RU2323690C1 - Method of forming uretrointestinal anastomosis - Google Patents

Abstract

FIELD: medicine, oncology surgery, urology.

SUBSTANCE: to form ureterointestinal anastomosis, lesion in intestine wall resulted from appendectomy is used. For this purpose, six nodal seromuscular stitches around appendix base are sutured. Seromuscular layer of appendix base is dissected circularly, and mucous is transected 2.5-3 cm from cecum cupula. Ureteral stent with ureter fixed upon it is inserted into intestine through hole in cylinder, formed by conserved appendix mucous. Meanwhile, stent is inserted until ureter contacts with conserved appendix mucous. Conserved appendix mucous is ligated by absorbable sutures to ureteral stent. Traction of ureteral stent is used to invaginate mucous and all layers of cecum wall into its lumen to level of early sutured seromuscular stitches. After that, muscular layer of ureter is sutured using ligates of early sutured seromuscular stitches, at level of cecum wall, and tie ligates. In particular case, knotted stitches are sutured at cecum cupula 2.5-3 cm from appendix base, at equal distance one from another. At the same time, ligates of stitches are not tied but hold in foreceps.

EFFECT: provides even and firm approximation of spliced homogenous surfaces in forming ureterointestinal anastomosis and decreases possibility of ureter trauma, due to simplification of intestine lumen invagination technique.

2 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, oncourology, can be used to form the ureter-intestinal anastomosis in intestinal plasty after cystectomy, for example, in patients with bladder cancer.

In the formation of the ureteral-intestinal anastomosis, it is necessary to ensure its reliability and antireflux properties. In most cases, this is achieved by forming a tunnel in the intestinal wall and holding the ureter into the intestinal lumen through the formed tunnel. However, this raises a number of difficulties associated with the need to ensure uniform tight fitting of the ureter wall with the tissues of the formed tunnel, as well as the need to reduce injuries of the ureter during its passage through the formed tunnel.

A known method of forming ureterosigmoanastomosis [Pat. 2183425 Russia, IPC А61В 17/00, А61В 17/11. The method of formation of ureterosigmoid anastomosis / B.K. Komyakov (RU), S.I. Gorelov (RU), A.I. Novikov (RU), A.I. Gorelov (RU), B.G. Guliev (RU), A .V. Sergeev (RU), V.A. Fadeev (RU), O.F. Kagan (RU), A.M. Granov (RU); Central Health Unit 122 (RU), Central Research X-ray and Radiological Institute (RU). - No. 2001120886/14; Claim 07/26/01; Publ. 06/20/02], in which the intestine is dissected in the rectosigmoid region along the mesenteric margin. Create a tunnel for implantation of the ureter with the formation of a rectosigmoid reservoir. The tunnel is created extramurally. The back wall of the reservoir is formed by applying gray-serous sutures. The ureters are placed on the created wall towards each other. The ureters are fixed to the wall of the intestine. Stitch the edges of the intestine with each other. The method allows to increase antireflux protection, reduce the risk of stricture of the ureters.

The disadvantage of this method is the low reliability of the formed anastomosis due to the fact that a large contact area of the fused surfaces is provided by the intestinal mucosa. Inflammatory processes in the mucous membrane, a violation of its blood supply during the formation of an anastomosis, can lead to the development of necrosis of the mucous membrane, which increases the risk of anastomotic suture failure in the near postoperative period, and subsequently can lead to the development of anastomotic stricture. In addition, the formation of an anastomosis involves the formation of an extramural tunnel, that is, stratification of the intestinal wall, which is technically not always easy. Creating a tunnel only from the mucous membrane cannot prevent subsequent reflux from the intestinal reservoir into the ureter.

