RU2378992C1 - Method of surgical treatment of rectocele - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, to colorectal surgery, is intended for treatment of rectocele. Strengthening of rectovaginal septum and plasty of anterior wall of rectum with polypropylene coarse-cellular transplant to Douglas space are performed. By means of goffering sutures muscular layer of anterior wall of rectum is restored. Anterior wall of rectum is stretched in transversal direction on transplant. Transplant base is fixed to pelvic peritoneum. By corners transplant is fixed to rectum wall in stretched state. In medial third transplant is fixed to muscles of levators. Only pedicles of levator muscles are brought together. Excess of mucous membrane on anterior wall of rectum is removed by its "tightening" on mesh with fixation of its base to rectum wall and pelvic peritoneum. Excess of posterior wall of vagina is dissected only in its lower third with further bringing down and sewing to vestibule.

EFFECT: removal of vagina wall excess, strengthening of recto-vaginal septum to pelvic peritoneum, restoration of muscular layer of rectum wall, carrying put plasty of anterior wall of rectum with removal of not only low but also of high rectocele, removal of excess of mucous membrane on anterior wall of rectum due to tightening on mesh, strengthening of pelvic bottom with preservation of normal functional-anatomic relationships of intestine wall and levators, reduction of pain syndrome and rate of post-operation complications.

1 ex, 5 dwg

Description

The invention relates to medicine, namely to colorectal surgery, and can be used to treat rectocele.

The following methods of treating rectocele are known.

1. Plastic surgery of the muscles of the pelvic floor by transvaginal access. This method allows you to excise the excess of the posterior wall of the vagina, it is good to highlight the front portions of the levators, leaves the intestinal wall intact.

Its disadvantages are:

- When using this method, the rectovaginal septum is strengthened by displaced front portions of the levator muscles, which is done by stitching them along almost the entire length. Also, for adequate mobilization of the anterior portions of levators and their subsequent movement into the rectovaginal septum, the intersection of a portion of the muscles in their upper third is required. The movement of muscle portions with their intersection can lead to pain and to a deterioration in the functional state of levator muscles;

- This method allows you to strengthen the rectovaginal septum only in its lower and middle thirds, without eliminating the high rectocele and without strengthening the pelvic floor;

- With this method, it is possible to form an excess of the mucous membrane along the front wall of the rectum, which may interfere with its adequate emptying in the postoperative period;

- About a third of patients operated on with transvaginal access in the postoperative period noted severe pain and dyspunia due to cicatricial changes in the vagina.

2. Perineal access allows adequate plastic surgery of the pelvic floor muscles, keeping the mucous membranes of the rectum and vagina intact, which reduces the risk of postoperative complications and the intensity of pain in the postoperative period.

The disadvantages of this method are:

- The possibility of forming an excess of the mucous membrane along the front wall of the rectum, which may prevent its adequate emptying in the postoperative period;

- With this method, an excess of the posterior wall of the vagina remains (may form after levatoroplasty) (it is important to emphasize that complaints of prolapse of the posterior wall of the vagina and dyspunia prevail in more than 30% of patients in the clinical picture);

- When using this method, the rectovaginal septum is strengthened by displaced front portions of the levator muscles, which is done by stitching them along almost the entire length. Also, for adequate mobilization of the anterior portions of levators and their subsequent movement into the rectovaginal septum, the intersection of a portion of the muscles in their upper third is required. The movement of muscle portions with their intersection can lead to pain and to a deterioration in the functional state of levator muscles;

- This method allows you to strengthen the rectovaginal septum only in its lower and middle thirds, without eliminating the high rectocele and without strengthening the pelvic floor.

3. Transanal methods can eliminate the excess rectal wall prolapse in the vagina.

The disadvantages of this method are:

- With these methods, the presence of a suture line in the lower ampullar part of the rectum increases the risk of developing postoperative complications (suppuration of a postoperative wound, formation of rectovaginal fistula);

- The use of transanal methods does not allow to strengthen the rectovaginal septum, to perform plastic surgery of the pelvic floor, which increases the risk of relapse in the long-term postoperative period;

- With these methods, it is possible to eliminate excess rectal wall only in its lower third, which does not allow to eliminate high rectocele (figure 1);

- When performing combined operations (resection of the mucous-submucosal layer of the lower ampullar rectum + levatoroplasty (rectovaginal septum allograft plastic)), the risk of postoperative complications increases due to the impossibility of transposition of the suture line in the intestine and allograft (suture line on the levator muscles);

- When using circular staplers (mucous-submucosal resection), in addition to the above disadvantages, the size of the removed section of the anterior rectal wall is limited by the capabilities of the working part of the apparatus (not more than 4-5 cm), while the length of the intestinal wall forming the rectocele is much larger and is an average of at least 9 cm (figure 1).

The prototype of the proposed method for the treatment of rectocele is the plastic of the rectovaginal septum with perineal access graft.

The purpose of the invention:

- to improve the results of surgical treatment of rectocele by reducing the risk of developing early and late postoperative complications and normalizing the evacuation function of the rectum, as well as to prevent the development (progression) of prolapse of the pelvic floor, enterocele, sigmocele, prolapse of the rectum by strengthening the rectovaginal septum, pelvic floor (Douglas pocket ) coarse graft.

Technique of operation: after hydropreparation of the rectovaginal septum, a flap of the posterior wall of the vagina is excised in its lower third from the vestibule to the apex of the protrusion (1.5-2.0 cm wide, not more than 3 cm long) (Fig. 2).

