined. Then they mobilize part of the greater omentum by cutting it off from the greater curvature of the stomach while maintaining the feeding leg, including the branches of the left gastro-omental gland. A flap of sufficient length 6-8 cm wide is cut out, which is brought to the anastomosis formation zone immediately after bowel resection using one of the proposed methods: para-mesenteric or trans-mesenteric.

 When using the para-mesenteric method, the omentum flap is brought to the zone of formation of the intestinal anastomosis after resection of the intestine behind its loops of the small intestine by fixation with separate interrupted sutures (2-3 cm apart) of the edges of the flap along the lateral surface of the root of the mesentery of the small intestine to the lower surface mesocolon (Fig. 4).

 When using the trans-mesenteric method, the omentum flap is brought to the anastomosis formation zone behind the loops of the small intestine by perforating the mesentery in the avascular zone (window diameter 2.5-3 cm) with a scalpel and fixing the flap edges with separate rare interrupted sutures to the edges of the formed window in the mesentery ( Fig. 5).

 In the distal part of the flap, a rounded window is formed, departing from its edges by 2-3 cm (Fig. 6). The inner diameter of the window in the flap maximally corresponds to the outer diameter of the adducting loop of the resected intestine. The formed window is put on the end of the driving loop to a depth of 1.5-2 cm in the proximal direction (Fig. 7). An intestinal anastomosis is applied with two-row interrupted sutures: the first, inner row with catgut, and the second, outer one with non-absorbable suture material (Fig. 8). The threads of the outer row of seams are left uncut. But upon completion of the anastomosis application, the flap window in the gland is moved from the leading loop to the suture line so that the inner edge of the window is located around the entire perimeter of the anastomosis. Left unseparated threads of the second row of seams, the inner edges of the window into the flap are sutured to the seam line of the anastomosis, capturing to a depth of 0.5-1 cm (Fig. 9). Restore the integrity of the mesentery of the resected intestine with interrupted sutures, capturing the edges of the omental flap in the avascular zone. After revision of the anastomosis zone and the abdominal cavity, the wound on the anterior abdominal wall is sutured in layers.

 Example 1

 Patient G., 63 years old. diagnosis: cancer of the hepatic angle of the colon. Concomitant diseases: ischemic heart disease, postinfarction cardiosclerosis, hypertension. After intensive preoperative preparation, a mid-median laparotomy was performed under endotracheal anesthesia. When revising the abdominal cavity, a tumor of the ascending colon of a diameter of 9-10 cm was detected. There are no distant metastases. Performed a hemicolectomy on the right with a portion of the terminal ileum. A flap on the feeding leg 25 cm long and 6 cm wide was cut from the left half of the greater omentum, which was brought to the anastomosis zone in a transmesenteric manner behind the loops of the small intestine by perforating the mesentery in the avascular zone and fixing the edges of the flap with separate interrupted sutures to the edges of the formed windows. Then, in the distal part of the flap, 2 cm away from its edges, a window was formed with an internal diameter of the corresponding loop of the resected intestine - 9 cm. The formed window was put on the end of the lead loop to a depth of 1.5-2 cm in the proximal direction. The primary end-to-end primary ileotransverzoanastomosis was laid with double-row interrupted sutures: the first row with catgut, and the second, external, with non-absorbable suture material, the threads of which were left uncut. After that, the flap window was moved to the seam line, while its inner edge was located around the entire perimeter of the anastomosis. The left edges of the window sutured to the anastomotic suture line, capturing to a depth of 0.5 cm. The mesentery of the resected intestine with nodal sutures was restored, capturing the edges of the omentum flap in the avascular zone. After revision of the anastomotic zone and the abdominal cavity, the wound on the anterior abdominal wall was sutured in layers. The postoperative period was uneventful. On the 3rd day after the operation, the gases began to independently discharge, on the 4th day after the enema there was a stool. Discharged on the 14th day in satisfactory condition.

 Example 2

 Patient L., 35 years old. diagnosis: multiple gunshot wounds of the ileum, diffuse serous peritonitis. An urgent mid-median laparotomy was performed under endotracheal anesthesia. In the abdominal cavity up to 200 ml of intestinal contents that are evacuated. During revision of the abdominal cavity, there were revealed through wounds of the terminal ileum at a distance of 3-4 cm from each other by number 6. Resection of 30 cm of the ileum was performed. From the right third of the greater omentum, a flap was cut on the feeding leg 20 cm long and 8 cm wide, which was brought to the anastomosis zone by the parasenteric method: behind the loops of the small intestine by fixing its interrupted sutures along the chord of the lateral surface of the mesentery root to the lower surface of the mesocolon. Then, a rounded window was formed in the distal part of the flap, which was put on the end of the adducting loop of the resected intestine. The end-to-end anastomosis is imposed. The flap window was moved to the seam line and its edges were hemmed to it. After drainage of the abdominal cavity, the wound on the anterior abdominal wall is sutured in layers. The postoperative period was uneventful. On the 2nd day, the patient's intestinal motility normalized. The patient was discharged on the 14th day. The condition is satisfactory.

Claims (2)

 1. A method of forming an intestinal anastomosis, including cutting a flap on the feeding leg from a large omentum, bringing it to the anastomosis zone and suturing to the intestinal wall, characterized in that the flap is brought to the anastomotic zone after resection of the intestine behind its loops by fixing separate nodal sutures of its edges along the lateral surface of the mesenteric root to the lower surface of the mesocolon, in the distal part of the flap, departing from its edges by 2-3 cm, form a rounded window with a diameter corresponding to the outer diameter of the leading the intestine, on the end of which it is worn, then anastomosis is applied with double-row interrupted sutures, with the first internal - mucous-muscular-serous - applied with catgut, and the second external - serous-serous - with non-absorbable suture material, the threads of which are left uncut, after which the window the flap is moved to the suture line so that its inner edge is located around the entire perimeter of the anastomosis, and suspended from the suture line by the left threads.  2. A method of forming an intestinal anastomosis, including cutting a flap on the feeding leg from a large omentum, bringing it to the anastomosis zone and suturing to the intestinal wall, characterized in that the flap is brought to the anastomotic zone after resection of the intestine behind its loops by perforating the mesentery in the avascular zone with subsequent fixation by separate interrupted sutures of its edges to the edges of the windows formed in the mesentery in the distal part of the flap, departing from its edges by 2-3 cm, form a rounded window with an inner diameter corresponding to the outer diameter of the adducting loop of the intestine, on the end of which it is put on, then anastomosis is applied with double-row interrupted sutures, with the first internal - mucous-muscular-serous - imposed with catgut, and the second external - serous-serous - with non-absorbable suture material, the threads of which are left uncut, after which the flap window is moved to the seam line so that its inner edge is located around the entire perimeter of the anastomosis, and is sutured to the seam line with the left threads.

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