A known method of forming the ureter-intestinal anastomosis [Pat. 2229853 Russia, IPC А61В 17/00. The method of the ureteral-intestinal anastomosis / V.A. Atduev (RU), V.A. Ovchinnikov (RU), A.A.Senichev (RU), N.P. Shachkova (RU), A.I. Abelevich (RU) ; SI Nizhny Novgorod State Medical Academy (RU). - No. 2002133178/14; Claim 12/09/02; Publ. 10.06.04], including the formation of an opening in the intestinal wall comparable with the outer diameter of the ureter and the application of an anastomosis, characterized in that the distal part of the ureter is first dissected along the non-vascular surface, the formed end of the ureter is flashed with ligatures, one of which is located in the center, the other two are at the corners of the ureter, the ligature is carried out into the intestinal opening and stitched from the inside out to a certain distance from the edge of the intestinal opening pulling on the ligature, immersed distally into the intestinal lumen the ureter, the ends of the ligatures are tied in pairs, forming the first row of anastomotic sutures, the second is formed between the adventitious layer of the ureter and the serous layer of the intestine.

The disadvantage of this method is the small contact area of the fused surfaces, equal to the thickness of the intestinal wall, which reduces the reliability of the formed ureteral-intestinal anastomosis, and also does not prevent the occurrence of reflux from the intestine into the ureter. In addition, the method involves the use of a large number of sutures, as a result of which there may be a violation of blood supply in the walls of the anastomosed organs and lead to the development of insolvency of the sutures of the anastomosis.

A known method of the ureteral-intestinal anastomosis [Vasilchenko M.I., Sergienko I.O., Belyaev LB, Zagarova V.I., Proletarsky A.V. New variants of intestinal bladder plastic surgery in the experiment // Urology. - 2001. - No. 5. - S.7-12], in which “the ureters were intubated and implanted above the formed valve according to the antireflux technique by separating and removing the serous-muscular layer in the form of a rectangle of 0.6 × 3.0 cm. The mobilized ureter was fixed with single nodal sutures to the proximal the edge of the site at a distance of 1.5 cm from their free end, the end of the ureter was anastomosed with single-row interrupted sutures in the center of the site, invagination sutures were applied to the distal and proximal edges of the submucous site, which tightened whether, simultaneously immersing the wall of the intestine with a dissector in the abduction direction. Intubators were removed through the “front wall” of the urinary reservoir to the skin. ”

The disadvantage of this method is the use of a large number of sutures, as a result of which there may be a violation of blood supply in the walls of anastomosed organs and lead to the development of insolvency of the sutures of the anastomosis. In addition, the operation of this method is technically difficult and not always feasible. So, when separating and removing the serous-muscular layer in the form of a rectangle, the integrity of the intestinal mucosa can be violated, as a result of which the reliability of the formed anastomosis will decrease.

A known method of transplantation of the ureter into the intestine [Pat. 2263474 Russia, IPC А61В 17/00. The method of transplantation of the ureter into the intestine / V.F.Kasatkin (RU), S.V. Kruglov (RU), O.I. Glushkova (RU), Yu.A. Gevorkyan (RU), A.Yu. Maksimov (RU) , M.A. Kozhushko (RU), V.V.Pototsky (RU), N.B. Chizhikov (RU); Rostov Cancer Research Institute of the Ministry of Health of the Russian Federation (RU). - No. 2003129198/14; Claim 02.10.03], in which the ureter is mobilized. A vascular anastomosis is formed between the distal end of the umbilical artery and the internal iliac artery. Why they cross and bandage the umbilical artery proximally at the place of its discharge from the internal iliac artery. The umbilical artery is crossed distally at such a level that the length of the vascular graft allows the ureter to be moved enough to create a uretero-intestinal anastomosis. Re-analyze the umbilical artery. The method allows to maintain adequate blood supply to the ureter.

The disadvantage of this method is the technical complexity of the formed anastomosis, involving the formation of a vascular anastomosis, which requires the involvement of vascular surgeons. The formation of a vascular anastomosis can lead to thrombosis, which increases the risk of inconsistency of the joints of the uretero-intestinal anastomosis.

