RU2391056C1 - Method of forming compression colorectal anastomoses on transanal intubation drainage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, surgery and aims at restoring the continuity of colon in patients who underwent anterior-upper resection of rectum, as well as prevention of stenosis and failure of colorectal anastomosis. On the edge of the resected edge of the rectum stump four traction sutures are made at an equal distance from each other through the entire thickness of the wall. The thread is fixed from the lumen to the rectum mucosa at a distance of 2 cm from the resected edge of the perimetre at the eight points at equal distance from each other. The ends of the thread are put through puncture of the wall outside. Transanaly into the rectum and adducting segment of bowel an intubation drainage is inserted which is a PVC pipe with holes at the end of input, so that the distance from the leading edge of the resected segment of bowel distal to the drainage hole is at least 5 cm. Threads of traction suture are fixed at equal distances from each other along the circumference to the wall of intubation drainage and edge of the adducting segment of bowel. Threads of traction suture are sutured to the adducting segment of bowel at a distance of 0.4 cm from the edge of the resected through the entire thickness of the wall. All threads of traction suture are alternately tightened, closing to each other edges of resected segments of intestine and fixing them to intubation drainage. Intubation drainage is pulled out of the anus in a distal direction into the lumen of the rectum to intussusception fixed to the ID of the resected bowel edges so that the outer surface of the intestine segments were facing each other below the threads, stitched earlier in the rectal mucosa. The ends of the threads are knotted up tightly placed on the intubation drainage of invaginated walls faced to each other with outdoor surfaces. "П"-shaped sliding sutures are stitched on a circle to the pelvic diaphragm muscle and with the serous-musculo-submucous layer of adducting segment of intestine.

EFFECT: method prevents of stenosis and failure of colorectal anastomosis in a confined space of pelvis and a short stump of rectum.

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Description

The invention relates to medicine, namely to surgery, and can be used in operations ending with the formation of a colorectal anastomosis.

The widespread increase in the number of patients with complicated forms of colon tumors, unsatisfactory postoperative results increase the quality requirements for surgical suture of the colon. The development of alternative methods for the formation of intestinal anastomoses in colon surgery is considered as one of the ways to reduce the incidence of postoperative complications.

The formation of anastomosis after the anteroposterior rectal resection seems to be a technically difficult task, which leads to a rather high risk of postoperative complications. According to some authors, approximately 20% of the operated patients develop anastomotic insufficiency, which entails serious consequences. Complications arising from the failure of anastomoses, such as fecal peritonitis, pelvic fiber phlegmon, abscesses of the abdomen, fecal fistula, sepsis, not only negatively affect the final result of treatment, but are often associated with a risk to the patient's life (Motycka P., Dolezal B ., Ferko A., Subrt Z.).

The incidence of insolvency of colorectal and coloanal anastomoses remains high and, according to various authors, ranges from 6 to 45% (Tur G.E., Gedrevich Z.E., Tsemakhov Yu.G., 1998; Halbook O., Nystrom PO, Sjoahl R ., 1997; Jarvinen HJ, Luukkonen P., 1991).

Thus, one of the ways to improve the immediate results of surgical interventions is to develop new methods for applying manual colorectal anastomosis.

A known method of forming the esophageal anastomosis of Popov G. (Shalimov A.A. and Polupan V.N. Atlas of operations on the esophagus, stomach and duodenum. M: Medicine, 1975, p. 81). For this, a cuff is formed: the muscle layer is separated from the mucous membrane of the esophagus, a special device is introduced into the esophagus - a plexiglass prosthesis, the prosthesis is fixed with two ligatures to the esophagus mucosa. Using 4-6 catgut sutures, the mucous membrane of the esophagus is sewn with the intestine, the latter is pushed onto the prosthesis. This line of sutures is covered with a muscular cuff of the esophagus, which is fixed to the serous membrane of the intestine. After two weeks, the prosthesis is removed using a ligature fixed to the prosthesis.

