RU2321363C2 - Method for applying intestinal suture at forming anastomoses upon the organs of gastro-intestinal tract - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should treat suturing ligature with 10%-ximedone solution, suture intestinal wall through all the layers at the distance of 3 mm against the edge, capture muscular and submucous layers of both edges of intestinal wound with a circular backward suture, withdraw the ends of ligature onto the opposite side of serosa at the distance of 3 mm against the edge, treat the line of suture with 10%-ximedone solution, tighten the ends of ligature outwards to form a knot, prescribe the intake of ximedone per 0.4 g 4 times daily for 10 d. The innovation enables to decrease the risk of infection of the suturing ligature and suturing canals and accelerate tissue regeneration.

EFFECT: higher efficiency.

3 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery, and is intended for the formation of intestinal anastomoses in patients with pathology of the gastrointestinal tract.

Known double-row intestinal suture when stitching hollow organs according to Albert, which consists in the fact that the inner row is superimposed through all layers with a marginal twisted suture, and the outer one with a serous-muscular suture. However, it has the following disadvantages: 1) the application of a significant mechanical injury to the mucous membrane is not ruled out, which causes the development of severe inflammatory phenomena in the anastomotic zone; 2) the possibility of infection of the suture thread is created, and in a number of observations, the formation of an extensive ulcerative defect in the anastomotic region and the growth of granulation tissue with the formation of a wide and rough scar [7, 9].

Known double-row intestinal suture (SP Zhuchenko et al.) [8], devoid of the above disadvantages, taken by us as a prototype, which consists in the fact that, having retreated 5-6 mm from the edge of the intestine, the serous-muscular layer is sutured, punctured carried out at 0.4 cm from the edge, then with the same needle and thread, departing from the edge by 2-3 mm, stitch the serous, muscle membrane with the capture of the submucous opposite edge of the intestine. After that, the thread is passed through the submucosal, muscle and serous membranes, 2-3 mm from the edge of the wound of the opposite segment of the intestine, then the serous-muscle layer of the opposite edge is sutured with the same thread, making an injection at a distance of 4 mm, and a puncture at a distance of 6 mm from the edge of the intestine. After that, tighten and tie the thread. When forming an anastomosis, the first suture is applied and it is clamped, then the second, then the third, and the second is tied, the fourth is applied, and the third is tied. However, this method has the following disadvantages: 1) an exact comparison of stitched tissues with serous surfaces is not achieved, since the edges of the mucous membrane are turned outward [10];

2) turning the intestinal mucosa outward violates the biological integrity of the suture and leads to leakage of intestinal contents into the abdominal cavity, thereby causing bacterial contamination and enzymatic alteration of tissues, which leads to the development of local peritonitis in the anastomosis zone, healing of the suture line by secondary tension, followed by a high risk of insolvency intestinal anastomosis of cicatricial stricture of the anastomosis;

3) when suturing, there is no adaptation of the mucous membranes of stitched sections, therefore, when using this method, there is no biological tightness, healing of the suture line occurs by secondary tension with a high risk of formation of scar stricture; 4) when suturing in the prototype, it is necessary to reload the needle with a thread that sutures at the moment of suturing the serous membrane, thereby contamination of the surgeon’s hands with intestinal microflora occurs.

To improve the healing process, methyluracil is used locally in the form of a 0.8% solution and inside in the form of tablets of 0.5 g 3 times a day [1, 4, 5]. However, this method has the following disadvantages: 1) with local and internal use does not have an antimicrobial effect [2, 3]; 2) does not cause a noticeable intensification of regeneration processes; 3) does not have a positive therapeutic effect on the motility of the gastrointestinal tract, the dysfunction of which exists after surgery [5, 6].

The method of using methyluracil locally and internally was taken by us as an analogue.

The purpose of the invention is the prevention of complications during operations on the gastrointestinal tract.

The goal is achieved by pre-treating the suture with 10% xymedon solution, after which the intestinal wall is first sutured through all layers at a distance of 3 mm from the edge, and the mucous membrane is sutured not through and through, but at the base tangentially, after which only muscle muscle is captured with a circular return suture and submucosal layers without the mucous membrane of both edges of the intestinal wound, the thread is brought to the opposite side of the serous membrane at a distance of 3 mm from the edge, the loose threads are pulled, the suture line is treated with a 10% xymedo solution and then knotted yarn ends outside the node and xymedon designate the interior of 0.5 g 4 times a day for 10 days.