A known method of transplantation of the ureter into the intestine [Pat. 2256410 Russia, IPC А61В 17/00. The method of transplantation of the ureter into the intestine / V.F.Kasatkin (RU), S.V. Kruglov (RU), O.I. Glushkova (RU), R.E. Gromyko (RU), A.Yu. Maksimov (RU) , D.G. Ilchenko (RU), O.Ya. Danilchuk (RU), A.L. Terpugov (RU); Rostov Cancer Research Institute of the Ministry of Health of the Russian Federation (RU). - No. 2003129280/14; Claim 02.10.03], in which the ureter is isolated together with the fibromuscular layer around the juxtavesical part and a section of the bladder wall around the mouth with a diameter of 7-15 mm. They are prepared using microsurgical technique and the branches of the upper urinary bladder artery and nerves around the ureteric loop going to the ureter are kept. The ureter is transplanted into the intestine. The method allows to mobilize the ureter, while maintaining a natural closure apparatus, blood supply and innervation.

The disadvantage of this method is the need to maintain a section of the bladder in the area of the mouth of the ureter, which in patients with bladder cancer is in most cases not permissible. Another disadvantage of this method is the need to use microsurgical technique, which is technically difficult.

A known method of transplantation of the ureter into the intestine [Pat. 2256409 Russia, IPC А61В 17/00. The method of transplantation of the ureter into the intestine / V.F.Kasatkin (RU), S.V. Kruglov (RU), O.I. Glushkova (RU), R.E. Gromyko (RU), A.Yu. Maksimov (RU) , D.G. Ilchenko (RU), S.V. Sanamyants (RU); Rostov Cancer Research Institute of the Ministry of Health of the Russian Federation (RU). - No. 2003129197/14; Claim 10/02/03; Publ. 07/20/05], in which, when the ureter is mobilized, an ellipsoid flap is cut out of the bladder wall around its intravesical part and urethral opening, the larger diameter of which corresponds to the distance between the ureter and urethral openings and departing from them 2-3 mm laterally. The smaller one is determined individually depending on the anatomical structure of the bladder triangle and the degree of bladder damage by the tumor, but not less than 1 cm.The method of transplantation of the ureter into the intestine allows you to maintain the closure muscle apparatus of the ureter and urethra, improve the quality of life and improve long-term results of treatment of patients.

The disadvantage of this method is the need to maintain part of the urinary bladder triangle, which in patients with bladder cancer in most cases is not permissible.

A known method of transplantation of the ureter into the intestine [Stepanov E.A., Sakovich P.V., Kurnosov A.V., Abdullaev F.K., Ulliev Yu.B. An isolated urinary reservoir from the ileocecal segment // Urology and Nephrology. - 1991. - No. 6. - P.63-66]: “The implantation of the ureters into the ascending segment of the segment was carried out according to the original method: the distal parts of the ureters at a distance of 0.5-1.0 cm were tightly bandaged on polyethylene intubators and implanted in the cecum through a submucous tunnel with a length of about 2 cm, lip-shaped anastomoses were formed by the discharge of the intubators. ”

The disadvantage of this method is the low reliability of the formed anastomosis due to the fact that a large contact area of the fused surfaces is provided by the intestinal mucosa. Inflammatory processes in the mucous membrane, a violation of its blood supply during the formation of an anastomosis, can lead to the development of necrosis of the mucous membrane, which increases the risk of anastomotic suture failure in the near postoperative period, and subsequently can lead to the development of anastomotic stricture. In addition, the creation of a tunnel only from the mucous membrane cannot prevent subsequent reflux from the intestinal reservoir to the ureter, since in most cases part of the mucous membrane in the anastomotic region is necrotic and rejected into the lumen of the hollow organ.

A known method of forming an anastomosis between the ureter and the intestine according to Maydl [cit. according to Dzirne I.Kh. Operative urology. - Petrograd: Publishing house "Practical Medicine", 1914. - 504 p.], In which, after removal of the bladder, the ureter is sutured into the intestine along with part of the urinary bubble.

The disadvantage of this method is the need to use part of the bladder in the region of the bladder triangle, which is possible only if the tumor does not take the place of this triangle.

