RU2195205C2 - Method for developing vasoepididymoanastomosis - Google Patents

Abstract

FIELD: medicine, urology. SUBSTANCE: method is applied in treating male sterility. Spermatic duct is resected for 12-15 mm. Adnexal capsule is resected for 9-12 mm. Ansa of adnexal twisting canaliculus is developed. Inferior "lip" of anastomosis between muscular layer of spermatic duct and the wound's edge of testicular adnexal capsule is formed. Ansa of twisting canaliculus is crossed. Distal department of ansa is coagulated. Proximal department of canaliculus ansa is invaginated into the lumen of spermatic duct with the help of three holders. The upper "lip" of anastomosis is formed above adnexal twisting canaliculus. The method enables to increase efficiency of therapy in case of male sterility at obstruction of spermatic ducts. EFFECT: higher efficiency. 3 dwg

Description

 The invention relates to medicine, to the field of surgery and directly to the technique of forming an anastomosis of hollow organs.

 In the formation of side-by-side vasoepididymanastomosis according to Hanger, Humphreys et Hotchkiss (Amelar RD, Dubin L., Walsh P. C. - Male Infertility. Pfiladelphia, WB Saunders, 1977; cited in the book "Principles of Microsurgery in the Treatment of Infertility" edited by J.V. Reignac and N.H. Loersen, Moscow, “Medicine”, 1986, p. 238) the authors impose an anastomosis “between a small elliptical opening in the vas deferens with the same opening in the epididymis, from which viable sperm cells. "

 A variant of this technique is the transverse intersection of the vas deferens. The end of the crossed duct is incised longitudinally along the upper edge and a “racket” is formed, which is sewn with the lateral surface of the appendage (I. D. Kirpatovsky. “Essays on Surgical Andrology.” Study Guide. - Moscow: Publishing House UDN, 1989, p. 26 )

 The frequency of fertility recovery after such plastic surgeries remains quite low. This is due, firstly, to a high risk of scarring of anastomoses after surgery due to the formation of spermiogranuloma, when restoration of patency of the vas deferens occurs only in 20-37% (up to 47% with bilateral intervention), and secondly, with pronounced changes in testicular tissue capable of restore fertility in only 20-39% of cases after successful microsurgical interventions.

 Another option for vasoepididymoanastomosis is end-to-end anastomosis. Silber SJ in 1978 proposed a delicate microsurgical technique for creating an end-to-end anastomosis between the mucous membrane of the vas deferens and a separate, secreting epididymal tubule, intersected in the thickness of the appendage, following complete intersection of the duct and appendage (Silber SJ, Microscopic vasoepididymostomy. - Fertil. Steril., 1978, 30, 565).

 Anastomosis by Silber S.J. It provides for the anatomical connection of the mucous membrane of the vas deferens with the excreting tubule of the appendage and is a classic end-to-end anastomosis. But a connection of this type requires very careful adaptation of the anastomotic ends in diameter, while the diameter of the lumen of the vas deferens when the mucosa is straightened is 2-3 times larger than the diameter of the convoluted tubule of the appendage, which, after creating the anastomosis with frequent separate nodal sutures, inevitably causes tissue corrugation and relative narrowing anastomosis. The conditions for the formation of this anastomosis require frequent nodal sutures, which is a factor in severe trauma to the anastomosis line, which, according to the author himself, is the reason for his early cicatricial obstruction in a large percentage of cases ("Principles of Microsurgery in the Treatment of Infertility." / Ed. J.V. Reignac and N.H. Loersen. - Moscow: Medicine, 1986, p. 241).

 In addition, in the formation of the anastomosis, the sympathetic lower sperm nerve, which provides the motility of the vas deferens, intersects. Preserved sympathetic innervation apparently plays a significant role in the transport of sperm from the epididymis during ejaculation. Without such innervation of the duct and epididymis, it is unlikely that a complete recovery of sperm ejection is possible even with an anastomosis (cited by J. W. Reignac, N.H. Loerson. Principles of microsurgery in the treatment of infertility. - M., 1986, p. 232).

 The objective of the invention is to increase the effectiveness of the treatment of male infertility in obstruction of the vas deferens.

