RU2323688C1 - Method of ileocystoplasty - Google Patents

Abstract

FIELD: medicine, urology.

SUBSTANCE: segment of large intestine is mobilised together with 25-30 cm of ileum. Intestine is transected at the level of mobilisation. Intestine continuity is restored. Walls of large and small intestines are dissected by single 8-10 cm incision along antimesenteric edge and crossing ileocecal (Bauhin's) valve. Vermiform appendix is removed. Tunnel is made below mesentery of sigmoid colon. Mobilised segment of ileum is passed through tunnel into the left lateral flank. Mobilised segment of large intestine is transferred into small pelvis. Urethrointestine anastomosis is formed. Left and right urethrointestine anastomoses are formed. Left urethrointestine anastomosis is formed between small intestine and left ureter without transfer. Incisional wound of large and small intestine is sutured crosswise.

EFFECT: reservoir function of de novo formed urinary bladder is restored.

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Description

The invention relates to medicine, namely to the technique of forming the bladder from the ileocecal angle of the intestine in the surgical treatment of cancer.

A known method of bladder replacement according to Gil Vernet [Chukhrienko D.P., Lyulko A.V., Romanenko N.T. Atlas of urogynecological operations. - Kiev: Vishcha school, 1981. - 344 p. (C.112)], in which "use the ileocecal segment. The bladder is replaced by a segment of the colon, and the ureter is replaced by a segment of the ileum. The transplanted intestinal segment is peritonized. ”

The use of this method is limited to subtotal bladder resection. The method cannot be used when performing a cystectomy, since the use of this method involves the preservation of the bladder in the urethra, which is unacceptable in patients with cancer.

There is a method of creating a urinary reservoir [Stepanov EA, Sakovich P.V., Kurnosov A.V., Abdulaaev F.K., Ulliev Yu.B. An isolated urinary reservoir from the ileocecal segment // Urology and Nephrology. - 1991. - No. 6. - S.63-66], in which a laparotomy is performed, segment mobilization with the release of 10 cm of the ascending and 8 cm of the ileum. Restore the continuity of the gastrointestinal tract by forming a small intestinal anastomosis. Ureters are implanted in the ascending part of the segment through a submucous tunnel about 2 cm long. The colonic section of the created reservoir is sutured tightly. The ideal part is removed on the skin, the tank is drained with a rubber tube.

The disadvantage of this method is the excretion of urine on the anterior abdominal wall, which is antiphysiological, as well as the need for independent excretion of urine by the patient himself using a catheter, which practically cannot ensure the quality of life of the patient. With this option, plastic surgery requires significant mobilization of the left ureter and its movement under the mesentery of the sigmoid colon, as a result of which it changes its natural location, which will negatively affect urodynamics. In addition, the mobilization of the ureter for a considerable extent can lead to a violation of the blood supply to its wall.

The known "method of forming a large intestinal reservoir for urine" [Gotsadze D.T., Nemsadze G.G., Chigogidze T.G., Danelia E.V., Pirtsakhalaishvili G.G., Chovelidze Sh.G. Formation technique for urine of a large intestinal reservoir // Urology and Nephrology. - 1990.- No. 6. - S.35-39], in which use the right half of the colon and the terminal section of the small intestine with a length of 15-20 cm. Appendectomy is performed. The transverse colon is crossed in the proximal third with the UO-60 apparatus and sutured tightly. The ileum is crossed 15-20 cm before the ileocecal valve. An ileotransversoanastomosis is formed. Through the exposed retroperitoneal space at the intersection of the ileum, mobilization, intersection at the bladder and intubation of the ureters are performed. Mobilize the posterior surface of the cecum. Produce cecotomy. Under visual control, a submucosal canal is formed along the posterior wall of the intestine, the ureters are transplanted retroperitoneally, and they are fixed to the colon mucosa. The colotomy wound is sutured tightly. A urine restraining device is formed. Kutaneourinostomy is formed in the right iliac region below the navel. Ureteric catheters and a drainage reservoir tube are removed along it. After suturing the abdominal cavity, the incision is extended to the pubic joint and a cystectomy is performed. A restraining mechanism is then formed to prevent spontaneous flow of urine. The lumen of the terminal portion of the small intestine is narrowed (prior to mucosal contact) by applying serous sutures along the mesenteric edge of the segment of the small intestine.

The disadvantage of this method is the excretion of urine on the anterior abdominal wall, which is antiphysiological. In addition, the disadvantages of the method include the need for excretion of urine by the patient using a catheter every 5-6 hours, which significantly reduces the quality of life of the patient. Removal of the appendix leads to the formation of a sutured wound on the wall of the cecum, which reduces the mechanical strength of the reservoir. With this option, plastic surgery requires significant mobilization of the left ureter and its movement under the mesentery of the sigmoid colon, as a result of which it changes its natural location, which negatively affects urodynamics, and mobilization of the ureter for a considerable length can lead to disruption of blood supply to its wall.