A known method of forming an anastomosis between the ureter and the intestine according to Chaput-Witzel [cit. according to Dzirne I.Kh. Operative urology. - Petrograd: Publishing house "Practical Medicine", 1914. - 504 p.], In which the back half of the edge of the upper segment of the ureter is a little oblique with 2-3 thin thread or catgut sutures sewn to the back inner side of the colon. In this case, sutures are applied either through the entire thickness of the walls or bypassing the mucous membrane. Parallel to the sewn edge of the ureter, 0.2-0.5 cm from it, the intestinal wall is cut for 1 cm.Then the lower edges of both wounds are also connected with a suture - first the mucous membrane is sutured, and then a suture is placed on the rest of the walls. The ends of the intestinal incision are closed with sutures. On both sides of the lower end of the ureter, folds are formed with the help of tweezers from the serous membrane of the intestine, which connect over the ureter.

The disadvantage of this method is the small contact area of the fused surfaces, equal to the thickness of the intestinal wall, which reduces the reliability of the formed ureteral-intestinal anastomosis, and also does not prevent the occurrence of reflux from the intestine into the ureter. In addition, the method involves the use of a large number of sutures, as a result of which there may be a violation of blood supply in the walls of the anastomosed organs and lead to the development of insolvency of the sutures of the anastomosis.

A known method of forming an anastomosis between the ureter and the intestine according to Tikhov [cit. according to Dzirne I.Kh. Operative urology. - Petrograd: Publishing house "Practical Medicine", 1914. - 504 p.], In which the peritoneum is opened over the ureter, where it descends into the small pelvis. The ureter is first released for 3-4 cm. Then, the central end of the liberated part is sutured to the rectum at the place where the formation of the anastomosis is supposed, and the peripheral part is cut and pre-ligated, or squeezed with an elastic terminal. A little below the sutures, the rectum is opened with a longitudinal incision for 1 cm; the peripheral ureter, freed from ligature or terminal, is inserted into this incision so that the latter enters the lumen of the intestine by 1-1.5 cm. The ureter is sewn as follows: the sutures are passed through the serous membrane and muscle layer of the intestine, through the ureteric tissue and muscle membrane of the ureter. During attachment of the ureter to the intestine, Tikhov does not use a ureteral catheter. The peritoneum, which was located above the freed part of the ureter, is used to cover the part of it, which is sewn into the intestine.

The disadvantage of this method is the low reliability of the anastomosis, due to the small contact area of the fused surfaces, the thickness of which is essentially equal to the thickness of the intestinal wall.

A known method of implantation of the ureter in the urinary reservoir [US Pat. 2170057 Russia, IPC А61В 17/00. The method of implantation of the ureter into the urinary reservoir / A.A. Teplov (RU), I.G. Rusakov (RU); Moscow Cancer Research Institute P.A. Herzen (RU). - No. 99111915/14; Claim 05/31/99; Publ. 07/10/01], selected as a prototype, in which a tunnel is formed from a full-layer wall of the urinary reservoir by screwing it into the lumen of the urinary reservoir. A cuff is formed from the distal end of the implantable segment of the ureter by inverting the walls of the ureter. Extraluminal nodal sutures are applied between the walls of the urinary reservoir and the ureter. The method allows to prevent the development of vesicoureteral reflux.

The disadvantage of this method is the difficulty of ensuring compliance with the dimensions of the formed tunnel from the full-layer wall of the urinary reservoir with the diameter of the ureter. At the same time, the formation of a tunnel narrower than the outer diameter of the ureter threatens the development of anastomotic stricture. On the contrary, when forming a tunnel with a larger diameter than the outer diameter of the ureter, the risk of anastomotic suture failure due to the lack of close contact of the fused surfaces increases. Another disadvantage of this method is the technical complexity of the formation of the tunnel from the full layer wall of the bladder by screwing it and the possibility of trauma to the ureter.

The invention solves the problem of ensuring a uniform and dense comparison of intergrowth of homogeneous surfaces during the formation of the ureter-intestinal anastomosis, reducing trauma to the ureter by simplifying the technique of its invagination into the intestinal lumen.

