RU2261053C2 - Method for restoring large intestine continuity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out obstructive resection of the rectum. The rectum is transected 8 cm far from external anus boundary. Colon is descended to the interior sphincter level. Anastomosis is built between them in two stages. The colon is descended in retrorectal way to the coccyx and then into the perianal area along the left lateral wall of the rectum. Colostoma and longitudinal colorectal side-to-side anastomosis is formed at the first stage. The colostoma is closed at the second stage.

EFFECT: retained accumulating and holding sphincter function.

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Description

The invention relates to medicine, in particular to surgery during reconstructive surgery on the colon with a low located rectal stump and cancer of the rectum with localization in the upper and middle ampullar sections.

There is a method of surgical treatment of restoring the continuity of the colon in patients after obstructive resection of the rectum for various diseases of the colon with a short stump less than 7 cm in length - Duhamel operation (1956). The operation is performed as follows: the rectum is crossed at the level of the pelvic peritoneum with suturing it tightly. A mobilized colon is carried out in a formed tunnel behind the rectum at the level of the internal sphincter, which is dissected. Anastomosis is formed by suturing the posterior wall of the colon along the cut line of the rectum wall and applying two clamps to the “spur”, consisting of the posterior wall of the rectum and the anterior wall of the reduced colon. After spontaneous discharge of the clamps due to necrosis of the walls of the intestine, a wide colorectal anastomosis is formed between them (V.D. Fedorov, G.I. Vorobiev, V.L. Rivkin. Clinical surgical coloproctology. - M .: SSC Proctology, 1994, - p.238 )

However, this method has the following disadvantages:

- the formation of fecal blockages in the cult of the rectum;

- violation of the cumulative function;

- transanal lowering of the colon, which leads to anal incontinence.

The closest method selected as a prototype is the Duhamel operation in the modification of the Research Institute of Proctology.

The transplant prepared from the colon is fixed in a special conductor, the end of which is inserted into the canal and brought to the posterior wall of the rectum.

The posterior wall of the rectum is dissected in the transverse direction on the conductor. Through the incision of the rectum, a conductor is withdrawn with a colon fixed in it, which is withdrawn in excess, protruding 5-6 cm from the outer edge of the anus. The colon is fixed to the rectum by sutures previously placed on its wall. The excess of the reduced intestine is fixed with interrupted sutures to the perianal skin.

The second stage of surgical intervention - cutting off the excess of the reduced intestine and the final formation of a colorectal anastomosis - is performed after 12-14 days in the operating room under general anesthesia. (V.D. Fedorov, G.I. Vorobyov, V.L. Rivkin. Clinical operative coloproctology. - M .: SSC proctology, 1994, - p.239-242).

However, this method has the following disadvantages:

- violation of the cumulative function;

- the complexity of technical performance, the need for special tools;

- transanal lowering of the colon, which leads to anal incontinence.

The objective of the invention is to create a method of treatment that allows you to save the function of accumulation and retention of the sphincter.

The problem is solved in that in a method for restoring the continuity of the colon, including obstructive resection of the rectum and its intersection at a distance of 8 cm from the outer edge of the anus, lowering the colon at the level of the internal sphincter and forming an anastomosis between them in two stages, the colon is brought down retrorectally to the tailbone further along the left lateral wall of the rectum into the perianal region with the formation of a colostomy at the first stage and a longitudinal colorectal anastomosis "side to side" with the closure of the colo ostomy in the second stage.

The invention is illustrated by drawings, which depict in figure 1 - diagram of the colon through the formed tunnel along the posterolateral wall of the stump of the rectum with the formation of a colostomy in excess in the perianal region at the first stage of the method; figure 2 is a diagram of the formed side-by-side colorectoanastomosis with elimination of the colostomy in the perianal region in the second stage of the method, where 1 is the colon, 2 is the stump of the rectum, 3 is side-by-side colorectoanastomosis.

The method is as follows.

The patient's position on the operating table on the back, legs on special supports, access - wide median laparotomy. During reconstructive surgery with a short stump of the rectum (2) less than 7 cm, adhesions in the abdominal cavity are separated, the pelvic peritoneum is opened, and then in the retrorectal space they bluntly form the tunnel to the coccyx and further along the left side wall of the rectum. The previously sutured colostomy is removed and this section is resected using the UO-40 or UO-60 apparatus. The colon is mobilized in such a volume that the portion of the intestine, selected as the site of application of the perineal colostomy, reaches the Scarp triangle of the opposite side of the body and is viable. From the perineum in the perianal region in the projection from 1 to 4 hours on the dial in the patient's position, as in hemorrhoidectomy, a lunar incision is made, facing the anus. Further along the left side wall of the stump a message is made with the tunnel in retrorectal space. The newly formed tunnel is enlarged bluntly to approximately the size of the diameter of the lower colon (1). The colon is brought down to the perianal region with an excess of 2-4 cm and hemmed to the skin. Presacral through a contraperture in the perineum, a drainage tube is installed on the right. In the abdominal cavity, the window in the mesentery of the reduced colon and the pelvic peritoneum are sutured. Drainage is established in the pelvic cavity and the abdominal cavity is sutured tightly. The colostomy is opened by excision of the line of mechanical sutures. Drainage is removed as discharge is reduced.