Then, the rectovaginal septum of this access is cleaved, the front wall of the rectum, the front portions of the levator muscles are mobilized. With large protrusions, the wall of the intestine is often represented only by the mucous-submucous layer. With this in mind, to restore the muscle layer, if necessary, separate corrugating sutures (no more than three) are applied to the front wall of the rectum, then a coarse-mesh polypropylene graft of a triangular, drop-shaped or T-shape (polypropylene coarse mesh) is freely placed on the front wall of the rectum 3)). The shape of the graft depends on the length of the selected front wall of the rectum, the nature of the levator diastasis, etc. In this case, the wall of the rectum is stretched across the grid. The mesh is fixed to the wall of the rectum at the upper corners in a "stretched" state, due to which the excess of the mucous membrane along the front wall of the rectum is eliminated. In the presence of a high rectocele (in 70% of cases), the mesh base is located directly below the pelvic peritoneum, while the mesh is fixed to the peritoneum with separate sutures. It is important to note that most of the graft is located outside the wound under the vaginal wall.

Next, the polypropylene graft (in its middle third) without tension is fixed to the muscles of the levators at the corners of the mesh with two sutures (Polysorb 03) in their upper third. Then, with separate sutures (Polysorb 03), only the legs of the front portions of the levator muscles are sutured with the capture of the tip of the polypropylene flap (1-2 sutures).

After that, the allocated and mobilized back wall of the vagina is reduced to the vestibule. The wound is sutured without tension.

Thus, the proposed method allows to eliminate the excess wall of the vagina with the minimum size of the postoperative wound (most often the wound is located on the border of the vaginal mucosa and the vestibule, its size does not exceed 1.5-2.0 cm). Strengthening of the rectovaginal septum along the entire length and plastic surgery of the anterior wall of the rectum with the elimination of not only low but also high rectocele. Due to the "stretching" of the rectal wall along the anterior semicircle on the graft, followed by germination into the last connective tissue and fixation, the excess mucosa along the anterior rectal wall is eliminated. The use of polypropylene coarse mesh allows the intestinal wall to maintain elasticity and does not interfere with natural peristaltic movements. The location of the base of the graft under the pelvic peritoneum of the douglas space prevents its deepening and strengthens the pelvic floor (Fig. 4 a, b).

The normal anatomy of the anterior portions of the levator muscles is maintained, but the graft is fixed with its edges to them, which leads to the restoration of normal functional and anatomical relationships of the intestinal wall and levators and, therefore, their coordinated interaction in the act of defecation. Also, when the posterior wall of the vagina is reduced, the line of postoperative sutures and the graft are disposed.

Clinical example:

Patient M., 29 years old, IS No. 3040-06, was admitted with complaints of difficulty in defecation, the need for manual benefits during defecation, a feeling of incomplete emptying of the rectum, discomfort with coition.

With an external examination of the perianal region, the anus is closed, the perianal reflex is alive. When straining, there is a prolapse of the lower third of the posterior wall of the vagina beyond the labia majora. With a digital examination of the rectum, the sphincter tone and volitional efforts are satisfactory. In a bi-digital study, the rectovaginal septum is thinned, there is a discrepancy in the front portions of the levators. Along the front wall of the rectum, there is a prolapse of the latter in the form of a blind sac in the vagina in its lower third with the extension of the labia majora.

In the department examined. When proctography with straining - rectocele 3 tbsp. The omission of the perineum in the stage of subcompensation of the muscles of the pelvic floor (figure 5).

In a functional study of the obturator apparatus of the rectum, there are electrophysiological indicators of the contractility of the muscles of the external sphincter within the lower normal range. Reflex responses saved.

The patient was diagnosed with rectocele 3 degrees.

October 24, 2006, the patient underwent surgery by the proposed method. The postoperative period was uneventful. There was no pain. The postoperative wound at the border of the vaginal mucosa and its vestibule healed by primary intention. With stool, the patient did not note the above complaints. On day 7 was discharged.

The follow-up was 3 months. During this period, the patient regulates the stool with a diet. There are no complaints about the difficulty of defecation and the need for manual benefits. The patient leads a normal sexual life (1.5 months after the operation), does not experience discomfort. There is no data for relapse.

The proposed method in comparison with the known methods of surgical treatment of rectocele makes it possible

- reduce pain;

- reduce postoperative bed day;

- reduce the incidence of postoperative complications;

- improve functional results;

- carry out pelvic floor surgery

Bibliography:

1. Clinical operative coloproctology (edited by Fedorov VD, Vorobyev GI) M., 1994, p.363-367.

2. Coloproctology and the pelvic floor (edited by M.M. Henry, M. Swosh).

3. Medscape Womens Health 1998 Jul; 3 (4): 4.

Pelvic prolapse: diagnosing and treating cystoceles, rectoceles, and enteroceles. Cespedes RD, Cross CA, McGuire EJ.

4. Surgical management of anorectal and colonic diseases. Marc-Claude Marti, Jean-Claude Givel. 1998.

5. The basics of coloproctology, edited by G. Vorobyov, M .: Medical Information Agency LLC, 2006, p.193-209.

Claims (1)

A method of surgical treatment of rectocele, based on the strengthening of the rectovaginal septum and plastic surgery of the anterior rectal wall with a coarse-grained polypropylene graft, characterized in that the rectovaginal septum and plastic surgery of the rectum anterior wall are reinforced with a polypropylene coarse-grained transplant to the Douglas space, stretching the anterior wall to the transverse rectum mesh, the base of the graft is fixed to the pelvic peritoneum, and at the corners to the wall of the rectum in When the state is pulled in the middle third, the graft is fixed to the muscles of the levators, only the legs of the muscles of the levators are reduced, the excess of the mucosa along the front wall of the rectum is eliminated due to its “tension” on the mesh with fixation of its base to the wall of the rectum and pelvic peritoneum, the muscle layer is restored by corrugating seams the anterior wall of the rectum, an excess of the posterior wall of the vagina is excised only in its lower third, with subsequent reduction and hemming to the vestibule.

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