RU2383306C1 - Method of levator formation on brought down intestine in case of rectum resection with ablation of various parts of external sphincter - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, surgery. On anti-mesentric portion of intestine in transversal direction dissection of seromuscular envelope is performed on length of 15-18 mm. Dissection is performed 20-30 mm higher than unstriped-muscular press-cuff. From apexes of marked flap in proximal direction two more parallel cuts of seromuscular envelope 65-70 mm long are performed along right and left sides of anti-mesentric portion of intestine. Cuts are made on edge of mesentery and appendices. Marked flap from seromuscular layer is separated from underlying submucous membrane in direction from apex in region of transversal dissection towards its base on proximal end. Connection of flap base with intestine wall is preserved. After suturing subcutaneous site in transversal direction bringing down of intestine is carried out. Anastomosis is formed in perineum. By abdominal approach seromuscular flap is fixed with 2-4 interrupted sutures to pelvic peritoneum on anterior semi-circle of small pelvis correspondingly to projection of pubic-rectal loop.

EFFECT: method allows to create mechanism of holding after extended resections rectum with ablation of internal sphincter, portions of external sphincter, levator excision by formation of levator for creation of anorectal angle between pelvic and perineal parts of brought down intestine.

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Description

The invention relates to medicine, surgery, and can be used for resection of the rectum with the removal of various portions of the external sphincter involved in the formation of the anorectal angle.

The latest principles of sphincter-preserving surgery for rectal cancer allow maneuvering with the distal and lateral resection lines by completely or partially removing the internal sphincter, various portions of the external sphincter, and excision of the levators. In this case, the implementation of lowering the colon into the perineum cannot guarantee the maintenance of a normal anorectal angle. Therefore, in addition to the pathology of reservoir function, which is clinically manifested by frequent bowel movements, tenesmus, multi-stage, prolonged and incomplete emptying, patients experience severe dysfunction of the sphincter apparatus in the form of fecal incontinence and gas, the inability to ignore the urge and delay stool, etc.

To date, many methods have been developed to restore the ampoule by forming various types of colonic reservoirs [1, 3-5, 7-9]. As for the restoration of the function of sphincters after sphincter-preserving and sphincter-bearing interventions, recent studies have shown that the use of striated muscles to create an artificial sphincter is significantly inferior in effectiveness to the neosphincter from its own muscle membrane of the intestine [2, 6]. Therefore, to restore the sphincter, the authors propose to apply the technique of smooth muscle pulp by circularly separating the serous-muscular membrane at the end of the reduced intestine and fixing it in the form of a cuff [4, 10]. In this case, methods for the formation of levators with the aim of restoring the anorectal angle while lowering the colon to the perineum were not found in known sources of information.

A new technical task is the creation of a holding mechanism after extended resections of the rectum with removal of the internal sphincter, portions of the external sphincter, excision of the levators by forming a levator to create an anorectal angle between the pelvic and perineal sections of the reduced intestine.

To solve the problem in the method of forming a levator on the reduced intestine during resection of the rectum with the removal of various portions of the external sphincter on the anti-mesenteric section of the intestine in the transverse direction, dissection is performed over 15-18 mm of the serous-muscular membrane 20-30 mm above the smooth muscle pulp cuff ; then, from the tops of the corners of the target flap in the proximal direction, two more parallel sections of the serous-muscular membrane 65-70 mm long are made along the right and left sides of the ant mesenteric section of the intestine along the edge of the mesentery and pendants; The flap from the serous-muscular layer thus designated is separated from the underlying submucosa in the direction from the apex in the transverse section to its base at the proximal end, while maintaining the connection between the flap base and the intestinal wall; then, after suturing of the submucosal area in the transverse direction, the intestines are reduced and anastomosis is formed in the perineum; with an abdominal access, a serous-muscle flap is fixed with 2-4 interrupted sutures to the pelvic peritoneum along the anterior semicircle of the small pelvis, respectively, of the projection of the pubic-rectal loop.