 The problem is solved in that in the method of forming a vasoepididymoanastomosis, including a microsurgical anastomosis between the vas deferens and the epididymis in the area of the crossed convoluted tubule, the vas deferens is dissected to the lumen 12-15 mm in length, and the epididymis capsule is dissected in the tail region along the midline along the tail line 9-12 mm, form a loop of the convoluted tubule of the appendage of 2-2.5 cm, form the lower "lip" of the anastomosis between the muscle layer of the vas deferens and the edge of the wound of the capsule of the epididymis, cross the loop and twisted tubule in the middle, its distal section is coagulated, and the proximal tubule loop is invaginated into the lumen of the vas deferens in the antegrade direction to a depth of 4-6 mm for three holders, which fix the Canadian there with separate interrupted sutures, then form the upper “lip” of the anastomosis above the submerged into the lumen of the duct with a convoluted tubule of the appendage.

 The proposed method is illustrated by drawings.

 The figure 1 shows the location of the anastomosed holes on the vas deferens in the capsule of the appendage and the formation of a free loop of the convoluted tubule by "unwinding" and isolation from the tissues of the appendage. Figure 2 shows the formation of the proximal tubule secreting seminal fluid before immersion into the lumen of the vas deferens. The figure 3 shows the formation of the anastomotic anterior lip over the tubule invaginated into the duct and fixed there, where 1 is the vas deferens, 2 is the epididymis, 3 is the convoluted tubule of the appendage, immersed in the lumen of the duct, 4 is the posterior lip of the anastomosis, 5 is the suture that fixes tubule in the lumen of the duct, 6 - anastomosis anterior lip.

 The method is as follows.

 Before surgery, a permanent urethral catheter is inserted into the bladder, which is fixed to the penis with a band-aid. Under endotracheal or intravenous dissociative anesthesia after shaving and treatment of the surgical field with antiseptics with scrotum access 4-4.5 cm long with hemostasis, a testicle with an appendage and an initial section of the vas deferens is excreted, which is removed into the wound. From this moment, an operating microscope (magnifier MBS-10) with a magnification of 2x-6x, microsurgical instruments and equipment is used. In the projection of the tail of the appendage, the vas deferens are punctured in the distal direction with a needle 21, through which a dye is injected with a syringe in a volume of 1.5-2 ml. Urine staining in the urethral catheter assesses patency of the vas deferens. In the case of patency of the vas deferens, on it as close as possible to the tail of the appendage choose an avascular zone that does not contain branches of the lower sperm nerve. In a selected place with a scalpel 11, the vas deferens is dissected along 12-15 mm across the entire thickness of the duct wall to its lumen. With a scalpel 11 over the stagnant tubules of the tubule in the tail area of the appendage, as distal as possible, the capsule of the latter is cut in the midline along 9-12 mm. The edges of the dissected capsule are used in the future to strengthen the anastomosis by the outer row of sutures between the epididymis capsule and the muscular wall of the vas deferens. With two anatomical tweezers, fiber is separated around the tubule, separating it from the surrounding tissues, and a 2-2.5 cm free loop is not injured by tools. Using the m / x technique, atraumatic material 3 / 0-4 / 0 has separate interrupted sutures with a step of 0.8-1.0 mm impose an anastomosis between the lower lip of the wound of the vas deferens and the corresponding lip of a dissected capsule of the epididymis. With scissors, the selected loop of the tubule of the appendage is crossed approximately in the middle of the free part. The material extracted from the convoluted tubule is subjected to express microscopy to detect the presence of sperm in it. By lightly massaging the head and body of the appendage, semen is excreted from the proximal tubule stump. After identifying the proximal tubule, the distal end undergoes electrocoagulation at the base of its free part. Using the m / x technique, the length of the semen-releasing tubule stump prepared for immersion in the lumen of the duct is measured. The excess part of the tubule stump is obliquely cut off with a scalpel 11 with the formation of an oval-shaped opening. For the formed “little mouse” and two more places, the tubule is asymmetrically stitched over the edge with atraumatic material 8/0, pulled into the lumen of the duct by these “holders” and tied with single interrupted sutures drawn through all layers of the vas deferens. Above the tubule immersed in the lumen of the duct, the upper lip of the anastomosis is formed, as was done with his lower lip. After careful hemostasis, the scrotum wound is sutured in layers on a rubber graduate left for one day. Antiseptic. Aseptic dressing.