A known method of derivation of urine [Toktomushev A.T., Sayakov U.K., Mukambetov K.M., Iyazaliev K.T., Murzaliev A.Zh., Motuzova V.T. A method for urinary derivation in cystectomy for transitional bladder cancer / Urology and Nephrology. - 1996. - No. 1. - P.21-22], in which a laparotomy is performed, the ureters are mobilized, and a cystectomy is performed. Cross the right half of the colon at the level of the hepatic bend and the ileum at a distance of 15 cm from the ileocecal angle. Intestinal patency is restored by small bowel anastomosis. Perform appendectomy. The distal part of the formed intestinal reservoir is rotated 90 ° clockwise and placed retroperitoneally in the small pelvis. The ileum is narrowed (urinal) and removed into the right ileal region. The ureters are transplanted into the urinary reservoir. Peritonization and drainage of the bed of the bladder.

The method has the same disadvantages as the above analogue.

A known method of reconstruction of the bladder by a reservoir from the ileocecal section of the intestine [Komyakov B.K. Reconstruction of the bladder with a reservoir from the ileocecal section of the intestine // Urology and Nephrology. - 1996. - No. 5. - S.16-19], in which the mobilization of the blind and ascending colon. For plastics, a section of the cecum and ascending intestine is taken with a length of 15 cm and 30-50 cm of the ileum. The ileoascendoanastomosis is performed end to side, after which the selected ileocecal section is dissected along the mesenteric edge, the segment is laid to the segment, sutured with medial edges, and then turned through 180 ° and anastomosed with the urethra. Submucous antireflux transplantation of the ureters and the final formation of the intestinal bladder are performed. Drainage of the reservoir is carried out along the urethra with a Foley catheter, with which one of the ureteral intubators is removed, the second intubator is carried out through the suprapubic region.

The method has the same disadvantages as the above analogues. In addition, it is technically complex. The formation of an anastomosis between the urethra and the reservoir involves the connection of two tubular organs, one of which is at least 5 cm in diameter (stitched colon and ileum), and the other about 1.0-1.5 cm, with the final formation of the intestinal bladder after the formation of anastomosis between the intestine and the urethra, that is, the surgeon is forced to suture for the final formation of the reservoir deep in the pelvic cavity, and a 180 ° turn of the right half of the colon often causes a disturbance in the blood supply mobilized th segment of the colon, which can lead to the development of insolvency of the sutures of the reservoir. An unfavorable method, in addition, is the dissection of the colon and small intestine throughout, which increases the risk of developing anastomotic suture failure.

A known method of cystoplasty according to Goldwasser B. and Webster C. [Managadze L.G., Chigogidze T.G., Rodionov I.A., Gotsadze D.T. Methods of supravesical urinary diversion and cystoplasty // Urology and Nephrology. - 1994. - No. 3. - S.45-49], selected as a prototype, which is based on the detubularization of the segment of the blind-ascending colon. The segment is isolated on the leg, crossed in the proximal part of the transverse colon and in the region of the ileocecal angle. Further along the antimesenteric edge, the segment is opened. Only a section of the cecum 3-5 cm long remains tubular; urethrocolonostomy is formed. An open segment of the colon on the periphery is bent and anastomosed with the cecum. Remove the appendix. Anastomosis is applied between the stumps of the appendix and the urethra.

The disadvantage of the prototype method is that with this option, plastic surgery requires significant mobilization of the left ureter and its movement under the mesentery of the sigmoid colon, as a result of which it changes its natural location, which negatively affects urodynamics. In addition, mobilization of the ureter over a considerable period can lead to a violation of the blood supply to its wall and the development of insolvency of the sutures of the urethrointestinal anastomosis. The intersection of the ileum in the ileocecal angle can lead to the technical complexity of the further stages of the operation and the development of severe complications - inconsistency of sutures of the small intestine anastomosis or necrosis of the cecum wall. This is due to the fact that the terminal ileum has a common blood supply to the cecum (ileo-colon artery). After crossing the ileum at the ileocecal angle, the surgeon must lower the cecum into the pelvic cavity to form the urethrointestinal anastomosis, therefore, the ileo-colon artery should move into the small pelvis. At the same time, for the formation of a small intestinal anastomosis, the surgeon must move the terminal ileum to the transverse colon, and therefore, the ileo-colon artery should move opposite upward. As a result, either technical difficulty will arise in the formation of one of the anastomoses, or the surgeon should hope that the blood supply to the terminal ileum will be due to the small intestinal arteries. However, back in 1938, Ioffe I.L. [Ioffe I.L. Surgical anatomy of vascularization of the terminal ileum // Bulletin of Surgery. - 1938. - T. 56, No. 7. - S.96-99] showed that "the median division of ilei terminalis, corresponding to the lower periphery of the ileo-colic circle, eats worse than the marginal." In this regard, the author pointed out that “for the vast majority of cases, when choosing a site for resection or anastomosis in this mid section, insufficient nutrition can jeopardize the outcome of the operation. The blood supply conditions of ilei terminalis, therefore, dictate the need to transfer the site of resection or anastomosis in any case to the initial section of ilei terminalis, i.e. 20-25 cm proximal to coeci, where the uniformly supplied small intestine ends. ” This rule is followed by the majority of surgeons at present [Ganichkin A.M. Colon cancer - L .: Medicine, 1970. - 416 p.], [Efimov G.A., Ushakov Yu.M. Complicated colon cancer. - M .: Medicine, 1984. - 152 p.].