New in the invention is that for the formation of the levator on the antimesenteric portion of the intestine in the transverse direction, a dissection of 15-18 mm of the serous-muscular membrane is performed 20-30 mm above the smooth muscle pulp cuff; then, from the ends of this dissection in the proximal direction, two more parallel sections of the serous-muscular membrane 65-70 mm long are made along the right and left sides of the anti-mesenteric section of the intestine along the edge of the mesentery and pendants; The flap from the serous-muscular layer thus designated is separated from the underlying submucosa in the direction from the apex in the transverse section to its base at the proximal end, while maintaining the connection between the flap base and the intestinal wall; after suturing of the submucosal area in the transverse direction, the intestines are reduced and anastomosis is formed in the perineum; abdominal access, a serous-muscle flap is fixed with 2-4 interrupted sutures along the anterior semicircle of the pelvic peritoneum, respectively, of the projection of the pubic-rectal loop.

In the literature analyzed by the authors, this combination of distinctive features was not found, and this combination does not follow explicitly for a specialist from the prior art.

The method is as follows (Fig.4-6).

After laparotomy, extended proctectomy with resection of the internal and external sphincters at the end of the lower intestine, a smooth muscle pulp cuff is formed according to the known method [4].

Then proceed to the formation of the levator on the reduced intestine. Above the smooth muscle pulp, a sero-muscular membrane is dissected by 20-30 mm in the transverse direction to the entire width of the anti-mesenteric section of the intestine (15-18 mm). Along the right and left sides of the mesentery and suspensors of the antirenitant portion of the intestine, two more parallel sections of the serous-muscular membrane 65-70 mm long are performed. The rectangle thus designated from the serous-muscular layer is separated from the underlying submucosa, maintaining its connection with the intestinal wall at the proximal end (Fig. 4A). The submucosal area is stretched with the help of thread-holders in the transverse direction and sutured with interrupted sutures until the serous-muscular layer is compared. After releasing and fixing the intestine in the perineum, 2-4 nodal sutures are applied with abdominal access between the top of the flap and the anterior semicircle of the pelvic peritoneum (Fig. 5B; 6A), respectively, of the projection of the pubic rectal loop.

The formation of a smooth muscle artificial levator between the pelvic and perineal sections of the reduced intestine can significantly increase the efficiency of holding the smooth muscle cuff and the saved structures of the external sphincter after proctectomy. The strengthening of the holding mechanism in this case is associated with the restoration of the anorectal angle between the pelvic and perineal sections of the reduced intestine in the region of the smooth muscle levator. The appearance of an anorectal angle is due to traction of the intestinal wall - the levator flap, fixed to the front surface of the bottom of the pelvis (similar to the projection of the removed pubic-rectal levator loop), due to the ability of smooth muscles it is in an involuntary tone.

To date, there is sufficient evidence of difficulty evacuating from pelvic small intestinal reservoirs located horizontally in the pelvis. In this case, defecation can last for hours, after it there is a feeling of incomplete emptying, there is a need for constant use of suppositories and cleansing enemas to maintain the evacuation function of the reservoir. It should be noted that the created artificial levator prevents the tank from lowering and gives it a vertical position, thereby providing the necessary preventive measures for incomplete emptying.

The effectiveness of the proposed method demonstrates a clinical example.

Senior citizen of the Ministry of Defense of the Russian Federation (reserve captain) K., 62 years old (medical history No. 4423), was hospitalized at the military surgery clinic of the Tomsk Military Medical Institute on August 21, 2007 with complaints of spotting from the anus, pain in the anus during the act bowel movements. Over the past year, the patient began to notice the secretion of mucus and blood during bowel movements, lost 3 kg. A week before going to the clinic, the patient developed pain in the anus and an increase in body temperature to 37.4 ° C. Previously, the patient did not seek medical help.