A method is described, the essence of which is that the anastomosis is performed with a single-row precision suture with monofilament and the muscle pulp is formed from the free and stuffing muscle tapes of the colon with four 8-shaped sutures, thereby simulating the valve of the bauginium damper. In all the observations, a manual single-row colonic anastomosis was performed according to the standard clinic technique, the essence of which was that a colonic wound was formed on the open ends of the intestine. In this case, the main condition is a thorough wide comparison of the most regenerative submucosal layers of the anastomosed sections of the intestine. Non-absorbable monofilament 4 / 0-6 / 0 or absorbable (which is the best option) PDS 4 / 0-6 / 0 thread is used as suture material. Subtotal colectomy was completed by a primary loop-end single-row ileorectal anastomosis in 3 (2.0%) planned and 1 (1.9%) emergency patients. In the presence of an inoperable tumor in 4 (7.5%) emergency and in 1 (0.7%) planned cases, single-row bypass anastomoses were applied (Evgeny Kotelevsky // Precision technologies in the surgical treatment of colorectal cancer in elderly and senile patients, abstract. Diss Candidate of Medical Sciences, 2004).

The technique of closed single-row end-to-end anastomosis with interrupted sutures has been developed and over the past ten years. The features of this technique are the following technical methods: a) thorough release from fatty tissues of the comparable edges of the resected intestine at a distance of at least 0.5 cm from the edge of the resection; b) an oblique line of intersection (70-80 degrees with respect to the mesenteric margin) of the intestinal segments anastomosed end-to-end in order to increase the cross-section of the inter-intestinal anastomosis; c) the use of diathermocoagulation when crossing the intestine in order to “brew” tissues and achieve good hemostasis and greater asepticism of the intervention; d) the application of precision serous-muscular submucosal sutures on a traumatic needle no more than 5 mm from the edges, 4-8 mm stitches, with an interval of 5-6 mm between the sutures; e) tying of sutures after preliminary application of all ligatures around the entire perimeter of the anastomosis (at the beginning of the posterior and then the anterior semicircle); f) control and expansion of the lumen of the anastomosis with the thumb and forefinger, introduced towards each other through the walls of the anastomosed segments of the intestine; g) the application, if necessary, of additional sutures to the corners of the anastomosis (Ukhanov A.P., Gorbachev O.P., Belyakov O.I. // Use of single-row intestinal suture in the surgical treatment of colorectal cancer. - 3rd Congress of the Association of Surgeons named after . N.I. Pirogova).

Closest to the claimed invention is a method of connecting the tubular organs of the digestive tract (RF Patent No. 2018269, 1994.08.30), comprising applying an end-to-end anastomosis with compression between the outer surfaces of the anastomosed organs, characterized in that a purse string suture is applied to the mucous discharge of a segment of a tubular organ along its perimeter, the ends of the filament of a purse string suture are brought out through a puncture of the organ wall, the edge of the organ is invaginated into the lumen below the level of the purse string suture, which leads to the segment of the organ containing s internal drainage, introduced into the lumen intussusceptum and knotted thread ends purse-string suture.

Common disadvantages of these methods are:

- excessive trauma to the ends of stitched tubular organs;

- the presence in the lumen of the anastomosis of special devices made of solid material, exerting, at a larger size, pressure on the walls of the stitched organs, tissue ischemia in the anastomosis zone, and at a small size, reducing the internal diameter of the anastomosis in the early postoperative period;

- technical difficulties in the implementation, not conducive to improving the reliability of anastomoses and widespread adoption in surgical practice.

The problem solved by the claimed invention is the restoration of continuity of the colon in patients who underwent an anteroposterior resection of the rectum due to the formation of compression colorectal anastomosis on transanal intubation drainage, as well as the prevention of stenosis and colorectal anastomosis failure.

This object is achieved in that 0.4 cm depart from the resected edge of the stump of the rectum and four suture holders are applied at an equal distance from each other through the entire wall thickness, then from the lumen to the rectal mucosa at a distance of 2 cm from the resected edge at eight points at an equal distance from each other, a thread is fixed to the perimeter, the ends of which are brought out through a wall puncture to the outside, after which an intubation drainage (ID) is introduced, which is polychlorin sludge tube with through holes at the input end, so that the distance from the resected edge of the leading section of the intestine to the distal drainage hole is at least 5 cm. The threads of the suture-holders at equal distances from each other around the circumference are fixed to the endotracheal drainage wall and the edge of the leading segment of the intestine. To the leading segment of the intestine, the threads of the suture-holders are hemmed at a distance of 0.4 cm from the resected edge through the entire thickness of the wall. All the threads of the stitch-seams are tied in turn, bringing together the resected edges of the intestinal segments, and fix them to intubation drainage. Intubation drainage is pulled from the anus in the distal direction into the lumen of the rectum until invagination of the resected intestinal edges fixed to the ID so that the outer surfaces of the intestinal segments face each other below the level of the thread previously applied to the rectal mucosa. The ends of the thread are tied up until the invaginated walls facing each other by the outer surfaces are tightly pressed against the endotracheal drainage. Between the muscles of the pelvic diaphragm and the serous-muscular-submucous layer of the adducting segment of the intestine, “U-shaped” suture sutures are placed around the circumference.

