RU2363400C1 - Method of mobilising large bowel during treatment of cancer of middle third of sigmoid colon - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: parietal layer of the abdominal membrane is dissected in the region of the root of the mesosigmoid. Hypogastric plexus are separated from the mesosigmoid. The parietal layer of the abdominal membrane is dissected in the region of the upper bound of lymphadenectomy. Cellular tissue in front of the aorta, near the orifice of the inferior mesenteric artery to the origin of the last sigmoid artery is removed. All sigmoid arteries are transected while retaining the left colic and superior rectal artery. The sigmoid colon is mobilised and transected. Sigmoid anastomosis is formed. With the aim of removing malignant tumour in the middle third of the sigmoid colon, the sigmoid colon is mobilised. Paraaortal lymphadenectomy is done. The body of the inferior mesenteric artery is skeletonised from its origin from the aorta to the level of origin of the last sigmoid artery. All sigmoid arties are transected from their origin from the inferior mesenteric artery while retaining the left colic and superior rectal artery. The resected part of the sigmoid colon together with the mesentery and lymph nodes from level N1 to level N3 are removed as a single unit. Sigmoid anastomosis is formed between healthy sections of the sigmoid colon.

EFFECT: reduced injuries of the procedure, prevention of development of local recurrence of diseases with lymphogenic character without lowering quality of life of patients due to reduction of boundaries for resection of the colon and Paraaortal lymphadenectomy.

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Description

The invention relates to medicine, in particular to coloproctology, and can be used in operations for cancer of the sigmoid colon.

A known method of mobilization of the colon, in which the peritoneum of the left lateral canal is dissected and diverted towards the mesentery root. Then move the sigmoid colon laterally, dissect the inner sheet of the peritoneum of the mesentery and cross the sigmoid arteries. Intersection of the intestinal wall is carried out at a distance of 5 cm on both sides of the tumor. Patency of the resected intestine is restored by forming a manual end-to-end anastomosis (Black W.A., Waugh J.M. Surg. Gunec. Obstet., 1948, 87, 4, 457).

The disadvantage of this method is the complete lack of sanitation of the path of lymphatic drainage along the lower mesenteric artery. The authors carried out an economical resection of the sigmoid colon, not paying due attention to the lymphogenous spread of the tumor process, thereby leaving a substrate for a possible local return of the disease.

A known method of mobilization of the colon, in which the peritoneum of the left lateral canal is cut from the level of the middle third of the sigmoid colon to the left bend of the colon. The mesentery of the sigmoid and descending colon is separated from the paranephral tissue. Make the intersection of the inferior mesenteric artery at the place of its departure from the aorta and veins at the lower edge of the pancreas with the obligatory removal of lymph nodes at the root of the inferior mesenteric artery. After this, the mesentery of the transverse colon is dissected almost to the middle colon artery. An omentum bag is opened, a large omentum is resected with a transverse colon over its middle third to the left bend of the colon. Then the diaphragmatic-colon ligament is crossed, the adhesions between the intestine and spleen are divided. The intestine is crossed above and below the tumor with the formation of a transversorectal anastomosis end to end with the obligatory removal of adipose tissue and the lymph nodes located in it (N.A. Yaitsky, V.M.Sedov, S.V. Vasiliev. Tumors of the colon. M .: MEDpress-inform, 2004. - S.136-139).

However, the known method has significant disadvantages.

1. The method involves performing a left-sided hemicolectomy, in connection with which, in addition to the sigmoid colon, the left half of the transverse colon, the splenic flexure along with the descending colon and the rectosigmoid section are additionally mobilized, which significantly increases the duration and invasiveness of the surgical intervention.

2. Developing functional changes after left-sided hemicolectomy can be significant and require medical correction, thereby reducing the quality of life of the operated patients.

The objective of the claimed method is to reduce the morbidity of surgical intervention and prevent the development of local recurrence of a disease of a lymphogenic nature without reducing the quality of life of patients by reducing the boundaries of colon resection and performing paraaortic lymphadenectomy.

The problem is solved by the method consisting in the fact that when performing a resection of the sigmoid colon, the sigmoid colon is mobilized, paraaortic lymphadenectomy, the skeletonization of the trunk of the inferior mesenteric artery from the point of its departure from the aorta to the level of discharge of the last sigmoid artery, the sigmoid arteries cross at the place of their departure from the lower mesenteric artery with preservation of the left colon and upper rectal arteries. Next, the resected part of the sigmoid colon together with the mesentery and lymph nodes from level N1 to level N3 is removed with a single block, a sigmosigmoid anastomosis is formed, while maintaining the necessary sections of the sigmoid colon.