Objective inspection. The patient's condition is satisfactory. Skin integument, turgor preserved. The mucous membranes are pale pink, moist. Peripheral lymph nodes are not enlarged. The muscular system is developed satisfactorily, muscle tone is maintained. The chest is cylindrical in shape, the percussion sound is pulmonary. Vesicular breathing. Apical impulse in 5 intercostal space, not spilled, normal strength. Heart sounds are clear, the rhythm is correct 74 per minute. Blood pressure 130/70 mm Hg The abdomen is of the correct form; it is involved in the act of breathing, soft, painless. The peristalsis is even. The kidneys and spleen are not palpable. The edge of the liver does not protrude from the edge of the costal arch. Per rectum: sphincter tone preserved. Immediately after the sphincter, the edge of an exophytic growing tumor is determined, spreading within the ⅓-½ circle of the lower ampullar part of the rectum. Tumor tissue is dense, tuberous. There are traces of blood on the glove.

Survey data

Complete blood count (08/22/07) Hb 122 g / l; erythritol. 4.2 · 10 ¹² / l; lake. 8.2 · 10 ⁹ / l; n 6%; with 67%; e 4%; l 16%; m 7%; ESR 22 mm per hour.

Urinalysis (08.22.07) SG 1.015, PH 6, LEU neg, NIT neg, PRO neg, GLU norm, KET neg, UBG norm, Bil neg, ERY neg.

Biochemical blood test (08/22/07) total. protein 69 g / l; glucose 6.5 mmol / l; bilirubin 9.0 μmol / l; ACT 0.31 mmol / h · L; ALT 0.50 mmol / h · l; Potassium 4.5 mmol / L.

Coagulogram (08/22/07) PTI 91%; PTV 18.5 sec; fibrinogen 3.3 g / l; APTT 32.4 ± sec.

ECG (08.22.07) Sinus rhythm, heart rate 71 per minute. The vertical position of the EOS. Mild ventricular myocardial changes.

Ultrasound of the kidneys (08/22/07) right kidney 115 × 48 mm; left kidney 118 × 51 mm, renal mobility preserved. Renal parenchyma preserved, moderately thinned 12 mm, renal sinus differentiates clearly. On the left is divided by a layer of parenchyma in the middle part. CLS is not expanded. To the left in the parenchyma, a solitary cyst in the form of an anechogenic formation of 17 × 16 mm in a thin capsule with uniform contents. The adrenal glands are not enlarged.

ECHO cardiography (08.22.07) there is no expansion and hypertrophy of the heart, the valves are not changed, moderate compaction of the walls of the aorta.

Spirography (08.27.07) ventilation function of the lungs within normal limits.

Colonoscopy with chromoscopy (08.22.07).

The tone of the anal sphincter is preserved. Immediately after the sphincter, 1.5-2 cm from the anus is determined by the edge of the tumor with predominant exophytic growth. The circumference of the tumor takes from ½ to ⅔, along the length of 5-6 cm (figure 1). To objectify the spread of the tumor beyond its macroscopic boundaries, direct chromoscopy with methylene blue was performed (Fig. 2). Using the distinctive features of the relief of the mucous membrane of the intestine and tumor, a biopsy was performed: 1 fl. - 4 fr. from the proximal edge of the tumor, 2 fl. - 3 fr. from the zone of diffuse impregnation of the mucosa with dye, 3 fl. - 3 fr., From the central part of the tumor, 4 fl. - 3 fr. from the distal edge. The large intestine was examined to the dome of the cecum. In the left half of the colon, several 0.8 cm diverticulums are determined without signs of inflammation. The mucosa of the distal edema is hyperemic. In the sigmoid colon, a polyp on a wide base of 0.8 cm, biopsy 2 FR. Conclusion: colorectal cancer, type 2 sigmoid colon polyp, single colon diverticula.

Histological examination No. 4236-4238 of 08/22/07. Biopsy material identifies foci of necrosis with dense neutrophilic and lymphoid infiltration against the background of structures of moderately differentiated adenocarcinoma.

Computed tomography No. 56228 of 08/26/07. On a series of tomograms of the pelvic organs, the lumen of the rectal ampoule is circularly narrowed due to the thickening of the lower ampullar wall and filling defects at this level, 2.6x4.0 cm wide and 5.0 cm long. Pararectal fiber not changed. Regional lymph nodes up to 0.7-0.8 cm. Conclusion: an infiltrative form of colorectal cancer.

Radiography of the lungs No. 3411 of 08/22/07 without pathology.