A new technical result achieved using the method of forming a colorectal anastomosis on transanal intubation drainage is the restoration of the normal act of defecation and the prevention of complications after the anteroposterior rectal resection.

The compression suture provides a reliable, tight connection of the intestinal walls with external surfaces without traumatizing them (there are no through punctures of the intestinal wall), which ensures minimal inflammation in the stitched tissues and smooth healing of the anastomosis wound by primary intention.

In the area of colorectal anastomosis after rejection of the invaginated intestinal walls and their removal along with drainage on day 9-12, there are no foreign bodies (ligatures, braces) that support inflammation in the tissues.

Improving the reliability of colorectal anastomosis is achieved by decompression of the adducting segment of the intestine due to transanal intubation drainage.

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. This technical solution can be used in clinical practice. Thus, this method meets the criteria of the invention of "novelty", "inventive step", "industrially applicable".

The implementation of the method is illustrated by drawings 1-5. Figure 1 shows the step of applying suture-holders and a suture to the mucosa, as well as the introduction of ID. Figure 2 shows the stage of flashing ID and the leading segment of the intestine. Figure 3 shows the step of reducing the resected edges of the intestines and their fixation on the ID. Figure 4 shows the step of intussusception of the resected intestinal edges into the rectal lumen. Figure 5 shows the step of fixing the outer layer of the leading segment of the intestine to the muscles of the pelvic diaphragm.

The method is as follows.

After performing an anteroposterior rectal resection according to a standard method, while maintaining the supply vessels and without disturbing the blood supply, the adductal intestine is mobilized until tension is completely eliminated during subsequent stitching of the segments. The leading segment and stump of the rectum are prepared for the formation of a colorectal anastomosis on transanal intubation drainage. To do this, along the entire circumference for 3 cm from the resected edge, the mesenteric elements and fatty suspensions of the adducting segment and the rectal mesorectum are removed.

The first step in the formation of a compression colorectal anastomosis on a transanal intubation drainage is 0.4 cm from the resected edge of the rectal stump and 4 suture-holders are applied at an equal distance from each other through the entire thickness of the wall (1). From the side of the lumen to the rectal mucosa at a distance of 2 cm from the resected edge around the perimeter at 8 points at an equal distance from each other, kapron thread No. 5 (2) is fixed by flashing, its ends are brought out through a puncture of the wall to the outside. Intubation PVC drainage with a diameter of 2 cm and a wall thickness of 0.1 cm is carried out transanally to the rectum and adduction gut (3). At the insertion end, there are 4 lateral openings (4) 0.5 cm in diameter, 6 cm from the edge. Drainage is introduced into the intestinal tract so that the distance from the resected edge of the gastric tract to the distal drainage opening is at least 5 cm.

At the second stage, the filaments of the suture-holders (1), previously placed on the stump of the rectum, are fixed at equal distances from each other around the circumference by flashing to the endotracheal drainage wall (3) and the edge of the leading segment. For each ligature, the fixation point (5) on the wall of the drainage is located 5 cm below the distal drainage hole, while avoiding the displacement of the thread relative to the axis of the endotracheal drainage. Filaments are sutured to the leading segment at a distance of 0.4 cm from the resected edge through the entire wall thickness.

In the third step, all the holder threads are tied in turn (6), thus, the resected edges of the segments are brought together and fixed to the endotracheal drainage (3).

In the fourth stage, intubation drainage (3) is pulled in the distal direction, thereby resected edges fixed to the drainage are invaginated into the lumen of the rectum below the level of the thread (2), superimposed on the rectal mucosa. The ends of the thread (2) are knotted until the invaginated walls facing each other by the outer surfaces are tightly pressed against the endotracheal drainage, this completes the formation of the compression suture.

