RU2359623C1 - Method of colostomy formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery, is intended for performing functionally improving operations in treatment of diseases of rectosigmoid part of large intestine. Retroperitoneal canal with peritoneum detachment and opening in anterior abdominal wall in direction of planned stoma projection are made. Adducting bowel is mobilised from mesentery and suspension loops. Serosomyotomy of adducting bowel is performed. Adducting bowel is led through formed retroperitoneal canal. End of exposed bowel is fixed on circumference to aponeurosis and skin. Peritoneum of internal opening of retroperitoneal canal is sawn with interrupted sutures with its fixation on circumference of adducting bowel. Stroma lumen is opened. Serosomyotomy of adducting bowel is performed by dissection in longitudinal direction of taenia up to under bowel mucosa for 20-30 mm, indenting 40-50 mm from its end. Dissected taenia are sutured in transversal direction with serous - muscular interrupted suture, forming reservoir. End of exposed bowel is additionally fixed to abdominal oblique muscles.

EFFECT: ensuring possibility to obtain in patient stable conditioned reflex in form of urge to empty colostoma with sufficient reservoir function of colostoma, to eliminate hemorrhage and bowel wall perforation, to improve patients' life quality.

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Description

The invention relates to medicine, namely to abdominal surgery, and is intended to perform functionally improving operations in the treatment of diseases of the rectosigmoid colon.

The closest technical solution in relation to the proposed set of essential features is the method of colostomy formation, which creates a retroperitoneal canal and an opening in the anterior abdominal wall in the direction of the projected stoma projection, the proximal loop is mobilized from the mesentery and pendants, serosomyotomy of the lead loop is performed, the peritoneum is exfoliated, the leading intestine is passed through the formed retroperitoneal canal, the end of the removed intestine is fixed around the circumference to the aponeurosis and skin, the peritoneum of the internal retroperitoneal channel tverstiya sutured intestine by circumferentially interrupted sutures and autopsied stoma lumen (see. Patent RU №2175527, 2001), adopted as a prototype.

The reasons that impede the achievement of the following technical result when using the known method adopted for the prototype include large tissue trauma, insufficient reservoir function of the colostomy, the occurrence of complications: bleeding, perforation of the intestinal wall.

The objective of the invention is to provide a method for the formation of a colostomy, providing a technical result, which consists in causing the patient to urge to empty the stoma, with sufficient reservoir function of the colostomy and eliminating complications such as bleeding and perforation of the intestinal wall.

The specified technical result in the method of colostomy formation is achieved by creating a retroperitoneal canal and an opening in the anterior abdominal wall in the direction of the projected stoma projection, the proximal loop is mobilized from the mesentery and pendants, the lead loop is serosomyotomy, the peritoneum is peeled, the leading intestine is passed through the formed retroperitoneal canal, the end of the removed intestine is fixed around the circumference to the aponeurosis and skin, the peritoneum of the internal opening of the retroperitoneal canal is sutured around the circumference of the intestine with interrupted sutures, open the lumen of the stoma.

The peculiarity lies in the fact that serosomyotomy of the lead loop is carried out by dissecting in the longitudinal direction the tenia to the submucosa of the intestine for 20-30 mm, departing from the end of the loop by 40-50 mm, then the dissected tenies are sutured in the transverse direction by serous-muscular interrupted sutures, forming a reservoir, while the peritoneum is fixed around the circumference to the colon of the proximal loop, and the end of the removed intestine is additionally fixed to the oblique muscles of the abdomen.

The invention is illustrated by drawings, where Fig. 1 shows the proximal section of the sigmoid colon (longitudinal section of muscle tapes), Fig. 2 shows the proximal section of the sigmoid colon on the anterior abdominal wall.

The method is as follows.

The sigmoid colon is resected, a purse string suture is applied to the proximal section of the sigmoid colon and tightened. The distal loop is sutured. The proximal loop is mobilized from the mesentery for 20-30 mm, and from suspensions for 80-100 mm.

A serosomyotomy of the adductor loop is performed. To do this, dissect in the longitudinal direction (figure 1) muscle tape - tenia 1 - to the submucosa of the intestine for 20-30 mm, retreating from the end of the lead loop by 40-50 mm. Then, dissected tenii 1 are sutured in the transverse direction (Fig. 2) by serous-muscular interrupted sutures, forming a reservoir.

At the planned point, the stomas form an opening on the anterior abdominal wall 2 in the left iliac region. To do this, excise the skin with the underlying fiber in a circular incision, dissect the aponeurosis and exfoliate the muscles. Then create a retroperitoneal canal. For this, the peritoneum is dissected, peeled off with two fingers around the circumference in the direction from the formed hole in the anterior abdominal wall 2 over a length of 40-50 mm.

Then, the adducting intestine is passed through the formed hole in the peritoneum so that the serosomyotomic region is in the retroperitoneal canal, and the end of the excreted intestine rises 15-20 mm from the anterior abdominal wall 2.

The integrity of the parietal peritoneum 3 in the region of the internal opening of the retroperitoneal canal is restored with interrupted sutures, which fix the peritoneum around the circumference to the colon of the proximal loop below the line of sutures that form the reservoir, by 15-20 mm.

The end of the removed intestine is fixed directly around the circumference to the oblique muscles of the abdomen, aponeurosis and skin of the anterior abdominal wall 2. The purse string suture is removed from the proximal loop and the stoma is opened.