The invention solves the problem of reliably restoring the reservoir function of a newly formed bladder by preventing urodynamic disturbances and ureter blood supply, ensuring the mobility of the mobilized intestinal segment and preventing its blood supply disturbance, and simplifying the technique for suturing a bowel wall defect.

The problem is solved in that the colon is mobilized together with 25-30 cm of the ileum, a tunnel is formed under the mesentery of the sigmoid colon and a mobilized segment of the ileum is drawn through it into the left lateral flank, the wall of the colon and small intestine is cut with one cut for 8 10 cm passing through the Bauginium damper, the left urethrointestinal anastomosis is formed between the small intestine and the left ureter without moving the latter, moreover, when the right urethrointestinal anastomosis is invaginated niruyut colon wall, while forming the left wall invaginate uretrokishechnogo anastomosis of the small intestine, forming a tunnel polnosloynoy wall of the colon and small intestine, respectively, and then wound colon and small intestine sutured in transverse direction.

New in the claimed solution is that the mobilization of the colon is carried out together with 30 cm of the ileum, which is introduced into the left side flank through the tunnel under the mesentery of the sigmoid colon, which allows the formation of the left urethrointestinal anastomosis without additional mobilization and movement of the ureter. This, in turn, helps to maintain normal urodynamics and eliminates the possibility of a violation of its blood supply. Mobilization of the colon along with 30 cm of the ileum allows you to provide the necessary mobility of both the mobilized segment of the colon and small intestine, and a segment of the intestine designed to form a small bowel anastomosis. In addition, mobilization of the colon along with 30 cm of the ileum allows you to maintain adequate blood supply to the terminal ileum due to the preservation of the ileo-colon artery. The dissection of the wall of the colon and small intestine, followed by suturing of the wound of the intestinal wall in the transverse direction, which is technically much simpler than the formation of an anastomosis between the bent and open on the periphery segment of the colon and cecum, is also new.

The essence of the method is illustrated by drawings, where

figure 1 - mobilization of the right half of the colon, flashing hardware suture of the colon and ileum, where

1 - ureteral catheters;

2 - the right ureter;

3 - the left ureter;

4 - the direction of mobilization of the right half of the colon;

5 - large intestine;

6 - ileum;

7 - hardware seam;

figure 2 - the formation of colonic anastomosis, the formation of the tunnel under the mesentery of the sigmoid colon, where

8 - small bowel anastomosis;

9 - a tunnel under the mesentery of the sigmoid colon;

10 - mesentery of the sigmoid colon;

11 - sigmoid colon;

figure 3 - holding a mobilized segment of the ileum through the tunnel under the mesentery of the sigmoid colon in the left side flank, where

5 - large intestine;

6 - ileum;

9 - a tunnel under the mesentery of the sigmoid colon;

12 - the direction of the mobilized segment of the ileum through the tunnel under the mesentery of the sigmoid colon in the left side flank;

13 - left side flank;

figure 4 - section of the wall of the colon and small intestine, appendectomy, where

5 - large intestine;

6 - ileum;

14 - direction of dissection of the wall of the colon and ileum;

15 - level of intersection of the appendix;

16 - appendix;

figure 5 - the formation of both urethrointestinal anastomoses, excretion of the ureteric catheters through an opening in the wall of the colon at the site of the removed appendix, where

1 - ureteral catheters;

2 - the right ureter;

3 - the left ureter;

5 - large intestine;

6 - ileum;

17 - right urethrointestinal anastomosis;

18 - left urethrointestinal anastomosis;

19 - hole in the wall of the colon at the site of the removed appendix;

6 - suturing of the wound of the intestine and the imposition of nodal sutures between the wall of the colon and the crossed end of the urethra, where

5 - large intestine;

6 - ileum;