At the final stage, between the muscles of the pelvic diaphragm and the serous-muscular-submucosal layer of the adducting intestine, 7 “U-shaped” skid sutures are applied (7). To do this, at a distance of 0.5 cm from the rectal wall around the circumference at equal distances from each other, ligatures are fixed by stitching to the muscles of the pelvic diaphragm (8) and the serous-muscular-submucous layer of the adducting segment of the intestine, and are tied in turn. This completes the formation of compression colorectal anastomosis on transanal intubation drainage.

In the early postoperative period, the patency of the endotracheal drainage is monitored. If necessary, several times during the day, the drainage is washed physiologically with a solution, thereby ensuring its decompression function. By 9-12 days, a scar forms in the anastomotic zone. Below the compression line from the side of the intestinal lumen, necrosis of the invaginated edges occurs and they are completely rejected along with intubation drainage, after which the drainage is removed. The performance of the proposed method is confirmed by the following clinical example.

Example 1

Patient Peninsula, 59 years old. Case history No. 1506, was admitted to the Department of Reconstructive Plastic Surgery OKB 05/12/06, with a diagnosis of cancer of the rectosigmoid colon T1N0M0 (histological conclusion No. 2385/17 - adenocarcinoma). 05/17/06, performed the operation: anterior resection of the rectum, followed by the formation of colorectal anastomosis on transanal intubation drainage by the developed method. At the end of the main stage, the pelvic cavity was drained with a silicone tube. The postoperative period was uneventful, there were no complications in the postoperative period. After 10 days, endotracheal and pelvic drainage removed. The sutures were removed on the 10th day, the healing of the postoperative wound by primary intention. 05/29/06, in satisfactory condition, the patient was discharged from the department. After 1.5 months with a control rectoscopy, stenosis in the rectum was not found.

These conclusions are confirmed by the results obtained in the Department of Reconstructive Plastic Surgery of the Design Bureau, where since 2005 anastomoses with anteroposterior rectal resection in 15 patients have been performed using this technique.

Changes in indicators of the hemostatic system, water-electrolyte disturbances, and a decrease in the number of blood cells were not detected in any patient. Complications associated with anastomotic insufficiency were not observed, there were no fatal outcomes. The postoperative period in comparison with similar methods was reduced by 4 days.

The method of forming a compression colorectal anastomosis on transanal intubation drainage in comparison with similar methods has several advantages.

1. The simplicity of the technical methods of the method allows you to create a reliable compression anastomosis in a limited space of the small pelvis and short stump of the rectum without the use of special staplers and devices, which eliminates the technical errors associated with their use (incomplete flashing of the intestinal walls, distortions in the suture area, poor adaptation of stitched fabrics of segments of different diameters, etc.).

2. Compression-ligature suture on the endotracheal drainage allows you to form a reliable tight connection of segments of different diameters, their full adaptation without taking into account the thickness of the intestinal wall.

Claims (1)

A method of forming a compression colorectal anastomosis on transanal intubation drainage, including end-to-end anastomosis, suturing the mucosa of the outlet segment of the intestine along its perimeter, bringing the ends of the thread out through a puncture of the wall, introducing a drainage tube and invaginating the edges, characterized in that equidistant from each other through the entire thickness of the wall of the stump of the rectum impose four suture-holders, then from the side of the lumen to the mucosa of the rectum at a distance of 2 cm from the resected about the edge around the perimeter at eight points at an equal distance from each other, a thread is fixed, the ends of which are brought out through a wall puncture to the outside, after which an endotracheal drainage is introduced, which is a PVC pipe with through holes at the input end, so that the distance from the resected edge the leading segment of the intestine to the distal drainage hole was at least 5 cm, after which the threads of the suture-holders around the circumference at equal distances from each other are fixed to the wall of the intubation dr to the edge and the edge of the leading segment of the intestine, to which the filaments of the suture-holders are hemmed at a distance of 0.4 cm from the resected edge through the entire thickness of the wall, all the threads of the seams-holders are tied in turn, bringing together the resected edges of the segments of the intestine, and fix them to the intubation drainage, which is pulled from the anus in the distal direction into the lumen of the rectum until invagination of the resected intestinal edges fixed to it so that the outer surfaces of the intestinal segments face each other below the level of Iti, previously applied to the rectal mucosa, the ends of the thread are tied up until the invaginated walls are tightly pressed against the endotracheal drainage, between the muscles of the pelvic diaphragm and the serous-muscular-submucous layer of the adducting segment of the intestine, U-shaped sled sutures are placed around the circumference.

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