The practical implementation of the method consists in the fact that during the resection of the sigmoid colon, the parietal sheet of the peritoneum is cut in the region of the root of the mesentery of the sigmoid colon and fascia preureterica from two sides, leaving the fascial leaf covering the kidneys and ureters. The lower hypogastric plexus is identified and it is separated from the mesentery of the sigmoid colon. They outline the boundaries of the upcoming lymphadenectomy. The lateral border of lymphadenectomy corresponded to the projection of the ureters, the upper - the lower horizontal branch of the duodenum. In the region of the upper border of lymphadenectomy, the parietal sheet of the peritoneum is dissected. The mouth area of the inferior mesenteric artery is determined. The fiber located in front of the aorta is removed, descending in the caudal direction to the place of discharge of the last sigmoid artery. Cross all sigmoid arteries using the LigaSure apparatus, preserving the left colon and superior rectal arteries. The sigmoid colon mesentery is removed as much as possible, while maintaining the viability of the rectosigmoid region due to the superior rectal artery. To determine the viability of the sigmoid colon at the intersection level, the intensity of bleeding from the marginal vessel and the vessels of the fatty suspensions during their notching is estimated. The sigmoid colon with a tumor is crossed between two linear devices, after which a sigmosigmoid anastomosis is formed.

Signs of the proposed method, distinguishing it from the known, are not found in the medical and patent literature, which allows us to conclude that its criterion of "novelty."

Example. Patient B., 73 years old, underwent resection of the sigmoid colon with the formation of a hardware sigmosigmoid anastomosis, paraaortic lymphadenectomy for cancer of the sigmoid colon. They mobilized the sigmoid colon, paraaortic lymphadenectomy, skeletonized the trunk of the inferior mesenteric artery from the place of its departure from the aorta to the level of discharge of the last sigmoid artery, crossed the sigmoid arteries at the place of their departure from the inferior mesenteric artery while preserving the left colon and superior rectal arteries. Further, the resected part of the sigmoid colon together with the mesentery and lymph nodes from level N1 to level N3 was removed with a single block, a hardware sigmosigmoid anastomosis was formed between the viable sections of the sigmoid colon.

The postoperative period was uneventful. Chair on the third day. Discharged from the hospital on the 11th day. After 6 months, bowel function is not impaired. 1 year after surgery, the condition remains satisfactory, there are no signs of a return of the disease.

The method does not require additional mobilization and resection of the left half of the transverse colon, splenic flexure of the colon, descending colon and rectosigmoid section, which reduces the invasiveness of the operation, allows it to be used in a larger number of patients, and the implementation of paraaortic lymphadenectomy prevents the development of local relapse of the disease of a lymphogenic nature . All this allows to significantly improve functional results by reducing the volume of colon resection and a sufficiently complete treatment of the lymph drainage path from the sigmoid colon, including the removal of third-order lymph nodes, which improves the immediate and long-term results of treatment.

The proposed method is implemented in the coloproctology department of the State Research Center for Science named after Academician B.V. Petrovsky RAMS, had no complications during its implementation, made it possible to prevent the development of local recurrence of the disease, to carry out labor rehabilitation of operated patients and found wide application in clinical practice.

Claims (1)

A method for mobilizing the colon in the treatment of cancer of the middle third of the sigmoid colon, including dissecting the parietal sheet of the peritoneum in the root area of the sigmoid mesentery root, separating the hypogastric plexus from the mesentery of the sigmoid colon, dissecting the parietal sheet of the peritoneum in the upper border of the lymphadenectomy, removing fiber in front of the aorta, at the mouth inferior mesenteric artery to the place of discharge of the last sigmoid artery, the intersection of all sigmoid arteries with preservation of the left colon and superior rectus arterial arteries, mobilization and intersection of the sigmoid colon, the formation of a sigmosigmoid anastomosis, characterized in that, in order to remove a malignant tumor of the middle third of the sigmoid colon, mobilize the sigmoid colon, paraaortic lymphadenectomy, skeletonization of the trunk of the inferior mesenteric artery from its origin from the aorta to the level of the last sigmoid artery, all sigmoid arteries cross at the place of their departure from the inferior mesenteric artery while maintaining the left colon and upper straight ischemic arteries, the resected part of the sigmoid colon together with the mesentery and lymph nodes from level N1 to level N3 is removed in a single block, a sigmosigmoid anastomosis is formed between the viable sections of the sigmoid colon.