RU2248186C2 - Proctoplasty method for treating children for high forms of rectum atresia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves cutting muscle structures along median line. V sacral vertebra is excised. The inferior and medial rectal arteries are ligated. The rectum is mobilized. Rectolysis is carried out upon the perineum. The rectum is sutured to skin. The wound is sutured layer-by-layer.

EFFECT: reduced risk of traumatic injuries of pararectal nerve plexuses; wider atresic rectum mobilization.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of high forms of anorectal malformations in children.

Anorectal defect is a congenital malformation of the distal colon, in which the rectum can blindly end at different heights from the skin of the perineum or its end is represented by a fistulous passage that can open into the genitourinary system, to the perineum. Depending on the shape of the defect and the diameter of the fistula, complete or low partial intestinal obstruction may occur with this pathology.

Conducted research on the scientific and medical literature revealed a number of methods for treating anorectal malformations in children, depending on their form.

With a low form of rectal atresia, perineal proctoplasty is used. The essence of the operation with a low form of vice without fistula is that they make a cross-shaped skin incision in the projection of the anal fossa. Spreading the fibers of the external sphincter, they penetrate into the sublactor space, where the blind end of the rectum is found, it is mobilized and lowered to the perineum, the intestinal lumen is opened and its edges are sutured to the skin (G. Bairov, Yu.V. Doroshevsky, T.K. Nemilova, T.K. Atlas of operations in newborns. - Leningrad, 1984, p.143).

In the case of low anorectal atresia with rectovestibular fistula, perineal proctoplasty according to Stone-Benson is used. The essence of the operation is that an incision is made around the fistulous opening, a fistulous passage and distal rectum are mobilized, then a cross-shaped skin incision is made above the anal fossa, and through this incision the fistulous passage and rectum are reduced to the perineum, the fistula is resected, and the edge of the intestine hemmed to the skin (Lenyushkin A.I. Children's Coloproctology. - M., 1990, p.113).

The disadvantages of known methods of perineal proctoplasty are damage to the urethra and vagina during mobilization of the rectum dome, cicatricial narrowing of the anus and anal canal, incontinence in the postoperative period (Bairov G.A., Doroshevsky Yu.V., Nemilova T.K. Atlas of operations in newborns. - Leningrad. - 1984, p. 144; Lenyushkin A.I. Children's Coloproctology. - M., 1990, p. 114; Doletsky S.Ya., Pugachev A.G. Obstruction of the digestive tract in newborns and infants. - M., 1968, p. 280).

With intermediate and high forms of anorectal malformation, they resort to abdominal-perineal proctoplasty. The idea of the operation of abdominal-perineal proctoplasty with non-fistulous forms of anorectal atresia is that the fibers of the external sphincter are revised from the perineal access, the levator, separating the fibers of its pubococcygeal portion, and the changed portion of the rectum is mobilized and resected, the unchanged part of the rectum is reduced through the pectoral the loop and the center of the external sphincter on the perineum, hemming to the skin (Doletsky S.Ya., Pugachev A.G. Obstruction of the digestive tract in newborns and infants. - M., 1968, p. 282).

The disadvantages of this technique include great difficulties in determining the position of the puborectal loop, since conducting the intestine outside the center of this loop will lead to fecal incontinence, as well as the possibility of stenosis of the anal canal (G. Bairov, Yu.V. Doroshevsky, T.K. Nemilova Atlas of operations in newborns. - Leningrad, 1984, p.150).

The essence of abdominal-perineal proctoplasty with anorectal atresia with a fistula in the genitourinary system is that a tunnel is created from the perineal access in the center of the external sphincter, and the intestine is mobilized, the fistula is isolated and crossed, the changed part of the rectum is resected and reduced to the perineum the intestine through the center of the puborectal loop and external sphincter. The edge of the intestine is sutured to the skin (Doletsky S.Ya., Pugachev A.G. Obstruction of the digestive tract in newborns and infants. - M., 1968, p. 282; Margorin EM. Surgical surgery of children. - Leningrad 1960, p. 384).

The disadvantages of this technique include the high risk of damage to the ureters, seminal vesicles, urethra during the fistula neck, difficulty in identifying the position of the puborectal loop, stenosis of the anal canal, fecal incontinence (Bairov G.A., Doroshevsky Yu.A., Nemilova T.K. Atlas of operations in newborns. - Leningrad, 1984, p. 152).

A common drawback of all abdominal-perineal operations to create a tunnel for lowering the colon to the perineum is a violation of the urinary system, which manifests itself as persistent atony of the bladder, which leads to severe violations of urodynamics in the postoperative period (Boemers TM, Bax KM, Rovekamp MH The effects of posterior sagittal anorectoplasty and its variants on lover urinary tract fanction in children with anorectal malformations. J. Of Urology. - 1995. Jan. - 153 (1). - p. 191-193).

For the treatment of high forms of anorectal malformations of A.Pena (A.Pena, deVries P. Posterior Sagittal Anorectoplasty: Important Techical Considerations and new applications, J. Ped. Surg. - 1982. - Vol.17, n.6. P.796 -811, de Vries P, Pena A. Posterior Sagittal Anorectoplasty. - J. Ped. Surg. - 1982. Vol.17, n.5.- P. 638-649) proposed a technique by which a mid sagittal section is performed, which goes from the sacrum to the anal fossa, while in the midline all muscle structures cross behind the rectum, mobilize the rectum for subsequent reduction, and if a fistula is found, it is ligated and crossed, then the wedge but the enlarged rectum is resected to facilitate its passage through the center of the sphincter ring, the edge of the intestine is sutured to the skin of the perineum, and the muscle fibers are sutured together behind the reduced rectum.