1. Stitching of the intestine through all layers with the capture of the mucous membrane not through, but at the base tangentially initially from the outside to the inside, and then additional suturing from the inside with a circular return suture of only the submucosal and muscle layers with the suture at the edge of the serous layer and then removing it outside allows first by pulling the withdrawn ends of the thread to accurately match all layers of the intestinal wall, and then when tying the knot of the ends of the thread outward, reliably cover the suture line with the serous membrane, thereby increasing physical and biological tightness of the anastomosis.

2. Sewing the intestinal wall through all layers with the capture of the mucous membrane not through and through, but at the base tangentially prevents the mucous membrane from wrapping up, thereby increasing the biological tightness of the anastomosis, which reduces microbial contamination and prevents the development of postoperative complications during operations on the organs of the gastrointestinal tract.

3. The additional holding of the suture with an internal circular return suture with the internal capture of only the submucosal and muscle layers with a puncture at the edge of the serous layer without its capture, first on the one and then on the other hand, allows to obtain the correct ratio of the layers of the intestinal wall, strict adaptation of its edges, increase strength postoperative scar and thereby reduce the number of postoperative complications.

4. Additional capture of the submucosal layer with an internal circular return suture without suturing the mucous layer prevents the eversion of the latter, enhances the mechanical strength of the anastomosis.

5. Uniform simultaneous pulling of the ends of the thread from the two edges of the intestinal wound allows you to accurately match the layers of tissue of the connected wound.

6. When connecting the edges of the wound with an internal suture, they are not screwed in and out, and the additional strengthening of the suture line with the serous membrane allows a good adaptation of the edges of the wound, creating optimal conditions for its healing and thereby preventing various complications.

7. The inner loop of the circular return suture, which is under the cushioning effect of the outer loop of the thread tied into the knot from the outside, provides not only good adaptation of the butt edges of the wound, but also subsequently, with a decrease in mechanical strength and tightness for 4-7 days, creates sutures as easy as possible when they erupt not outward, but into the intestinal lumen. In this case, the adaptation of the serous membrane by the external loop of the suture prevents infection of the anastomotic zone, and by that time complete regeneration in the mucous membrane has occurred, which prevents infection of the suture line from the intestinal lumen. In addition, the eruption of the inner loop leads to decompression of the intestinal wall and thereby to improved microcirculation in the area of the suture line.

8. Preliminary impregnation of the suture with 10% xymedon solution and treatment of the anastomosis line with 10% xymedon solution helps to reduce infection of the anastomotic tissue area itself as a result of contact between the suture channels and suture material (ligature infection) with the organ lumen and its contents, as well as massive collagen lysis in zone of anastomosis and the change of this process by collagenogenesis. As a result, this increases the mechanical and biological strength, and also improves the reparative regeneration of stitched tissues and thereby prevents subsequent complications (inconsistency of sutures, anastomositis, cicatricial stenosis).

9. The use of xymedon inside at a dose of 0.5 g 4 times a day for the next 10 days stimulates the processes of reparative regeneration of the suture line, stimulates the body's defenses and thereby contributes to the formation of a dense but elastic postoperative scar.

The stages of the implementation of the adaptive precision seam are presented in figures 1, 2, 3.

The proposed method is as follows.

An atraumatic needle with a synthetic absorbable thread with a diameter of not more than 4/0, previously impregnated with a 10% solution of xymedon, is injected into the serous membrane (A) at point 1 at a distance of 3-5 mm from the proximal edge of the anastomosed intestine. Then the needle is drawn obliquely inward through all layers and punctured at a point 2 located in the mucous membrane at a distance of 2-2.5 mm from the edge of the cut (Fig. 1). After this, the next injection is made at point 3 on the opposite edge of the anastomosed intestine, also located in the mucous membrane. At the same time, the mucous membrane is not stitched through, but tangentially at the base. Then the needle is directed outward, capture the muscle membrane (B). The needle is punctured at point 4 of the muscle layer of the distal edge of the intestinal wound. The third injection is performed at the opposite point 5 of the muscle layer of the proximal edge of the intestinal wound. Subsequently, the needle is carried out to the submucosal layer (B), where a puncture is performed at point 6 and a subsequent injection at point 7 of the distal edge of the intestinal wound (Fig. 2). The needle is passed through all layers at a distance of 2-2.5 mm from the edge of the cut obliquely outwards and is punctured through the serous layer at point 8 at a distance of 3-5 mm from the distal edge of the intestinal wound. Then the free ends of the threads are pulled and tied outside. The anastomosis line is treated with a 10% solution of Xymedon, and in the postoperative period, Xymedon is administered orally at 0.5 g 4 times a day for 10 days.