Preoperative preparation included infusion therapy aimed at improving the rheological properties of blood and myocardial metabolism, sedation, prevention of thromboembolic disorders (elastic bandaging of the lower extremities, administration of fraxiparin), mechanical cleaning of the colon (fortrans).

As planned, on September 5, 2007, under combined anesthesia (intubation anesthesia with epidural anesthesia), an operation was performed: proctectomy with resection of the internal sphincter, a deep portion of the external sphincter, sacrointestinal and rectal levator loops with reduction, modeling of the smooth muscle sphincter, reservoir and left serous-muscle flap on the reduced intestine according to the claims.

Lower middle laparotomy. When revising the abdominal organs, signs of distant and regional metastasis were not detected. The diaphragmatic and visceral surface of the right lobe of the liver are soldered to the omentum and the anterior abdominal wall (a history of viral hepatitis). When examining the bottom of the pelvis, the tumor is not detected. Abdominal access performed dissection of the peritoneum along the left lateral canal, the bottom of the pelvis with the transition to mesosigma. The superior rectal artery is ligated. Along the lower mesenteric artery, two enlarged lymph nodes are determined with a smooth surface of up to 7 × 8 mm and 8 × 12 mm, not fused with the surrounding tissues, of elastic consistency. Lymphatic dissection was performed along the mesenteric artery (lymph nodes aimed at histological examination). The sigmoid colon was mobilized for reduction, stitched with a mechanical suture and crossed. With some technical difficulties associated with a narrow pelvis, a total mesorectumectomy was performed to the level of transition of the levators to the longitudinal muscle of the anal canal (Fig. 3, A). A smooth muscle pulp is formed at the end of the sigmoid colon by separating the serous-muscular membrane with a height of 15 mm and fixing it with separate sutures in the form of a cuff. Above the smooth muscle pulp, a serous-muscular membrane is dissected by 25 mm in the transverse direction by 17 mm of the width of the anti-mesenteric section of the intestine. Along the right and left edges of the mesentery and suspensions of the anti-mesenteric section of the intestine, two more parallel sections of the serous-muscular membrane 65-70 mm long were made. The thus designated rectangle of the serous-muscular layer is separated from the underlying submucosa, while maintaining its connection with the intestinal wall at the proximal end (Fig. 4, A). The submucosal area formed after the formation of the flap is stretched with the help of filaments-holders in the transverse direction and sutured by interrupted sutures until the serous-muscular layer is compared (Fig. 4, B). Sphincter deviation was performed by perineal access and 4 filaments were placed at the level of the anocutane line. The lumen of the rectum is sealed with a purse string suture 1.5 cm proximal to the level of the filaments of the holders and crossed. The internal sphincter was mobilized from the subcutaneous portion of the external sphincter in one block with a deep portion of the external sphincter, sacro-and pubic-rectal levator loops. The drug is removed through the perineum. Control for hemostasis and foreign bodies. Through additional cuts on the perineum, to the right and left of the anus, two drainages are installed in the small pelvis so that the lateral hole of one of the drainage tubes is located in the upper part and the other in the lower part of the small pelvis. The pelvic cavity is washed. Lowering the sigmoid colon to the perineum. With technical difficulties due to the limited length of the vascular pedicle, the sigmoid colon was fixed with interrupted sutures around the circumference of the edge of the muscular cuff and subcutaneous portion of the external sphincter. Separate nodal sutures were placed between the perianal skin and the submucosal excess in the reduced intestine. Through abdominal access, a flap from the serous-muscular layer is fixed similarly to the projection of the pubic-rectal muscle loop with 4 interrupted sutures along the anterior semicircle of the pelvic peritoneum, respectively, the projection of the pubic-rectal loop (Fig. 5, A; Fig. 6, A).

The integrity of the retroperitoneal space is restored above the level of the reduced intestine. Drainage of the lower floor of the abdominal cavity through an additional incision in the right iliac region. Layered closure of the anterior abdominal wall. Dressings.

Macro drug: rectum with surrounding fiber. In the lower ampullar part of the intestine, a saucer-shaped tumor of 65 × 55 mm with protruding edges above the mucous membrane above the anucutan line by 10 mm is determined along the front wall (Fig. 6, B).

