RU2251985C1 - Method for surgical treating rectocele - Google Patents

Abstract

FIELD: medicine, coloproctology.

SUBSTANCE: one should suture in the defects of anterior rectal wall, posterior vaginal wall, anterior portion of a muscle that lifts patient's anus followed by the plasty of rectovaginal septum. One should cut a fascial-muscular transplant including a distal end with above-situated leaf of broad femoral fascia. Then one should isolate proximal muscular end by keeping a vascular-nervous bundle as an intact one. Then one should dissect the muscle against pubic bone. Transplant should be turned at the angle of 140-150° in frontal plane in area of vascular-nervous pedicle. One should apply proximal end through the tunnel between anterior rectal wall and posterior vaginal wall. It is necessary to fix transplant's muscular part towards anterior semicircumference of external rectal sphincter. Then one should fix transplant's fascial section due to laparoscopic access to fascial rectal sheath being above the line of sutures and in its strained state. The innovation enables to prevent post-operational complications and increase reliability of plasty of rectovaginal septum.

EFFECT: higher efficiency of therapy.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to operative coloproctology, and can be used in the surgical treatment of rectocele.

Rectocele is one of the common proctologic diseases and according to routine examinations and reversibility of rectocele, 0.7% of people of working age suffer [1]. Rectocele - protrusion of the anterior wall of the rectum into the vagina as a result of weakening of the muscular skeleton of the pelvis, rectovaginal septum tissue and excessive divergence of the anterior portions of the muscle that raises the anus. Surgical treatment is indicated for rectocele II and III degree [2]. Half of patients with rectocele have damage to the anterior semicircle of the anal pulp, which justifies the development of new myoplastic methods of restoring the rectovaginal septum and anal pulp.

A study of patent and medical literature has revealed the following methods of surgical treatment of rectocele.

A known method of surgical treatment of rectocele [3], as follows. A lunar incision is made at the border of the vestibule of the vagina and perineum. The front wall of the rectum and the front portion of the levators are mobilized. Corrugate stitches are applied to the front wall of the rectum. Stitch the front portion of the levators with pulling the intestinal wall in the cranial direction. Transanally mobilize the excess rectal mucosa along the anterior semicircle with its reduction into the anal canal. Cut off the excess mucosa. Hem edges to the dentate line of the anal canal. The method allows to normalize the evacuation function of the rectum. The disadvantages of the method is the use as a basis for fixing the overlying rectal wall. In order to strengthen the anterior triangle of the pelvic diaphragm, levororrhphography is used, whereas normally there is a space between the puborectal portions of the muscle that lifts the anus in the area bounded by the rectum and the vagina, suturing of which will lead to a narrowing of the vagina and will not create barriers to prolapse of the rectum wall in the vestibule last one.

A known method of treating rectocele and prolapse of the vagina [4], in which they perform posterior colpotomy. The back wall of the vagina is excised in the form of a triangular flap with the apex facing in depth. The sacro-uterine ligaments are exposed. A surgical mesh of a trapezoidal shape is introduced with a large base in depth. The mesh is fixed to the sacro-uterine ligaments at the place of their discharge and to the anterior wall of the rectum, to the muscles that raise the anus, to the anterior semicircle of the sphincter. The mesh is hemmed to the edges of the posterior wall of the vagina. Excess vagina is resected. However, a surgical mesh, which is a foreign body, leads to aseptic inflammation and cannot be used between the sutures on two hollow organs, predisposed to the formation of interorgan fistulas.

A known method of performing median colporography with prolapse of the uterus and vagina [5], including the separation and removal of flaps of the anterior and posterior walls of the vagina, the connection of the separated surfaces of the bladder and rectum, characterized in that a porous implant is inserted between the separated surfaces of the bladder and rectum. titanium nickelide with a porosity of 40-60%, a thickness of 0.2 mm, dimensions corresponding to the dimensions of the separated surfaces. As well as the method according to claim 1, characterized in that in the presence of an imbalance in the anterior and posterior walls of the vagina, the flaps of different sizes are separated and removed, a larger flap is cut out on the wall of the vagina having a greater stretch and, accordingly, a larger, separated surface is obtained than on the other wall , the large separated surface is sutured to a smaller size, and the dimensions of the implant are selected in accordance with the dimensions of the smaller separated surface. The authors argue that the method can also be used to treat rectocele, but it is known that metal implants in soft tissues cause not only aseptic inflammation and a foreign body sensation, but also pain sensations, the occurrence of which is inevitable when using the latter in well-innervated erogenous areas. The use of titanium nickelide will violate the act of deicion.

