RU2271752C1 - Method for descending left colonic half in patients with colostoma - Google Patents

Abstract

FIELD: medicine, coloproctology.

SUBSTANCE: the present innovation deals with treating of large intestinal and rectal tumors. At descending left colonic half in patients with colostoma after Hartmann's type operation it is necessary to mobilize a colon participating in developing colostoma at keeping wall-nourishing vessels. Colostoma with cutaneous fragment should be dislocated into abdominal cavity. Then one should form a foramen in rectal cupola, apply an assayer's tongs from anal side to capture cutaneous fragment with stoma and replace it through anal canal onto perineum. Then it is necessary to fix the fragment to the skin of perineum, along anal circumference one should apply sutures between serous membrane of descended colon and anal mucosa. For internal fixation one should apply sero-serous sutures along colonic circumference between rectal stump and descended colonic department. On sutures' healing one should dissect the transplant's excess up to the place of anal mucosa transition into perineum skin. The innovation enables to simplify the operation on colonic descending in patients with colostoma after Hartmann's type operation.

EFFECT: higher efficiency.

1 cl, 1 ex

Description

The invention relates to medicine, namely to coloproctology. Due to the widespread occurrence of colorectal cancer and colorectal tumors of "low localization", one has to resort to performing an unnatural anus operation, which is a significant medical and social problem. In this case, an alternative method of treatment is to perform the Hartmann operation - the formation of a colostomy and stump of the rectum. Sometimes, in some cases, taking into account clinical and radiological data, it is possible to carry out the next step an operation aimed at eliminating the unnatural anus, by conducting reconstructive surgery on the colon, the operation of its reduction. The latter contributes to a significant solution to the medical rehabilitation problem in colostomized problems and requires surgeons to intensively search for its solution.

The prototype of the operation of lowering the left half of the colon in patients with a colostomy is Duamel's operation of lowering the rectum. After the lower or paramedial laparotomy, the sigmoid colon rises and is marked with gray-serous sutures at the level of the proximal resection line, then the lower part of the sigmoid colon is skeletonized up to the rectum, and then resected; both stumps are closed with a two-row seam. The back wall of the stump of the rectum is bluntly, with the index finger of the right hand released from the front surface of the sacrum, without touching the vascular and nerve trunks passing in both lateral ligaments of the rectum. Then the operation is continued from the perineum, while the posterior half of the circumference of the anus is cut with a scalpel along the boundary between the skin and the mucosa. The posterior wall of the rectum is dissected inside the ring of the external sphincter. Bottom fit, connecting with the retrorectal cavity formed from the abdominal cavity, forceps are inserted into it, with which the proximal stump of the sigmoid colon is captured and reduced. The sigmoid colon should be reduced until marking gray-serous sutures appear in the anus. At this point, the sigmoid colon intersects transversely, and the posterior half of its circumference is sewn with catgut sutures to the posterior edge of the anus. The reduced colon in the abdominal cavity is strengthened with several sutures to the rectal stump and the pelvic floor peritoneum is reconstructed above it.

A few days later, a septum consisting of a posterior rectal wall and anterior colon wall is squeezed by Kocher's strong and long clamps, so that the converging ends of the instruments come into contact with each other at the top of the septum. After the crushed triangular section of the intestinal wall is necrotic, Kocher clamps fall off and a single cavity of the rectum ampoule forms (I. Littmann - “Abdominal Surgery” - third edition - Budapest - 1970 - p. 385).

However, the above method has several disadvantages:

1. The method is expensive, so its widespread use in ordinary surgical clinics is limited and possible only in highly specialized coloproctology centers;

2. The second stage of Duhamel’s operation is quite complicated and requires surgeons to have special training and operating equipment;

3. When releasing the colon according to Duhamel, it is not always possible to achieve a sufficient transplant length for releasing the intestinal tube;

4. One of the frequent and formidable complications of the method described above is ischemia of the wall of the reduced intestine with the subsequent occurrence of extensive perineal phlegmon.