In the postoperative period, a natural decrease in red blood counts was noted against the background of normalization of the level of leukocytes and leveling of the leukocyte formula.

Complete blood count (6.09.07) Hb 91 g / l; erythritol. 3.1 · 10 ¹² / l; lake. 11.2 · 10 ⁹ / l; n 13%; with 78%; l 9%; ESR 42 mm per hour.

Complete blood count (7.09.07) Hb 70 g / l; erythritol. 2.2 · 10 ¹² / l; lake. 9.0 · 10 ⁹ / l; p 2%; with 82%; e 1%; l 13%; m 2%; ESR 55 mm per hour.

General blood test (09/10/07) Hb 70 g / l; erythritol. 2.7 · 10 ¹² / l; lake. 6.6 · 10 ⁹ / l; p 5%, s 56%; e 10%; l 19%; m 10%; thrombus. 240 g / l; ESR 70 mm per hour.

Biochemical blood test (09/10/07) total. protein 54 g / l; Alb. 38 g / l; glucose 5.5 mmol / l; bilirubin 14.9 (2.0-12.9) μmol / L; urea 10.1 mmol / l; creature. 0.071 mmol / L; amylase 11.8 mmol / L; ALT 0.141 μkat / L.

Drainage from the abdominal cavity was removed on the 3rd day. In the postoperative period, passive drainage of the pelvis through perineal drainage, which were sequentially removed on the 4th and 5th day, was performed. Stool from 7 days, liquid and involuntary, up to 10-12 times a day, including at night. The patient constantly wears a diaper. During the patient’s stay in the hospital before discharge, the consistency of feces in the form of liquid slurry, defecation is multi-stage, prolonged. Periodically, maceration of perianal skin occurs. To reduce stool frequency and prevent perineal maceration, Imodium is prescribed, perineal hygiene after defecation and ointment applications on the perianal area are performed.

Sutures were removed on the 10th day. The patient was discharged on September 19, 2000 in satisfactory condition under the supervision of an oncologist at the polyclinic with recommendations on the regimen, diet, and extension of medical gymnastics. At the time of discharge, the patient remains involuntary, multi-stage and prolonged bowel movements up to 5-9 times a day, fecal and gas incontinence is noted, requiring constant wearing of diapers.

A year later, on September 17, 2008, patient K., 63 years old, was hospitalized in the clinic for follow-up examination after adjuvant monochemotherapy (xeloda 2500 mg / m ² / day, in 2 doses, days 1-14, every 3 weeks for 6 months (8 courses)). He makes no complaints, he is satisfied with the results of treatment, considers himself socially rehabilitated. He returned to the work of the guard. Marks incontinence of intestinal gas, which differentiates from feces.

Defecation conscious 1, rarely 2 times a day, erectile function is preserved. The last 5-6 months, it became possible to ignore the urge for more than 15-40 minutes with the retention of solid feces. The patient uses underlays, visits public places, for several decades before the operation and currently visits the public bath once a week.

Per rectum: with irritation of the perianal region, a lively anal reflex is noted. The anus at the skin level is somewhat narrowed, misses the nail phalanx. Produced by devulsion. For 3-4 cm behind the anus, a zone of increased pressure is determined. Volitional contraction of the sphincter is sufficient. In the lumen of the intestine, decorated feces are of a normal color.

Reservoirography. Using a contrast enema, the distal colon is seamlessly filled with barium. In the frontal projection behind the anus, a zone of increased pressure is determined with a length of 20-25 mm (Fig. 7, A). Proximal to this zone, the intestine smoothly passes into a reservoir resembling a natural rectal ampoule. The leading loop of the tank is the usual size. In the oblique projection between the perineal and pelvic sections of the reduced intestine, the anorectal angle is determined, which is formed due to traction of the smooth muscle flap formed (Fig. 7, B). The angle is within 120 °.

During the examination (ultrasound, computed tomography, colonoscopy) data for the progression of the main process were not identified. The patient was discharged in satisfactory condition under the supervision of an oncologist at the clinic with recommendations for dynamic monitoring.