The prototype of the present invention as the closest in combination of features to the claimed method, the method of surgical treatment of rectocele [6], including oral and intravaginal administration of bactisporin in the preoperative period, was selected. Use access by splitting the rectovaginal septum. Corrugate the wall of the rectum. Sutured muscles that raise the anus. An autodermal flap is fixed over the sutures.

The method of surgical treatment of rectocele in the modification claimed by the authors has the following disadvantages:

1. The location of the flap proposed by the authors does not restore the rectovaginal septum.

2. Despite the fact that the autodeomal flap is an autotissue, it is deprived of blood supply and innervation, its removal is associated with the formation of a skin defect.

3. The excess of the anterior wall of the rectum must be removed, not corrugated, since during corrugation an excess of soft tissues is formed, which prevents normal deformation, which, like preperitoneal lipoma, can contribute to the recurrence of rectocele.

4. Processing of an autodermal flap according to V.N. Yanov cannot fully prevent the formation of dermoid cysts.

The task of the invention is the prevention of postoperative complications and improving the reliability of the plastic vaginal-rectal septum.

The task is achieved in that the fascial-muscular transplant, including the distal end with the leaf of the wide fascia of the thigh located above it, is cut out on the basis of the thin muscle of the thigh, the proximal end of the muscle is extracted with an intact neurovascular bundle left, the muscle is cut off from the pubic bone, then the graft is deployed at an angle of 140-150 ° in the frontal plane in the region of the neurovascular leg and the proximal end is passed through the tunnel between the anterior wall of the rectum and the posterior wall of moisture then the muscle part of the graft is fixed to the anterior semicircle of the external sphincter of the rectum, and the fascial part of the graft through laparoscopic access is fixed to the fascial case of the rectum above the suture line in a tense state.

The method is as follows. In the patient’s position on the back, the legs are bent at the knee and hip joints and laid on the supports, the rectovaginal septum is infiltrated with a 0.5% solution of novocaine and 10 ml of dimexide on novocaine, an arcuate perineal section of 6-7 cm is symmetrically made in front of the anus, the rectovaginal septum is separated to a depth of 10 cm, leaving the peritoneum of the rectal uterine cavity intact on the right and left, the inner edges of the muscle raising the anus are distinguished. The front wall of the rectum is isolated. The rectocele is stitched with a suture-holder and excised with two half-moon incisions, the wound is sutured with a two-row suture. At the border of the upper and middle third of the vagina, Alice grasps the posterior wall of the vagina with a clamp and pulls it on herself, excises excess tissue corresponding to the rectocele with a scalpel, the lower edge of the section corresponds to the edge of the posterior wall of the vagina, which is sutured to normal sizes. On the line drawn from the pubic tubercle to the medial edge of the base of the patella, the skin, subcutaneous tissue and superficial fascia are cut in two places. From the pubic tubercle to the patella, the thigh muscle is secreted. A fascial case of the tailor muscle in the lower third of the thigh is opened through the grooved probe and pulled outward. With a dull and sharp way, a U-shaped flap adjacent to the thin muscle is isolated from the broad fascia of the thigh with the expectation that the anterior semicircle of the rectum will be wrapped (Fig. 1). The distal tendon of the small muscle is crossed at the site of attachment to the fascia of the lower leg. The fascial-muscle flap is isolated bluntly in the direction from the bottom up, while ligating the muscle branches from the femoral artery, descending knee and obturator arteries. The preparation of the muscle is stopped in the upper third of its lateral section, since the main neurovascular bundle, represented by the superficial branch of the internal artery enveloping the femur and the eponymous vein, as well as the anterior branch of the obturator nerve, is introduced into it. On the grooved probe, the fascia is opened in the gap between the long adductor and thin muscles. Through this gap they approach the pubic bone. To ensure greater mobility of the graft, increase its length and prevent tension, the latter is cut off subperiosteally from the pubic bone and left on the feeding leg. Next, the flap is deployed at an angle of 140-150 ° in the frontal plane in the area of the feeding leg and the proximal end is sutured to the front surface of the long adductor thigh muscle. This completely prevents the compression and kink of the neurovascular bundle. In the iliac regions, trocars are introduced, and the abdomen and pelvis are revised. The fascial part of the flap is inserted between the vagina and the rectum, after which it is endoscopically tightly fixed to the fascial capsule of the rectum with 3-5 sutures over the sutures of the rectum (figure 2). The muscle part of the flap is fixed side by side with the sutures to the external sphincter of the rectum, while the latter is somewhat corrugated, which allows it to restore its full closure. Levators sew edge to edge in front of the flap, so that they do not violate the trophism of a complex transplant. Carry out hemostasis, layer by layer suture the wounds on the thigh and perineum.