The problem is solved in that for the formation of the uretero-intestinal anastomosis, a defect in the intestinal wall is used, formed at the site of the removed appendix, for which six nodular serous-muscular sutures are applied to the dome of the cecum, around the base of the appendix, and a serous-muscular layer is dissected of the appendix at its base, and its mucous membrane is intersected at a distance of 2.5-3 cm from the dome of the cecum, after which the ureter catheter is fixed with an ureter injected into the intestine through an opening in the cylinder formed by the preserved mucous membrane of the appendix, while the catheter is inserted to the level of contact of the ureter with the preserved mucous membrane of the appendix, the preserved mucous membrane of the appendix is fixed to the ureter catheter, and the ligature cleans the catheter from Initially, the mucous membrane is invaginated, and then all the layers of the wall of the cecum in its lumen to the level of previously applied ce ozno neuromuscular joints, whereupon previously sewn ligatures superimposed sero-muscular sutures muscular layer of the ureter wall at the level of cecal ligation and knotted. Nodal sutures are placed on the dome of the cecum around the base of the vermiform appendix, retreating 2.5-3 cm from the vermiform appendix, at an equal distance from each other, while the ligatures of the sutures are not tied, but taken into the clamps-holders.

New in the claimed solution is that the sutures on the intestinal wall are laid before the formation of the tunnel, an opening in place of the removed appendix is used as an opening in the intestinal wall, and also that part of the mucous membrane of the appendix is retained, which is fixed to the ureter catheter.

Suturing the wall of the intestine before the formation of the tunnel ensures uniform suturing and eliminates uneven invagination of the intestinal wall.

The use of a hole in the intestinal wall at the site of the removed appendix does not require an additional incision in the intestinal wall, which increases the reliability of surgical intervention.

Preservation of a part of the mucous membrane of the appendix and its fixation to the ureter catheter allows the intestinal wall to be invaginated by traction over the ureter catheter, which makes this stage of the operation technically easy and eliminates the possibility of damage to the ureter.

The essence of the method is illustrated by drawings, which show:

figa - fixation of the ureter with a ligature to the ureter catheter, suturing the dome of the cecum;

1 - the ureter;

2 - ureteral catheter;

3 - ligature, which fix the ureter to the ureter catheter;

4 - the base of the appendix;

5 - dome of the cecum;

6 - nodular sero-muscular sutures.

figb - suturing the dome of the cecum;

4 - the base of the appendix;

5 - dome of the cecum;

6 - nodular sero-muscular sutures;

figure 2 - dissection of the serous-muscular layer of the appendix, traction at the apex of the appendix;

4 - the base of the appendix;

5 - dome of the cecum;

7 - the direction of dissection of the serous-muscular layer of the appendix;

8 - direction of traction of the appendix;

figure 3 - tension of the prolapse of the mucous membrane of the appendix and its intersection;

5 - dome of the cecum;

9 - the mucous membrane of the appendix;

10 - the direction of intersection of the mucous membrane of the appendix;

figure 4 - the introduction of the ureteral catheter into the opening of the cylinder formed by the preserved mucous membrane of the appendix;

1 - the ureter;

2 - ureteral catheter;

9 - the mucous membrane of the appendix;

11 - direction of insertion of the ureteral catheter into the opening of the cylinder formed by the preserved mucous membrane of the appendix;

figure 5 - fixation of the preserved mucous membrane of the appendix to the ureteric catheter ligature;

1 - the ureter;

3 - ligature, which fix the ureter to the ureter catheter;

5 - dome of the cecum;

9 - the mucous membrane of the appendix;

12 - ligature, which fixes the preserved mucous membrane of the appendix to the ureteric catheter;

6 - traction for the ureter catheter;

1 - the ureter;

2 - ureteral catheter;

3 - ligature, which fix the ureter to the ureter catheter;

13 - direction of traction of the ureteral catheter;

Fig.7 - invagination of the mucous membrane of the vermiform process and all layers of the wall of the cecum into its lumen;

14 - invaginated mucous membrane of the appendix;

15 - invaginated layers of the wall of the cecum;

Fig. 8 is a final view of the urethrointestinal anastomosis;

14 - invaginated mucous membrane of the appendix;

15 - invaginated layers of the wall of the cecum;

16 - tied ligatures of sutures imposed between the wall of the cecum and the ureter.