According to this technique, 7 patients aged from 38 to 74 years were operated on for the high- and medium-differentiated lower ampoule rectal adenocarcinomas with spread to the anal canal. In 4 cases, the tumors occupied ½ of the intestinal circumference, the intestinal wall grew, did not have regional and distant metastases (T3N0M0). One patient had metastasis to the pararectal lymph node (T3N1M0). And two patients were with stage IV tumor process with bilobar multiple liver metastases (T3N0M1 and T4N21M1).

During the first three months, patients had involuntary, multi-stage and prolonged bowel movements from 3 to 7 times a day, incontinence of all components of intestinal contents. This required constant wearing of diapers. After 6 months, a conscious defecation appears with an urge 1-2 times a day, elements of holding solid feces, patients use underlays with periodic wearing of diapers. After 1 year, a defecation conscious 1 time per day. The possibility of ignoring the urge to defecate for more than 15-40 minutes while retaining solid feces was noted. Patients use underlays, visit public places (general bathhouse, theaters), the erectile function is preserved.

Thus, the formation of an artificial smooth muscle levator between the pelvic and perineal sections of the reduced intestine can significantly increase the efficiency of holding the smooth muscle cuff and the saved structures of the external sphincter after proctectomy. The strengthening of the holding mechanism in this case is associated with the restoration of the anorectal angle between the pelvic and perineal sections of the reduced intestine in the region of the smooth muscle levator. The appearance of the anorectal angle is due to traction of the intestinal wall by the levator, fixed to the front surface of the bottom of the pelvis (similar to the projection of the remote pubic-rectal levator loop), due to the ability of smooth muscles it is in an involuntary tone.

Figure 1 - video colonoscopy: A - the lower edge of the tumor at the border of the lower ampullar region and the anal canal (indicated by arrows); B - the spread of the tumor around the circumference of the lower ampullar part of the rectum (indicated by the dashed line).

Figure 2 - chromocolonoscopy: A - pathological relief of the lower edge of the tumor (white dashed line) against the background of the anal canal (indicated by black arrows); B - a typical relief of the rectal mucosa.

Figure 3 - total mesorectumectomy from abdominal access: A - mobilized rectum with surrounding fiber; B - the pelvic cavity after removal of the intestine.

Figure 4 - plastic stage: A - above the muscle cuff (1), a submucosal area (2) is formed by separating the muscle levator flap (3); B - at the base of the flap (3), the submucosal pad (4) is sutured in the transverse direction.

Figure 5 - the formation of the recto-rectal muscle from a smooth muscle flap: A - smooth muscle flap-levator in the anterior semicircle of the reduced intestine; B - fixation with interrupted sutures of the levator along the anterior surface of the pelvic peritoneum.

6 - fixation of the flap to the surface of the pelvic peritoneum (A); a gut macrodrug with a tumor of the lower ampullar region spreading to the anal canal (B).

Fig.7 - proctograms 1 year after the operation: A - reservoir in direct projection; B - reservoir in the lateral projection; dashed lines mark the reservoir-canal angle (5) and the projection of the smooth muscle flap of the levator (3).

Bibliography

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Claims (1)

A method of forming a levator on the reduced intestine during resection of the rectum with removal of various portions of the external sphincter, characterized in that on the anti-mesenteric section of the intestine in the transverse direction, a dissection is performed over 15-18 mm of the serous-muscular membrane 20-30 mm above the smooth muscle pulp cuff then two more parallel sections of the serous-muscular membrane 65-70 mm long along the right and left sides of the intestinal mesenteric section of the intestine are made from the vertices of the angles of the planned flap in the proximal direction of the mesentery and pendants, the flap thus designated from the serous-muscular layer is separated from the underlying submucosa in the direction from the apex in the transverse section to its base at the proximal end, maintaining the connection between the flap base and the intestinal wall, then after suturing of the submucosal area in the transverse direction produce intestinal reduction and the formation of an anastomosis in the perineum, abdominal access sero-muscle flap is fixed with 2-4 interrupted sutures to the pelvic peritoneum along the anterior semicircle of the pelvic axis according to the projection of the rectal rectal loop.

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