The method was tested on 9 patients in the coloproctology department of the Department of Surgical Diseases No. 4 of Rostov State Medical University.

An example of a specific implementation of the method.

Patient K, 39 years old, was admitted with complaints about the need for manual benefits during bowel movements, a feeling of incomplete emptying of the rectum, periodic gas incontinence, and difficulty in sexual life.

With an external examination of the perianal region, the anus is closed, the perianal reflex is alive. When straining, there is a prolapse of the lower third of the posterior wall of the vagina beyond the labia majora. With a digital study of the rectum, the sphincter tone and volitional efforts are slightly reduced, with a bi-digital study, the rectovaginal septum is thinned, a significant discrepancy in the anterior portions of levators is noted. Along the front wall of the rectum, there is a prolapse of the latter in the form of a blind sac in the vagina in its lower third with the extension of the labia majora.

The patient was diagnosed with a rectocele of the III degree, insufficiency of the anal sphincter of the I degree.

November 19, 2002, the patient underwent surgery.

In the position of the patient on the back, the legs are bent at the knee and hip joints and laid on the supports, the rectovaginal septum was infiltrated with a 0.5% solution of novocaine and 10 ml of dimexide on novocaine, a 7 cm long perineal perineum was symmetrically symmetrically made in front of the anus, the rectovaginal septum was separated into the septum 9 cm, the peritoneum of the rectal uterine cavity was left intact on the right and on the left the inner edges of the muscle lifting the anus were isolated. The front wall of the rectum was mobilized. The rectocele was stitched with a suture-holder and excised with two half-moon cuts, the wound was sutured with a two-row suture. At the border of the upper and middle third of the vagina, Alice grabbed the posterior wall of the vagina with a clamp, excised excess tissue corresponding to the rectocele with a scalpel, the lower edge of the section corresponded to the edge of the posterior vaginal wall, which was sutured to normal sizes. On the line drawn from the pubic tubercle to the medial edge of the base of the right patella, the skin, subcutaneous tissue and superficial fascia were dissected in two places. From the pubic tubercle to the patella, the thin muscle of the right thigh was isolated. A fascial case of the tailor muscle in the lower third of the thigh was opened through the grooved probe and pulled outward. With a dull and sharp path, a U-shaped flap adjacent to the thin muscle was isolated from the broad fascia of the thigh. The distal tendon of the small muscle was crossed at the site of attachment to the fascia of the lower leg. The fascial-muscle flap was isolated bluntly in the direction from the bottom up, while ligating the muscle branches from the femoral artery, descending knee and obturator arteries. The preparation of the muscle was stopped in the upper third of its lateral section, since the main neurovascular bundle, represented by the superficial branch of the internal artery enveloping the thigh, and the eponymous vein, as well as the anterior branch of the obturator nerve, was introduced into it. On the grooved probe, the fascia was opened in the gap between the long adductor and thin muscles. Through this gap we approached the pubic bone. The subperiosteal graft is cut off from the pubic bone and left on the feeding leg. The flap was deployed at an angle of 140-150 ° in the frontal plane in the area of the feeding leg and the proximal end was sutured to the front surface of the long adducting thigh muscle. In the iliac regions, trocars were introduced, and the abdomen and pelvis were revised. The fascial part of the flap was inserted between the vagina and rectum, after which it was endoscopically tightly fixed to the fascial capsule of the rectum with 4 sutures over the sutures of the rectum. The muscle part of the flap was fixed side by side with the sutures to the external sphincter of the rectum, while the latter was somewhat corrugated. The levators sewed edge to edge in front of the flap. Hemostasis was performed, and the wounds on the thigh and perineum were sutured in layers.