A method of forming a reservoir colostomy has been developed and introduced into the clinic in patients with diseases of the rectosigmoid colon.

Clinical example.

Patient K., 53 years old, was admitted to the 6th surgical department of the Ulyanovsk City Clinical Hospital for Emergency Medicine on June 12, 2007 at 10 a.m. with a diagnosis of Acute obstructive colonic obstruction. Upon admission, the patient complained of pain throughout the abdomen, nausea, repeated vomiting (four times) of food, and stool and gas retention. Sick for 2 days.

On examination: the general condition of the patient is severe. The skin is moist, normal color. The pulse is satisfactory filling and voltage of 102 beats per minute. Blood pressure 100/80 mm Hg

The tongue is dry, coated with a yellow coating. The abdomen is regular in shape, swollen, symmetrical, does not participate in the act of breathing. Palpation is mild and painful in all departments. Noise splashing in all departments. With percussion tympanitis. Intestinal motility is weakened. Symptom Shchetkina-Blumberg positive in the lower abdomen. Rectal examination: the rectal ampoule is dilated, empty, no feces. An abdominal R-graph was performed for the presence of Kloiber bowls, and Kloiber bowls were determined on the R-gram of the abdominal cavity. Diagnosed with Acute obstructive colonic obstruction. Local peritonitis.

For the purpose of preoperative preparation of the patient, replenishment of the water-electrolyte balance was carried out.

Operation: 06/12/2007 12 hours 25 minutes - 14 hours 00 minutes. A mid-midline laparotomy of 20 cm long was produced. About 300 ml of serous-fibrinous effusion were made in the abdominal cavity. Loops of the small intestine expanded to 40 mm, loops of the large intestine expanded to 90 mm. When revising the abdominal cavity, a tumor-like formation of a rectosigmoid colon was revealed, which circularly obstructs the intestinal lumen.

Obstructive resection of the rectosigmoid region was performed. The distal section of the resected intestine is sutured. The proximal loop is mobilized from the mesentery over 20 mm and suspensions over 90 mm. We performed serosomyotomy of the adductor loop, dissecting in the longitudinal direction the muscle tapes (tenia) to the submucosa over 30 mm, retreating from the end of the loop by 50 mm. Then, dissected muscle tapes were sewn in the transverse direction by serous-muscular interrupted sutures, forming a reservoir. At the planned point, the stomas formed a hole in the anterior abdominal wall in the left iliac region. For this, the skin with the underlying tissue was excised in a circular incision, the aponeurosis was dissected, and the muscles were stratified. Formed retroperitoneal canal. For this, the peritoneum was dissected, then peeled with two fingers around the circumference of the hole in the anterior abdominal wall for 50 mm. Then, the adducting intestine was led through this hole in the peritoneum so that the serosomyotomic region was in the retroperitoneal canal, and the end of the excreted intestine was raised 20 mm from the anterior abdominal wall. The integrity of the parietal peritoneum in the area of the internal opening of the retroperitoneal canal was restored with interrupted sutures, fixing it along the circumference of the colon, below the line of sutures that form the reservoir by 20 mm. The end of the removed intestine was fixed directly around the circumference to the oblique muscles of the abdomen, aponeurosis and skin of the anterior abdominal wall, revealing the lumen of the stoma.

Intestinal decompression through colostomy, debridement and abdominal drainage were performed.

Diagnosis: Cancer of the rectosigmoid colon. Acute obstructive colonic obstruction. Common serous fibrinous peritonitis.

The postoperative period was uneventful, smooth, the patient received complex pathogenetic therapy.

Pathological examination. Moderately differentiated adenocarcinoma.

The wounds of the anterior abdominal wall healed by primary intention. In satisfactory condition on June 24, 2007, the patient was discharged from the hospital under the supervision of a surgeon in the clinic at the place of residence. Examined December 24, 2007. Condition is good. No complaints. No specific paracolostomy complications were noted. Stoma emptying is multi-stage (in 2-4 doses) with a frequency of 1-2 times a day and lasting from 15 to 40 minutes with the obligatory urge. Subjective sensations preceded the process of emptying the colostomy, were observed on average 15-20 minutes before defecation and were a feeling of heaviness and bursting in the projection of the outer end of the stoma.

Thus, the simplicity and effectiveness of the proposed method, which is able to form a stable conditioned reflex in the patient in the form of a urge to empty the stoma, with sufficient reservoir function of the colostomy and eliminating complications such as bleeding and perforation of the intestinal wall, improves the quality of life and the results of medical and social and labor rehabilitation of "colostomized" patients.

Claims (1)

A method for forming a colostomy, including creating a retroperitoneal canal with detachment of the peritoneum and an opening in the anterior abdominal wall in the direction of the projected stoma projection, mobilizing the adducting intestine from the mesentery and pendants, serosomyotomy of the adducting gut, conducting the adrenal gut through the formed retroperitoneal canal, fixing the end of the excreted intestine around the circumference to aponeurosis and skin, suturing of the peritoneum of the internal opening of the retroperitoneal canal with interrupted sutures with its fixation around the circumference of the adducting intestine, opening of the lumen of the stoma characterized in that serosomyotomy of the adducting intestine is carried out by dissection in the longitudinal direction of the tenies to the submucosa of the intestine over 20-30 mm, departing from its end by 40-50 mm, then the dissected tenies are sutured in the transverse direction by serous-muscular interrupted sutures, forming reservoir, and the end of the removed intestine is additionally fixed to the oblique muscles of the abdomen.

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