The authors propose their own method of releasing the left half of the colon in colostomy patients. The operation begins traditionally - they perform a lower middle laparotomy, revision of the abdominal organs and the descending part of the colon, especially the knee of the intestine involved in the formation of a colostomy. In this case, a prerequisite is the length of the left half of the colon, such that it matches the length from the colostomy to the place of transition of the mucosa of the anal canal to the skin of the perineum. After this, the stage of mobilization of the colon participating in the formation of the colostomy begins. Moreover, an important point is the preservation of blood vessels that feed the wall of the colon. Next, a lanceolate skin incision is made before aponeurosis of the superficial oblique muscle of the abdomen, in the center of which is a colostomy. Through this incision, a colostomy with a skin flap is dislocated into the abdominal cavity, thus mobility of the colon section for subsequent reduction is achieved. The wound at the site of the colostomy is sutured tightly. The next stage of the operation is the formation of an opening in the dome of the rectum, which is carried out by blunt or acute perforation of the intestinal wall both from the side of the anal canal (using forceps) and from the side of the operating area (using a scalpel). The diameter of the hole in the dome of the intestine should provide free immersion in the lumen of the rectum of the skin flap with the stoma and the lower part of the left half of the colon to be reduced. The indicated stage of the operation is achieved as follows - from the anus into the anal canal and rectum, a forceps are inserted through the perforation hole, after which a lanceolate skin flap with a stoma is captured with subsequent traction on itself, thus moving the skin flap with a colostomy through the anal canal to the perineum . Then, from the perineal side, the reduced flap of the skin with the stoma is fixed to the perineal skin, and a traditional skin suture is applied. Also, for the purpose of external fixation, separate nodal sutures are made around the circumference of the anus between the reduced section of the intestine (serous membrane) and the mucous membrane of the anus in an arbitrary amount. From the side of the surgical wound, with the purpose of internal fixation of the reduced section of the intestine to the rectal stump, individual gray-serous sutures are made along the circumference of the intestine between the stump of the rectum and the reduced section of the colon. The operation is completed traditionally with adequate drainage of the pelvic spaces and layer-by-layer suturing of surgical wounds. In the postoperative period, after the sutures between the perineal skin and the skin flap with a colostomy are healed (approximately on the 14th day), an excess of the intestinal transplant is excised to the point where the mucosa of the anal canal passes into the perineal skin, thus achieving a cosmetic and plastic effect.

The method proposed by the authors has advantages:

1. The proposed method is the least traumatic;

2. The method does not require special equipment and equipment;

3. Simple enough in operational execution, therefore, can be used widely in practical health care;

4. The proposed method prevents lowering of the intestine, and therefore significantly reduces the likelihood of developing purulent-destructive complications in the pelvic cavity;

5. The method to a lesser extent changes the innervation of the pelvic organs, which is an important point in further preventive measures.

According to the method specified by the authors, 21 people were operated on. Clinical example: case history No. 2216. Patient K., 34 years old, was admitted to the oncology department for reconstructive surgery. In the patient’s history, cancer of the sigmoid colon of the second century, 6 months ago, was operated on an emergency basis due to intestinal obstruction of the obstructive genesis against the background of cancer of the sigmoid colon. During an emergency intervention, a Hartmann-type operation was performed: resection of the sigmoid colon with a tumor, followed by colostomy. With repeated hospitalization (in the oncology department) with contrast radiography of the rectum and irrigoscopy through a sigmoid, it was found that reconstructive surgery is possible. Under endotracheal anesthesia, a lower middle laparotomy was performed - adhesions were dissected, the pelvic cavity was revised, and a sufficiently long rectal stump was found. Next, the colostomy was isolated through a separate incision. After which a partial mobilization of the left half of the colon was made, all the vessels supplying its wall were preserved. Perforation of the dome of the rectum was performed, followed by reduction of the left half of the colon by the described method. The fixation of the reduced part of the intestine was made both from the side of the pelvic cavity and from the perineum. The excess of the reduced part of the intestine with a flap of skin on the perineum was 12 cm. The wounds were sutured in layers, the pelvic cavity through a separate contraperture was drained by a tubular drainage. The postoperative period is smooth, on day 15 under intravenous anesthesia, an excess of the intestine with a skin flap from the perineum was excised using a dielectric coagulator. The postoperative course is smooth. On the 22nd day after the operation, the patient was discharged home, able-bodied.

Based on clinical practice, the average length of stay of patients in a hospital operated on by the method proposed by the authors below is 23.4 days.

Claims (2)

1. The method of lowering the left half of the colon in patients with a colostomy after a Hartmann type operation, including performing a lower middle laparotomy, revision of the abdominal cavity and the lower part of the colon, characterized in that they mobilize the colon involved in the formation of the colostomy, while maintaining the nourishing wall of the vessels a lanceolate skin incision is made before aponeurosis of the superficial oblique muscle of the abdomen; through this incision, a colostomy with a skin flap is dislocated into the abdominal cavity, a wound at the site of the colostomy they sew tightly, form a hole in the rectum dome by blunt or sharp perforation of the wall from the side of the anal canal and the operating zone, forceps are inserted from the side of the anus into the anal canal and rectum, grab a lanceolate skin flap with a stoma with subsequent traction on itself and move it through the anal canal on the perineum, the reduced flap is fixed to the perineal skin with a skin suture, separate nodal sutures between the serous membrane of the reduced intestine and mucus are applied around the circumference of the anus for external fixation o of the anus, for internal fixation, gray-serous sutures are made around the intestine between the stump of the rectum and the reduced part of the colon, after which the pelvic space is drained, layered wounds are sutured, after the sutures are healed, an excess of the intestinal transplant is excised to the junction of the anal canal into the skin of the perineum. 2. The method according to claim 1, characterized in that the diameter of the hole in the dome of the intestine is formed sufficient for free immersion in the rectal lumen of the skin flap with the stoma and the left half of the colon to be reduced.