When performing surgery for rectal cancer with localization in the upper or middle ampullar region, the following is performed: the patient’s position on the operating table and access is similar to that described above. The upper rectal artery is ligated, the pelvic peritoneum is opened with a lyre-shaped incision, the rectum is mobilized at least 2 cm below the tumor. The intestine is crossed with the UO-40 apparatus, leaving a short less than 7 cm stump of the rectum. The sigmoid colon is crossed with a UO-40 or UO-60 device. The remaining steps are carried out according to the method described above.

The second stage of the method is performed after 12-14 days. The position of the patient on the operating table as in hemorrhoidectomy, under general anesthesia. Divine anal sphincter. Immediately after the sphincter, a longitudinal incision of up to 3 cm is made along the left wall of the stump of the rectum and the adjacent lateral wall of the colon, the mucous membranes of both intestines are compared and sutured, and a side-by-side colorectal anastomosis is formed (3). After this, the colostomy is removed and closed with the UO-40 or UO-60 apparatus with the immersion of the line of mechanical joints in two half-pockets. The device is applied as close to the formed anastomosis as possible. The skin of the perianal region is sutured.

The proposed method of treatment does not require additional special medical instruments, the absence of transanal lowering of the colon at the stages of surgical treatment allows avoiding the occurrence of anal incontinence and preserving the holding function.

We give clinical examples.

1. Patient J., 45 years old, was admitted to the surgical department No. 1 of the Omsk Regional Oncological Dispensary (OOD) on November 29, 02, with a diagnosis of Rectal cancer, mid-ampullar department of St III class II. Condition after preoperative radiation therapy SOD = 40 Gy.

12/04/02 operation - obstructive resection of the rectum with lymphadenectomy and lowering the colon into the perianal region with the formation of a colostomy. During surgery, a tumor in the mid-ampullar section of the rectum with a length of 7-8 cm to 11-12 cm from the anus, mobile, extends beyond the muscle membrane of the rectum. Enlarged, dense pararectal lymph nodes. No distant metastases were detected. Histology: differentiated dark cell adenocarcinoma with the germination of all layers of the intestinal wall, metastases of adenocarcinoma in the lymph node.

December 18, 02, the second stage was completed - a longitudinal colorectal anastomosis was formed side to side, the colostomy in the perianal region was closed. 01/04/03 transferred to the radiological department of OOOD, where he underwent a course of postoperative radiation therapy to SOD = 60 Gy. The patient was discharged in satisfactory condition with a diagnosis of Colorectal cancer, mid-ampullar department of St III (T3N1M0) class III. Condition after radiation therapy SOD = 60 Gy.

When viewed 4 months after surgical treatment, the sphincter function is satisfactory, the accumulation function is good.

2. Patient X. 50 years old was admitted to the surgical department No. 1, OOOD 04.01.03 with a diagnosis of Cancer of the rectum, upper ampullar department, St II, class III. Condition after obstructive resection of the rectum and postoperative radiation therapy SOD = 39 Gy.

From the anamnesis it is known that the patient on 08.10.02 for emergency care in connection with obstructive intestinal obstruction was operated on in the Regional Clinical Hospital. Surgery performed: obstructive resection of the rectum. Histology: low-grade adenocarcinoma with germination in adipose tissue, lymphadenitis in the lymph nodes. After discharge, the patient was sent to the Radiological Department, OOO, where she underwent a course of radiation therapy to SOD = 39 Gy. During the control examination, data for relapse were not detected, the stump is less than 7 cm.

01/05/03 the operation was performed: lowering the colon into the perianal region with the formation of a colostomy. Intraoperative data for relapse and generalization were not identified. 01/20/03 the second stage of surgical treatment. A longitudinal side-by-side colorectal anastomosis was formed, and the colostomy in the perianal region was closed.

The patient was discharged 05.02.03 in satisfactory condition. When viewed 3 months after discharge, the sphincter function is satisfactory, the accumulation function is good.

Claims (1)

A method for restoring the continuity of the colon, including obstructive resection of the rectum and its intersection at a distance of 8 cm from the outer edge of the anus, lowering the colon at the level of the internal sphincter and forming an anastomosis between them in two stages, characterized in that the colon is brought down retrorectally to the coccyx, further along the left lateral wall of the rectum into the perianal region with the formation of a colostomy in the first stage and the longitudinal colorectal anastomosis "side to side" with the closure of the colostomy in the second floor ne.

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