Thus, the adaptation-precision suture consists of two adaptive loops, the first mucous-serous, which prevents the mucous membrane from wrapping up; the second submucosal-muscular provides strength and tightness of the anastomosis (figure 3).

Examples.

1. Patient Kosepatov NP 73 years old. History No. 3042. He was hospitalized in the surgical department of MDLP GKB No. 12 from 11/15/2004 to 11/26/2004. Diagnosis: pancreatic cyst. Internal drainage was performed by the formation of a cystoyunoanastomosis with an adaptive-precision suture. The postoperative period is calm. Discharged in satisfactory condition.

2. Patient Yesaulov N.A. 53 years old. History No. 1042. He was hospitalized in the surgical department of MLPU GKB No. 12 from 04/18/2005 to 05/03/2005. Diagnosis: ulcer of the lower third of the body of the stomach. A resection of 2/3 of the stomach was performed according to Billroth-1. Gastroduodenoanastomosis is performed by an adaptive-precision suture. The postoperative period is calm. Discharged in satisfactory condition.

Information sources

1. Davletshin A.Kh., Izmailov S.G., Kedrin M.Yu. et al. Effect of Xymedon on the healing of wounds of the digestive tract. // Act. questions diagnosis and treatment. Squad scientific work. - Kazan. - 1997. - P.36.

2. Izmailov G.A., Reznik B.C., Izmailov S.G. and others. The experience of using the domestic drug Xymedon in surgery. // Act. questions diagnosis and treatment. Squad scientific work. - Kazan. - 1998. - p. 58.

3. Izmailov S. G., Gorbunov S. M., Izmailov G. A. Preclinical study of Xymedon. // Antibiotics and chemotherapy. - 1999. - No. 8. - p.12-17.

4.S.G. Izmailov., G.A. Izmailov., M.Yu. Averyanov., B.C. Resnick. Xymedon in clinical practice. - N. Novgorod: Publishing House of the Novosibirsk State Medical Academy, 2001, 188 p.

5. Kamilov F.Kh., Lazareva D.N., Plechev V.V. Pyrimidines and their use in medicine. // Ufa: Bashk. state medical Institute, 1992, 158 pp.

6. Kedrin M.Yu. Methods of improving the treatment of damage to the duodenum: Abstract. dis ... cand. honey. Sciences: 14.00.27 / Kazan, state medical science. University, VMI FPS of the Russian Federation at NGMA. - Kazan, 1999, 20 p.

7. Korepanov V.I., Stepanyan S.Kh., Pogosyan S.Sh. New types of intestinal suture (Review of foreign literature). J. "Surgery", 1991 - No. 9 - p. 167-172.

8. Zhuchenko S.P., Kostyuk G.Ya. The formation of a double-row intestinal suture. J. "Surgery", 1984 - No. 12 - p.105-106.

9. Kochnev OS. Emergency surgery of the gastrointestinal tract. - Publishing house of Kazan, state. University, 1984, p.200-201.

10. A.F. Chernousov., E.F. Stranadko., L.A. Vashakmadze., V.A. Makhovko. Precision suture during the formation of esophageal anastomoses. J. "Surgery", 1978 - No. 10 - p. 114-119.

Claims (1)

The method of applying an intestinal suture during the formation of anastomoses on the organs of the gastrointestinal tract, including flashing the intestinal wall with an atraumatic needle with a synthetic absorbable suture thread 4/0 in diameter, characterized in that the suture thread is pre-treated with a 10% solution of xymedon, after which the intestinal wall is first sutured through all layers at a distance of 3 mm from the edge, after which the circular and return suture capture the muscle and submucosal layers of both edges of the intestinal wound, after which the thread is brought to the opposite side gray heat of the sheath at a distance of 3 mm from the edge, the free ends of the threads are pulled, the seam line is treated with a 10% solution of Xymedon, after which the ends of the threads are tied on the outside into a knot, and Xymedon is prescribed inside 0.5 g 4 times a day for 10 days .

Images