The disadvantages of this technique include a violation of the function of the rectum due to a wedge-shaped resection of its distal part, since it functions as a rectal sensory receptor (Toszowski V. Acute processes in the abdominal cavity in children. - Prague, 1987, p. 227).

Closest to the claimed method according to the achieved technical result is "A method for the surgical treatment of some high forms of rectal atresia in children" (RF Patent No. 2096022, publ. 20.11.97, IPC A 61 B 17/00).

The essence of the prototype is that they make a cruciate incision in the region of the anal fossa to form the anus, create a tunnel in the center of the external sphincter, perform a posterior sagittal section along the midline from the coccyx down, not reaching 2 cm to the anal fossa, soft cut through the midline tissues and muscles of the pelvic floor, the coccyx is resected and a U-shaped flap is cut from the posterior wall of the rectum, which is the bottom of the wound, from which a tube is formed - the anal canal, which is brought down through the center of the puborectal nd loop tunnel and prepared at the crotch, formed anus hemming intestine to the skin and soft tissue by stitching layers behind the rectum.

The disadvantage of the prototype is the impossibility of applying the method in cases where the blind end of the intestine is located further than 4 cm from the skin of the perineum, since the length of the formed tube — the anal canal — will not be enough to lower it into the perineum without tension, and a wider mobilization of the atrezi rectum is impossible due to lack of surgical access, which may require mobilization of the rectum through a laparotomy incision.

The task to be solved by the claimed method is aimed at reducing the trauma of the pararectal nerve plexuses and eliminating complications from the urinary system.

The technical result achieved by the implementation of the proposed method is to reduce surgical trauma due to the use of only one surgical approach, required to mobilize and lower the distal part of the atresized rectum to the perineum.

The specified technical result is achieved by the fact that in the method of treating proctoplasty with high forms of rectal atresia in children, according to the invention, the surgical access is expanded by resection of the body of the fifth sacral vertebra, ligation of the upper and middle rectal arteries, mobilization of the rectum and lowering it to the perineum hemming to the skin, and suturing the wound in layers.

1 and 2 schematically depict fragments of the operation.

The method is as follows.

The patient is placed in a position on the stomach with the knees brought to the body. A cruciate skin incision is made in the region of the anal fossa to form the anus and a tunnel is created in the center of the external sphincter. Then perform posterior intermittent sagittal access, coming from the Vth sacral vertebra caudally in the midline, not reaching 2 cm to the anal fossa. Strictly in the midline cut the skin, subcutaneous fat, muscles of the pelvic floor. The coccyx 1 and the body of the Vth sacral vertebra 2 are resected. The bottom of the wound is a section of the atreated rectum 3. The posterior, lateral and anterior walls of the rectum are mobilized sequentially using hydrotreating soft tissues with a 0.25% novocaine solution. To mobilize the rectum, the superior rectal artery 4 from the system of the inferior mesenteric artery 5 and the middle rectal arteries 6 from the system of internal iliac arteries are ligated. Blood supply to the reduced rectum 3 is carried out at the expense of the last sigmoid artery 7 along the preserved marginal vessel. The mobilized intestine is laid in the pelvic tissue bed without tension, the intestine is brought down through the tunnel in the center of the external sphincter to the perineum and hemmed to the skin, muscle fibers and soft tissues are sewn in layers behind the intestine. Pararectal space is drained by a rubber graduate.

The proposed method of surgical intervention was used to treat high forms of anorectal malformation in the clinic of pediatric surgery at the Rostov Medical University in 4 patients on the basis of the City Clinical Hospital No. 20. We give the following observation as an example.

Patient X., and / b No. 2090, 1 year 1 month, was admitted to the pediatric surgery clinic 06/14/2001 to perform the radical stage of the operation with a diagnosis of high atresia of the rectum, rectourethral fistula, condition after colostomy. In the neonatal period, a colostomy was placed on the transverse colon. An additional ultrasound examination before the radical phase of the operation revealed a left-sided ureterohydronephrosis of the second degree in the child. A radical operation was performed - posterior sagittal proctoplasty. Under endotracheal anesthesia in the position of the patient on the abdomen with the knees brought to the body, a rear sagittal section was performed. To form the anus in the anal fossa, a cross-shaped incision is made and a tunnel is formed in the center of the fibers of the external sphincter. Soft tissues were dissected along the midline, and the tailbone was resected. When revising a wound in its upper corner, a dome of an atresized rectum was found. A resection of the body of the Vth sacral vertebra was performed. When mobilizing the anterior wall of the rectum, a fistula was revealed that flows into the posterior urethra. Produced dissociation of the fistula, its suturing on the urethral catheter. Ligated middle rectal arteries, suitable for the lateral walls of the atreated intestine. After mobilization of the posterior wall of the intestine for greater mobility, the upper rectal artery is bandaged and the intestine is brought down through the formed tunnel to the perineum without tension and sutured to the skin. Muscle structures are stitched behind the rectum. A rubber graduate is introduced into the pararectal space. The postoperative period was uneventful. In satisfactory condition, the child was discharged 07/16/01

As the comparisons of the proposed method of proctoplasty with high forms of atresia in children and the prototype method show, the proposed method has the following advantages: it allows to operate on all high forms of anorectal malformations using one surgical approach to mobilize and lower the atrezi rectum to the perineum, which reduces the traumatism of pararectal nerve plexuses, while maintaining an adequate function of the continent by reducing surgical trauma; eliminates complications from the urinary system, which lead to severe violations of urodynamics in the postoperative period.

Claims (1)

The method of proctoplasty with high forms of rectal atresia in children, which involves the creation of the anus, characterized in that after dissection in the midline of the muscle structures, the Vth sacral vertebra is resected, the upper and middle rectal arteries are ligated, the rectum is mobilized and brought down to the perineum, hemming to the skin, and the wound is sutured in layers.

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