RU2266063C2 - Method for applying large intestine-large intestinal anastomosis - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: while applying large intestine-large intestinal anastomosis one should make a single-row serous-muscular-submucous suture. Moreover, for applying sutures for posterior and anterior lips of anastomosis it is necessary to use separate ligatures. The first and the last fixing sutures should be performed due to puncturing in leaving about 1.0-1.2 cm against the edge of one anastomosed segment. Then one should puncture serous, muscular and submucous layers. Puncturing in should be performed due to leaving about 0.2-0.3 cm against the edge. In another anastomosed segment one should perform actions in reverse order. Ligature should be tightened. The rest sutures of every anastomosis lip should be performed as uninterrupted suture.

EFFECT: more simplified technique for anastomosis forming.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of diseases of the colon.

Currently, a single-row continuous method for applying a colonic anastomosis is known [1, 2, 3]. Its disadvantages are that: 1) it is imposed by a serous-muscular-submucosal suture with a tangential capture of the mucous membrane, while the deep submucous vascular plexus suffers; 2) it is possible to form a “stranglehold” with subsequent anastomositis and even stenosis; 3) there is a need for “reinforcement” of the first row of sutures with separate interrupted sutures in the so-called weak spots (mesentery, anastomosis angles); 4) suturing the posterior lip of the anastomosis is difficult due to poor differentiation of the walls of the layers of stitched organs due to prolapse of the mucous membrane into the area of the future anastomosis and leakage of blood and intestinal contents.

The purpose of the invention: facilitating the technique of formation and improving the reliability of colonic anastomosis.

The method is as follows. Prepared for anastomosis of the “end to end” type, the leading and discharging loops of the colon under a clamp applied transversely to the axis of the intestinal tube are dissected to the submucosal layer. The anastomosis is formed by an atraumatic suture material (polysorb 3/0, vicryl 4/0) by a single-row “semi-continuous” suture in a “semi-closed” way, that is, the formation of the posterior lip of the anastomosis is performed without opening the lumen of the stitched hollow organs. Features of the suture (Fig. 1, 2, 3) are: the first injection is made, departing 1.0-1.2 cm from the edge of the intestinal wall of the distal segment, while the serous, muscle and submucosal layers are pierced without trapping the mucous membrane; the puncture is made, stepping 0.2-0.3 cm from the edge of the cut. In the proximal segment, all actions are performed in the reverse order (inject, retreating 0.2-0.3 cm from the edge of the corresponding section, puncture - at a distance of 1.0-1.2 cm). The ligature is tied with the preservation of the short end, which is used later as a holder (the first seam is a modified Lambert suture, only in contrast to the latter with the capture of the submucosal layer). Subsequently, the posterior lip is formed by a continuous suture: an injection at a distance of 1.0-1.2 cm, an injection - at the border of the mucous and submucosal layers (without trapping the mucous membrane); the distance between the rounds of the intestinal suture is 0.5-0.6 cm with a strong tightening of the ligatures until the homogeneous layers of the intestinal wall are compared after each round. The stitching of the posterior lip ends with a suture similar to the first, after which the ligature is fixed by a knot and cut off with the preservation of the short end (holder). Then sections of the stitched segments of the intestine located between the jaws of the clips are cut off, thus the lumen of the hollow organs is opened, and the anastomosis is further applied in an open way. The anastomosis anterior lip is formed by the same procedure, with the exception of the first needle injection, which is performed in the proximal segment of the intestine. The first and last fixing sutures are superimposed, departing 0.4-0.5 cm from the corresponding seams of the rear lip. Nodules of the ligatures of the anterior and posterior lips of the anastomosis after tying remain from the side of the serous membrane.

Thus, the proposed method for the formation of an intestinal anastomosis combines all the positive aspects of the intestinal sutures of Harder and Kul, Lambert, Pirogov, and, in our opinion, is devoid of their shortcomings: 1) the deep submucous vascular plexus is not captured into the suture and the intestinal lumen is not stenosed (unlike a single-row seam of Harder and Kul); 2) forming the "corners" of the anastomosis with a modified Lambert suture, we achieve, along with satisfactory strength of the suture and wide layer-by-layer adaptation of the layers of the intestinal wall, the absence of nodules of suture material in the lumen of the hollow organs, as well as the contact of the serous membranes of both anastomosed organs; there is no need to “reinforce” the line of seams with single-row interrupted seams; in addition, the area of the intestinal wall (0.2-0.3 cm) remaining free of compression by the ligature helps to maintain blood supply in this section of the anastomosis; 3) a greater tightness of the anastomosis and a smaller amount of suture material left in the intestinal wound, distinguishes the proposed method from Pirogov suture; 4) the opening of the lumen of the hollow organs after the formation of the posterior lip of the anastomosis creates the conditions for the exact differentiation of the layers of the walls of the stitched organs, since it does not prolapse the intestinal mucosa, the blood and intestinal contents do not leak.