The method is as follows.

Cystectomy is performed. Ureteric catheter catheterized. The ureter 1 is fixed on the ureteral catheter 2 using a ligature 3 of absorbable suture material, while the ligature is located 0.5 cm from the edge of the ureter. Form a reservoir from the cecum. Having retreated 3 cm from the base of the appendix 4, six nodular serous-muscular sutures 6 are placed on the dome of the cecum 5 at an equal distance from each other, that is, the angle between the sutures is 60 °. The ligatures of the sutures are not tied, but taken into the clamps-holders. 7 Circular sero-muscular layer of the appendix 4 at its base is dissected. Traction 8 is carried out for the apex of the appendix in the direction from the dome of the cecum 5, which ensures the tension of the prolapsing mucosa 9. Cross the mucous membrane of the appendix at a distance of 3 cm from the dome of the cecum. The vermiform appendix is removed. In the opening of the cylinder formed by the preserved mucous membrane 9 of the appendix, 11 ureteral catheter 2 is inserted and it is brought out through the reservoir and the urethra. In this case, the ureter catheter 2 with a fixed 3 ureter 1 is inserted into the intestine 5 to the level of contact of the ureter with the preserved mucous membrane of the appendix. The preserved mucous membrane of the appendix is fixed to the ureteric catheter with a ligature 12 of absorbable material. Traction 13 for the ureteral catheter invaginates 14 first the mucous membrane, and then all the layers of the wall of the cecum 15 into its lumen to the level of previously applied serous-muscular sutures. The muscle layer of the ureter at the level of the cecum wall is flashed with ligatures of previously applied sero-muscular sutures and, tying the ligatures, complete the formation of the ureter-intestinal anastomosis.

An example of a specific implementation of the method.

Patient N., 62 years old, was admitted to the urology department with a diagnosis of T4N1M0 bladder cancer. On September 11, 2005, an operation was performed - radical cystectomy. Both ureters are catheterized. A reservoir of the cecum is formed. Produced the formation of the ureter-intestinal anastomosis according to the claimed method. The postoperative period was uneventful. The Foley catheter was removed on day 16. 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 strictures of anastomoses were found.

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

Claims (2)

1. The method of the ureteral-intestinal anastomosis, including the introduction of a catheter into the ureter, making a hole in the intestinal wall, forming a tunnel from the full-layer wall of the colon by screwing it into the lumen of the colon, holding the ureter into the lumen of the intestine and fixing it to the walls of the intestine, characterized in that for the formation of the urethrointestinal anastomosis, a defect in the intestinal wall is used, formed at the site of the removed appendix, for which purpose, on the dome of the cecum around the base of the appendix, Six nodular serous-muscular sutures are sutured, a serous-muscular layer of the vermiform appendix is cut at its base, and its mucous membrane is intersected at a distance of 2.5-3 cm from the cecum dome, after which the ureter catheter with the ureter fixed on it is inserted into the intestine through the hole in the cylinder formed by the preserved mucous membrane of the appendix, while the catheter is inserted to the level of contact of the ureter with the preserved mucous membrane of the appendix, the stored mucus is fixed the lining of the vermiform appendix to the ureteric catheter using a ligature made of absorbable material, traction for the ureteric catheter invaginates the mucous membrane first, and then all the layers of the cecum wall to its lumen to the level of previously applied serous-muscular sutures, after which they are sutured with ligomas -muscular sutures muscle layer of the ureter at the level of the wall of the cecum and tie ligatures. 2. The method of the ureteral-intestinal anastomosis according to claim 1, characterized in that the nodal sutures on the dome of the cecum are applied around the base of the vermiform appendix, retreating 2.5-3 cm from the vermiform appendix, at an equal distance from each other, with ligatures seams are not tied, but take in the clamps-holders.

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