The postoperative period was uneventful. There was no pain. The perineal wound healed by primary intention. With stool, the patient did not note the above complaints. On day 7 was discharged. During follow-up examinations after 6 and 12 months there were no complaints, no rectocele was found.

Compared with the prototype, the proposed method allows you to restore the vaginal-rectal septum, the external sphincter of the rectum, while restoring the layered structure of the region. Conducted anatomical and experimental studies, it was found that cutting out the fascial-muscle flap using the described method does not present technical difficulties, the fascial part of the formed flap has dimensions sufficient to fully restore the vaginal-rectal septum. The fascial-muscle flap is well supplied with blood, and its bimechanical properties become identical to those of the vaginal-rectal septum normal. Creating for the muscle part of the flap new attachment points located at the same level from each other and from the place of constant fixation, at the level of the pubic bones, completely eliminates the violation of blood supply and innervation of the fascial-muscle flap, functional inaction of the flap. Suturing the flap to homogeneous tissues, in particular to the muscle, which provides continuous contraction, accelerates the formation of interorgan vascular and nerve connections and increases the functional activity of the fascial-muscle flap of the thigh muscle. The process of continuous closure of the intestine. In this case, the closure of the lumen of the intestine is not accompanied by additional efforts of the patient. Changing the fixation points of the small thigh muscle also does not affect the function, since the new fixation points are located at the same level and distance from the pubis.

In addition, cutting a fascial-muscular flap according to the developed method ensures obtaining a flap of sufficient size. The present method of surgical treatment of rectocele allows you to strengthen the external sphincter of the rectum, and also in comparison with the prototype to reduce pain and improve functional results.

List of references

1. Kurdyukova P.G. The structure of proctologic diseases according to the advisory cabinet of the proctologist of the Republican Center for Coloproctology // Actual issues of coloproctology: Abstracts of the First Congress of Coloproctologists of Russia with international participation / Edited by Academician RAMS G.I. Vorobyov, corresponding member of RAMS G.P. Kotelnikov, Professor B.N. Zhukov. - Samara: SE “Perspective”; Samara State Medical University, 2003 .-- S.90-91.

2. Clinical operative coloproctology: A guide for doctors / Edited by Fedorov VD, Vorobyev GI, Rivkina VL, - M .: SSC Proctology, 1994. - 432 p.

3. RF patent 2187251 C1, 08.20.2002.

4. RF patent 2212860 C1, 09.27.2003.

5. RF patent 2209605 C2, 08/10/2003.

6. RF patent 2196518 C2, 01.20.2003.

Claims (1)

A method of surgical treatment of rectocele, including suturing defects of the anterior wall of the rectum, the posterior wall of the vagina, the anterior portion of the muscle that raises the anus and the plastic of the rectovaginal septum, characterized in that the fascial-muscular transplant, including the distal end, with a sheet of wide fascia of the femur located above it , cut out on the basis of the thin muscle of the thigh, produce the proximal end of the muscle, leaving an intact neurovascular bundle, cut the muscle from the pubic bone, then trans the antatum is deployed at an angle of 140-150 ° in the frontal plane in the region of the neurovascular leg and the proximal end is passed through the tunnel between the anterior wall of the rectum and the posterior wall of the vagina, then the muscle part of the graft is fixed to the anterior semicircle of the external sphincter of the rectum, and the fascial part of the graft through laparoscopic access, they are fixed to the fascial case of the rectum above the suture line and in a taut state.

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