Example 1

Patient T., 53 years old, was admitted to the clinic on 2.05.2003 with the clinical picture: acute obstructive colonic obstruction. On the survey radiograph of the abdominal cavity, fine and colonic fluid levels were determined. Conservative therapy was started, as a result of which a positive effect was achieved - gases began to flow away, there was a stool, cramping abdominal pains stopped. Irrigoscopy revealed a tumor in the middle third of the descending colon, narrowing the lumen to 0.4-0.5 cm with perifocal inflammation. No data were found for metastasis of the process.

Diagnosed with cancer of the middle third of the descending colon T4NxMxo; resolved colonic obstruction. Violation of intestinal patency II-III Art. Perifocal inflammation.

In a deferred order, an operation was performed on May 15, 2003: in addition to a tumor, a competing pathology was revealed intraoperatively: Crohn's disease of the transverse colon. Dolichosigma. In addition, dense, mobile, smooth lymph nodes with a total number of 7-8 pcs, increased up to 1.0 cm in diameter, were found along the terminal branch of the inferior mesenteric artery. The scope of the operation was expanded to subtotal colectomy with rotation of the right parts of the colon and ascendo-sigmoid anastomosis of the end-to-end type with a single-row semicontinuous suture with a semi-closed method according to the proposed method (Polysorb No. 3/0). The operation was completed by draining the left lateral canal and pelvis, suturing the abdominal cavity tightly, after the introduction of the last 40.0 ml. 1% solution of dioxidine. Postoperative diagnosis: locally advanced cancer of the descending colon T4N2M0. Perifocal inflammation. Violation of intestinal patency II-III Art. Crohn's disease of the transverse colon. Dolichosigma.

Histological conclusion: highly differentiated colon adenocarcinoma. In sent lymph nodes, tumor tissue of a similar structure. Crohn's disease of the colon.

The postoperative period was uneventful. The patient received, along with the usual scheme of postoperative management of abdominal coloproctological patients, stimulation of peristalsis with cerucal from the first day of the postoperative period. Peristalsis fully recovered on the 3rd day, the stool was on the 5th day. Discharged on day 14, healing of skin wounds by primary intention. Stool at the time of discharge 1-2 times a day, mushy; laboratory tests are within normal limits.

Example 2

Patient S., 51 years old, was admitted to the clinic on 05/19/2003 with a clinical and radiological picture of small bowel obstruction, previously diagnosed with a cecum tumor. Conservative therapy for 12 hours without effect. 05/20/2003, an emergency operation was performed (at the height of intestinal obstruction). Intraoperative diagnosis: locally advanced cecum cancer T4N2M0. Violation of intestinal patency III Art. Performed right-sided hemicolonectomy with the formation of ileotransversoanastomosis of the type "end to end" semicontinuous suture semiclosed method according to the proposed method (vikril 4/0). The postoperative period was uneventful. Peristalsis recovery was noted on the 2nd day. The first chair for 4 days. Sutures were removed on day 12, wound healing by primary intention. The patient was discharged on the 15th day. At the time of discharge, there were no complaints, the chair was regularly issued, laboratory tests were normal.

Tumor histology: moderately differentiated adenocarcinoma with metastases to the sent lymph nodes.

Sources of information

1. Korepanov V.I., Mumladze RB, Markov I.N., Vasiliev I.T. Intestinal suture. (Illustrated review of the literature). - RMA Postgraduate Education. - Moscow, 1997. - P.24-26.

2. Harder F., Kull Ch. Fortlaufende einreihije Darmanastomose. // Chirurgie. - 1987. - V.58. P.269-273.

3. Harder F., Vogelbah P. Single-lauer end-on continuous suture of colonic anastomoses. // American Journal of Surgery. - 1988. - V.155. - P.611-614.

Claims (1)

The method of applying a colonic anastomosis, including the application of a single-row serous-muscular-submucosal suture, the formation of the posterior lip of the anastomosis without opening the lumen of the hollow organs, characterized in that separate ligatures are used to suture the posterior and anterior lips of the anastomosis, the first and last fixing sutures of each the lips are performed as follows: they inject, departing 1.0-1.2 cm from the edge of one anastomosed segment, pierce the serous, muscular and submucosal layers, and make an injection, departing 0.2-0.3 cm from edges, in another anastomosed segment of the action, they are performed in the reverse order and the ligature is tied, the remaining seams of each lip are made in the form of a continuous seam.

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