RU2337630C1 - Method of orthotopic enteral cystoplasty - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: carry out an orthotopic plasty from a segment of an ileal intestine. Replace ureters in it using an antireflux operation and impose an anastomosis with proximal department of urethra. Resect an intestine segment during formation of a bladder. Put two average sites of an intestine in the form of a double-barrelled gun and dissect it on a counter-mesenteric edge. Stitch the back walls of the dissected intestine. Form a frontal wall of a bladder. For this purpose the bottom part of the obtained segment is placed cross-section up. Put a azygomorphously referring stitch and resect a proximal site of a forward wall of the bladder. At resecting of a distal site of a frontal wall of a bladder, leave the terminal piece unresected for "compressor" formation. Form a "compressor". For this purpose turn outside edges of a dissect wall of an intestine and in tension state longways and edgewise along an edge file them to the serous-muscular layer of an intestine. Stitch the ends of the formed "compressor" with "latch" creation. Thus stitch the extremity of the back wall "compressor" to the serous-muscular cover of a frontal wall of the bladder. Stitch the other extremity of the "compressor" to the back wall of the bladder. Tubularised parts of the bladder bring to the distal extremities of ureters with applying of an antireflux vesicoureteral anastomoses. In that specific case at applying of vesicoureteral anastomoses on the tubularised bladder sites, dissect the parts by excision of the serous-muscular cover.

EFFECT: improvement of life quality of patients at the expense of formation of a sufficient capacity bladder with a longeval and reliable keeping urine mechanism; prevention of vesicoureteral a reflux at low chance of trauma during intervention and reduction of its duration.

2 cl, 9 dwg, 1 ex

Description

The invention relates to medicine, to surgery and urology, namely to oncourology, specifically to methods and techniques of orthotopic intestinal plastic surgery of the bladder, and can be used in the surgical treatment of bladder cancer, after bladder removal operations.

Known methods (M. Camey, 1979; U.E. Studer, 1985, etc.) to create an orthotopic bladder from the ileum segment, which consists in the fact that after transplantation of the ureters, the articular bladder anastomoses with the urethra. The main disadvantages of these methods is the small capacity of the reservoir for urine, the presence of complications such as partial or complete urinary incontinence, vesicoureteral reflux, which significantly worsens the quality of life of patients in the postoperative period (Guide to Urology / Edited by N.A. Lopatkin. - M., 1998 .-- T.-3. S.-266-267).

Other disadvantages of the known methods are excessive mobilization and trauma of the ureters, the technical complexity of the formation of the bladder, as well as the duration of the surgical aid.

The closest analogue of the proposed method is the method of ileocystoplasty with a valve and "pulp" (Vasilchenko MI, Moscow, Doc. Dis., 2004), carried out by forming the bladder from the ileum segment, transplanting it into the proximal end of the ureters with the formation of a distal invagination valve, and then the creation of a “pulp” in the distal part of the orthotopic small intestine bladder, followed by anastomosis with the proximal urethra.

The main disadvantage of this method is the insufficient capacity of the reservoir for urine and not long enough and reliable "bagasse".

The main objective of this invention is to improve the quality of life of patients due to the formation of a bladder of sufficient capacity with a long and reliable urine-holding mechanism "pulp" with low invasiveness of the surgical intervention and a simultaneous reduction in its duration, as well as by the formation of antireflux vesicoureteral anastomosis that prevents cystic ureteral reflux.

The solution of the technical problems is achieved by the claimed new method of orthotopic small bowel plastic surgery of the bladder and the formation of antireflux vesicoureteral anastomosis from the ileum segment with the transplantation of the ureters according to the antireflux technique and the application of the anastomosis with the proximal urethra, while it transfers into "By dissecting all layers of the intestine along the mesenteric edge, wrapping them up and in a state of moderate tension along Ine and width along the edge, they are sewn to the serous-muscular layer of the intestine with separate interrupted sutures and the dissected edges of all layers of the intestine are sutured to create a “lock”, and the undetubulated sections of the bladder are brought to the distal ends of the ureters with the application of antireflux vesicoureteral anastomoses.