 This method complies with modern requirements for the technique of applying a vasoepididymoanastomosis.

 The restoration of patency of tubular organs by antegrade insertion of a smaller proximal tube (convoluted tubule of the appendage) into the lumen of a slightly larger but comparable diameter distal tube (vas deferens) is more anatomical, since it allows reliable comparison of the walls and especially the mucous membranes of anatomically sequential tubular organs, excluding interposition into the line of the anastomosis under the mucous layer of the vas deferens.

 In the proposed invagination method, adaptation of the outer diameter of the duct of the appendage to the lumen of the vas deferens can be ideal, since the convoluted tubule increases in diameter as it approaches the site of prolonged obstruction of the appendage and can reach 1-1.5 mm in diameter at the site of obstruction, which is comparable with the diameter lumen of the vas deferens when stretching its mucosa. Therefore, it is possible to isolate the part of the tubule that most closely matches the lumen of the duct in each particular case. At the same time, the lumen of the vas deferens is at rest in a closed state due to the presence of a pronounced layer of loose elastic submucous tissue. This circumstance allows for invagination to adapt to the lumen of the vas deferens even the tubule of normal diameter.

 This method of forming an anastomosis is the least traumatic, since the line of anastomosis of the tubular organs does not bear any mechanical load, and the proposed sutures only hold the edge of the epididymis in the lumen of the vas deferens, while the most durable mechanical load at the site of anatomical connection of the anastomosed organs tissue: the muscular wall of the vas deferens and the fibrous capsule of the appendage, not directly involved in the restoration of the lumen of the deferent their ways.

 The proposed method of anastomosis is more physiological, since the seminal fluid contacts the anastomosis line only with the edge of the wound of the appendage canaliculus. This significantly reduces the contact intensity of aggressive seminal fluid with immunologically active tissues, reduces the risk of spermiogranuloma formation at the site of the anastomosis and the development of anastomotic obstruction in the early postoperative period, which cannot be said about the side-to-side anastomosis according to Hanger, Humphreys et Hotchkiss.

 A significant reduction in the risk of developing anastomotic obstruction in the early postoperative period is promoted by saving in the proposed method the anatomical integrity of the vas deferens and preserving the full peristalsis of the latter, necessary for the formation of a passable anastomosis, which is impossible in the end-to-side anastomosis with the formation of a “racket” and end-to-end anastomosis end "by Silber SJ

 Thus, this method of vasoepididyimanastomosis differs significantly from the known methods of vasoepididydimostomy and, first of all, by the invagination type of restoration of the anatomical integrity of the vas deferens, combining the advantages of the anatomical sequence of the anastomosis of the end-to-end type and the anatomical and functional integrity of the vas deferens in the anastomosis side by side, "retaining its peristaltic activity. In addition, the technique of forming an anastomosis improves the adaptation of anastomosed lumens, significantly reduces the mechanical load on the anastomosis line and trauma to this area with sutures, reduces the intensity of local and systemic autoimmune aggression and, therefore, reduces the risk of anastomotic obstruction in the early postoperative period.

Claims (1)

 A method of forming a vasoepididymoanastomosis, including a microsurgical anastomosis between the vas deferens and the epididymis in the area of the crossed convoluted tubule, characterized in that the deferent duct is dissected to a clearance of 12-15 mm in length, and the appendage capsule is dissected in the tail region along the midline 9- 12 mm, form a loop of the convoluted tubule of the appendage of 2-2.5 cm, form the lower "lip" of the anastomosis between the muscle layer of the vas deferens and the edge of the wound of the capsule of the epididymis, cross the loop of the convoluted tubule in In the middle, its distal section is coagulated, and the proximal section of the tubule loop is invaginated into the lumen of the vas deferens in the antegrade direction to a depth of 4-6 mm for three holders, which fix it there with separate interrupted sutures, then form the upper "lip" of the anastomosis over the duct immersed in the lumen convoluted tubule of the appendage.

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