20 - sutured wound of the intestine;

21 - nodal sutures between the wall of the colon and the crossed end of the urethra;

22 - the urethra;

Fig.7 - removal of the ureteral catheters through the urethra to the outside and the Foley catheter into the colon through an opening in the wall of the colon at the site of the removed appendix, where

1 - ureteral catheters;

5 - large intestine;

19 - hole in the wall of the colon at the site of the removed appendix;

22 - the urethra;

23 - the direction of excretion of the ureter catheters through the urethra to the outside;

24 - Foley's catheter;

25 - the direction of the Foley catheter in the colon;

Fig - completion of the formation of the urethrointestinal anastomosis, a decrease in the diameter of the tunnel opening under the mesentery of the sigmoid colon and fixation of the small intestine to the medial surface of the mesentery of the sigmoid colon, where

10 - mesentery of the sigmoid colon;

11 - sigmoid colon;

21 - nodal sutures between the wall of the colon and the crossed end of the urethra;

26 - urethrointestinal anastomosis;

27 - seams that reduce the diameter of the tunnel opening under the mesentery of the sigmoid colon;

28 - sutures that fix the small intestine to the medial surface of the mesentery.

The method is as follows.

Cystectomy is performed. Catheterize with ureteral catheters 1 right 2 and left 3 ureters. 4 the right half of the colon 5 is mobilized to the border of the right and middle third of the transverse colon and 30 cm of the ileum 6, after which the large 5 and ileum 6 are double stitched with a hardware suture 7 at the mobilization level and intersected between the lines of the hardware suture. Restore intestinal continuity by forming a small intestinal anastomosis 8 end to end. A tunnel 9 is formed under the mesentery 10 of the sigmoid colon 11. A mobilized segment of the ileum 6 is guided 12 through the formed tunnel 9 into the left side flank 13. Cut the wall of the large 5 and ileum 6 along one side for 10 cm. In this case, the section passes through the Bauginium valve . The 15 appendix is removed 16. The right urethrointestinal anastomosis 17 is formed between the right ureter 2 and the anterior wall of the colon 5. The left urethrointestinal anastomosis 18 is formed between the left ureter 3 and the anterior wall of the ileum 6, drawn through the tunnel under the mesentery of the sigmoid colon of the left intestine. The ureter catheters 1 are removed through an opening 19 in the wall of the colon 5 at the site of the removed appendix. Sutured 20 wound of the colon 5 and ileum 6 in the transverse direction. A urethrointestinal anastomosis is formed, for which nodal sutures 21 are applied between the wall of the colon 5 and the crossed end of the urethra 22. The ligatures of the sutures are not tied. Ureteric catheters 1 through the urethra 22 lead 23 out. The Foley catheter 24, previously inserted into the urethra 22, is passed 25 into the colon 5 through hole 19 at the site of the removed appendix. The ligatures of the nodal sutures 21 are tied, completing the formation of the urethrointestinal anastomosis 26. The diameter of the tunnel opening under the mesentery 10 of the sigmoid colon 11 is reduced by separate sutures 27. The small intestine 28 is fixed to the medial surface of the mesentery 10 of the sigmoid colon 11. The abdominal cavity is drained. Suture the wound of the abdominal wall.

An example of a specific implementation of the method.

Patient K., 52 years old, was admitted to the urology department with a diagnosis of bladder cancer T4N0M0. On August 14, 2004, a radical cystectomy was performed. Both ureters are catheterized. Produced ileocecocystoplast according to the claimed method. Foley's catheter was removed on day 16, ureteral catheters on day 14. The patient was discharged from the department on the 22nd day. There are no signs of failure of the sutures of the anastomoses. Examined after 6 and 12 months. No anastomotic strictures were found. The capacity of the urinary reservoir created from the intestine is 400 ml.

According to the claimed method, 4 patients were operated on. Complications in the postoperative period and in the long term were not found.

Claims (1)

The method of ileoceocystoplasty, which includes cystectomy, mobilization of the right half of the colon, crossing the intestine at the mobilization level, restoration of intestinal continuity, dissection of the intestinal wall along the mesenteric margin, removal of the appendix, formation of the right and left urethrointestinal anastomoses, movement of the small intestinal mobilized pelvis, the formation of a urethrointestinal anastomosis, characterized in that the mobilization of the colon is carried out together with 25-30 cm of the ileum flanges, form a tunnel under the mesentery of the sigmoid colon and pass through it a mobilized segment of the ileum into the left lateral flank, cut the wall of the colon and small intestine in one section for 8-10 cm passing through the Bauginium valve, the left urethrointestinal anastomosis is formed between the small intestine and the left the ureter without moving the latter, and the wound of the colon and small intestine is sutured in the transverse direction.

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