For example, from the 60 cm of the isolated segment of the ileum, the artifactic bladder is formed by detubulating 40 cm of the middle part of the intestinal segment with the formation of “pulp”, by wrapping up the dissected layers of the intestine upward in the distal part of the small intestine bladder, which are in a state of moderate tension, both in length and in length and the width along the edge is hemmed to the sero-muscular layer of the intestine with separate interrupted sutures. Moreover, the dissected edges are stitched with the creation of a “castle”. For this, the dissected membrane of the posterior wall is slightly pulled and hemmed to the serous-muscular membrane of the anterior intestinal wall. After that, the dissected sheath of the anterior wall is similarly sutured to the posterior semicircle of the intestine. Thus create a "bagasse" at the distal end of the formed bladder. Non-tubularized sections of the artifactal bladder, 10 cm each, are led to the distal ends of the ureters with the formation of anastomosis by the antireflux technique.

The proposed new method for the formation of antireflux vesicoureteral anastomosis is as follows.

For example, the site is cut out by removing the muscle membrane 40 × 5-7 mm and the ureter is laid to the middle of the site and fixed with separate sutures at the proximal edge. Then open the intestinal lumen and form an anastomosis. To do this, before stitching the anastomosis front lip, the ureter is intubated with a polyvinyl chloride tube, and separate ligatures are placed on the proximal and distal edges of the site and, when pulling on the threads, the distal end of the ureter is invaginated into the lumen of the bladder.

The method is carried out using the following methods.

Perform median laparotomy from the xiphoid process to the pubis. Cystrostatectomy is performed according to the generally accepted method, with lymphadenectomy and preservation of the obturator nerve and testicular vessels. 4 long ligatures are applied to the stump of the urethra. At a distance of 20 cm from the ileocecal angle with the obligatory preservation of the ileo-colic artery, using a UKL-40 apparatus, a 60 cm ileal segment is cut out on the vascular pedicle. The cut out segment of the intestine is divided into sections - in the proximal and distal sections of 10 cm each and between them two sections of 20 cm. Intestinal end-to-end interstitial anastomosis is applied. The proximal and distal ends of the graft are stitched with a UKL-40 device and an additional purse string suture is applied.

The two middle sections of the intestine are folded in the form of a double-barreled shotgun and dissected along the mesenteric edge. The formation of the small intestine (artifical) bladder begins by suturing the posterior walls of the dissected intestine with a single-row interrupted suture. The front wall is sewn asymmetrically - the lower part of the obtained U-shaped segment is folded transversely upward, imposing a guide seam. A single-row interrupted suture sutures the proximal portion of the anterior wall of the bladder. The distal section of the anterior wall is sutured with a single-row interrupted suture, leaving a length of up to 2 cm unheated.

The raised edges of the serous-muscular-submucosal-mucous membrane of the dissected intestinal wall are wrapped up and in a state of moderate tension both in length and in width along the edge are sutured to the serous-muscular layer of the intestine with separate interrupted sutures, the dissected edges are sutured to create a “lock”. For this, the dissected membrane of the posterior wall is slightly pulled and hemmed to the serous-muscular membrane of the anterior intestinal wall. After that, the dissected sheath of the anterior wall is similarly sutured to the posterior semicircle of the intestine - this is the “pulp” at the distal end of the formed intestinal bladder.

The ureters, after preliminary intubation, are implanted according to the antireflux technique. Its essence is as follows: on the proximal undetubularized section of the intestinal bladder, a site is cut by removing the serous-muscular membrane 40 × 5-7 mm. The ureter is laid to the middle of the site and fixed with separate sutures at its proximal edge. Then open the intestinal lumen and form an anastomosis. Before stitching the front lip of the anastomosis, the ureter is intubated. Separate ligatures are placed on the proximal and distal edges of the site, while pulling on the threads, the distal end of the ureter is invaginated into the intestinal lumen. Similarly, anastomosis is performed from the contralateral side. Intubators remove through the "front wall" of the bladder to the skin.

The formation of an anastomosis between the orthotopic small intestine bladder and the proximal urethra is performed in the following sequence: previously applied long ligatures on the urethral stump, the lower edge of the pulp is sequentially stitched. A Foley catheter is passed through the urethra into the bladder. The surgeon, tightening the ligatures, and the assistant, pulling the Foley's catheter, lower the bladder until it comes into contact with the urethra and alternately tie the sutures. Drain the small pelvis. The wound of the anterior abdominal wall is sutured tightly.

Figure 1-9 illustrate the inventive method of orthotopic small intestinal plasty of the bladder.

In figure 1. Cut ileal segment on the vascular pedicle.

In figure 2. Two middle sections of the intestine, dissected along the mesenteric margin, folded in the form of a "double-barreled shotgun", and the posterior walls of the intestine stitched with a single-row interrupted suture.

In figure 3. The guide suture is made asymmetrically formed the front wall of the bladder.

In figure 4. The proximal section of the anterior wall of the bladder is sutured with a single-row interrupted suture.

In Fig.5. The distal section of the anterior wall of the small intestine bladder is sutured with a single-row nodal suture and an unheated terminal segment to form a pulp.

In Fig.6. The edges of the “pulp” wrapped outwardly are hemmed along the edge to the serous-muscular layer with separate interrupted sutures and the free ends of the “pulp”.

7. One end of the pulp is hemmed with an oblique interrupted suture to the front wall of the bladder, and the other is hemmed in the opposite direction.

On Fig. Orthotopic small intestinal bladder with “pulp” and “lock”.

In Fig.9. Orthotopic small intestine bladder with implanted ureters.

An example implementation of the method on outbred dogs.

Under thiopental anesthesia, a mid-median laparotomy is performed. A cystrostatectomy is performed and the small intestine bladder and vesicoureteral anastomoses are formed.

When observing animals during the first week after the operation, pronounced adynamia of the animal and lack of appetite were noted. Therefore, in the postoperative period, infusion and antibacterial therapy and parenteral nutrition were performed. In order to suppress enteritis and reduce the absorption capacity of the ileum, the artificial bladder was washed through an urethral catheter with 0.9% sodium chloride, followed by instillation of 10% synthomycin liniment or 2% collargol solution 1-2 times a day into the bladder cavity. After 6-8 days, the ureteric stents were removed. By the end of the third week after the operation, the urethral catheter was removed. The animals recovered self-urination.

Observations of animals over 6 months showed the full functional viability of the bladder. Leakage of urine through the urethra is not marked. Not a single episode of vesicoureteral reflux was recorded either.

After removing animals from the experiment, histological studies at various times after surgery showed that the intestinal bladder, pulp and vesicoureteral anastomoses retain their shape, structure and functional usefulness.

The method has passed a successful test in an experiment. The advantages of the method of orthotopic small bowel plastic surgery of the bladder are that the formed design of the intestinal bladder allows not to exclude the ureters in the proximal direction, performed according to the antireflux technique of neoureterocystoanastomoses, allows to exclude vesicoureteral reflux, and “pulp” creates an additional urine prevention mechanism.

Claims (2)

1. The method of orthotopic small bowel plasty from the ileum segment with the transplantation of ureters into it according to the antireflux technique and the application of an anastomosis with the proximal urethra, characterized in that when the bladder is formed, a segment of the intestine is cut out, two middle sections of the intestine are folded in the form of a double-barrel and a dissection along the mesenteric edge, the posterior walls of the dissected intestine are sutured, then the front wall of the bladder is formed, for this the lower part of the obtained segment is folded across but upwards, asymmetrically applied and suture guide sutured portion proximal anterior bladder wall, then when suturing of the distal portion of the front wall of the urinary bladder were left unsutured terminal segment for the formation of a "pulp"; then a “pulp” is formed, for which the edges of the dissected intestinal wall are wrapped outwardly and, under tension along the length and width, are hemmed to the serous-muscular layer of the intestine with separate interrupted sutures, the ends of the formed “pulp” are sutured to create a “lock”, and the end The "pulp" of the posterior wall is sutured to the serous-muscular membrane of the anterior wall of the bladder, and the other end of the "pulp" is sutured to the posterior wall of the bladder, then tubularized sections of the bladder are brought to the distal ends of the ureters with the application of antiref yuksnyh vesicoureteral anastomosis. 2. The method of orthotopic small bowel plasty according to claim 1, characterized in that when applying antireflux vesicoureteral anastomoses on tubularized sections of the bladder, the sites are cut by removing the serous-muscular membrane, the ureters are laid to the middle of the site and fixed with separate sutures at its proximal edges, then open the intestinal lumen and form an anastomosis, while before stitching the front lip of the anastomosis, the ureter is intubated, and on the proximal and distal edges of the site separate ligatures are imposed and, when pulling on the threads, the distal end of the ureter is invaginated into the intestinal lumen, and intubators are brought out through the front wall of the bladder to the skin.

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