RU2414861C1 - Method of surgical treatment of chronic coloproctogenic constipation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for surgical treatment of chronic coloproctogenic constipation. Midline laparotomy is performed. Rectum is pulled out in proximal direction. Parietal peritoneum is dissected. Anterior surface of V lumbar vertebra, sacrum and coccyx is prepared. Rectum is sewn with capturing internal edge of dissected parietal peritoneum to anterior longitudinal spine ligament in region of V lumbar vertebra body, promontory periosteum and upper and middle third of sacrum. Free edge of dissected parietal peritoneum is sewn to right antero-lateral surface of rectum. Excessively deep rectovesical recess of peritoneum is sewn hermetically. Entire large intestine is mobilised, starting from secum and finishing with sigmoid colon. Complete ablation of mobilised large intestine is performed. Isoperistaltic ileorectal side-to side anastomosis is applied.

EFFECT: method makes it possible to ensure regular pulpy or semi-liquid stool, eliminate occurrence of constipation.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of chronic coloproctogenic constipation associated with the presence in a patient of a pathologically elongated and poorly functioning colon (dolichocolon) and internal prolapse of the rectum.

In different countries, constipation affects from 28 to 50% of the adult population and more than 5% of children [1, 2, 3]. Often, signs of colostasis are noted in adolescence and young adulthood, especially in women, who in general show signs of chronic constipation more often than men.

The prevalence of chronic colostasis makes this problem a disease of civilization; in industrialized countries, up to 30-40% of the adult able-bodied population suffer from constipation [4, 5]. The pathogenesis of chronic constipation is diverse, one of the reasons for the slow movement of contents along the colon (cologenic constipation) is a significant lengthening of the colon or its parts (dolichocolon). In other cases, chronic colostasis may result from impaired function of the rectum, anal sphincter, pelvic floor muscles (proctogenic constipation).

To date, none of the many proposed methods for conservative and surgical treatment of chronic proctogenic constipation in patients with dolichocolon has one hundred percent effectiveness. According to many authors, the frequency of unsatisfactory results after surgery reaches 27.3-45.9% [5, 6].

There is a method of rectopexy according to Kümmmel-Zerenin in the modification of the Research Institute of Proctology of the Ministry of Health of the RSFSR, used for prolapse of the rectum with the removal of the rectum-uterine pocket of the peritoneum (in women) or recto-vesical pocket (in men) [7]. The closest analogue is the operation of resection of the elongated non-functioning left parts of the colon (left-sided hemicolectomy) in combination with the Kümmel operation proposed by G.I. Vorobyev et al. [8]. The latter method has the disadvantage that it cannot guarantee the restoration of peristalsis of the remaining elongated and atonic transverse colon and right half of the colon. Therefore, such an operation may not lead to the elimination of chronic coloproctogenic constipation, that is, it does not guarantee success.

The technical result to which the invention is directed is to create the possibility of free passage of semiliquid contents from the ileum through ileorectoanastomosis to the rectum, which eliminates the possibility of constipation, but at the same time provides regular soft or semi-fluid stools, as well as the prevention of relapse of anorectal obstruction.

The technical result is achieved by the fact that in the method of surgical treatment of chronic coloproctogenic constipation, including median laparotomy, stretching the rectum in the proximal direction and straightening an excessively deep rectovesical or utero-rectal pocket of the peritoneum, dissection of the parietal peritoneum, preparation of the anterior surface of the V lumbar vertebra, sacrum , hemming of the rectum with capture of the inner edge of the dissected parietal peritoneum to the anterior longitudinal ligament of the spine and in the region of the body of the V lumbar vertebra, periosteum of the promontory and the upper and middle third of the sacrum, suturing of the free edge of the dissected parietal peritoneum to the right anterior-lateral surface of the rectum, suturing tightly of an excessively deep rectovesical pocket of the peritoneum, mobilize the entire colon, starting from the blind and ending with the blind sigmoid colon, after which complete removal of the mobilized colon and the application of isoperistaltic ileorectal anastomosis side-by-side.

Thus, a method is proposed for simultaneous combined surgical treatment of chronic coloproctogenic constipation by performing Kümmel-Zerenin rectopexy in a modification of the Research Institute of Proctology of the Ministry of Health of the RSFSR with the removal of the recto-uterine peritoneal pocket (in women) or recto-vesical pocket (in men) in combination with total colectomy . An indication for total colectomy is the presence of chronic colostasis against a pronounced dolichocolon with a sharp slowdown in the transit of colonic contents over 96 hours, the presence of megarectum (an excessively wide ampule of the rectum), as well as indications of a long and unsuccessful intake of laxatives or an unsuccessful previous operation in the form of left hemicolectomy.

The method is illustrated in figures 1-4, where figure 1 shows the step of suturing the elongated proximal rectum to the periosteum of the anterior surface of the sacrum and V of the lumbar vertebra; figure 2 shows the final stage of the operation Kümmel-Zerenin - hemming the right edge of the dissected parietal peritoneum over the sutures that fix the rectum to the sacrum and V lumbar vertebra; figure 3 shows the stage of the operation of suturing an excessively deep utero-rectal pocket of the peritoneum with two purse string sutures; figure 4 shows the final stage of the operation of total colectomy - ileorectoanastomosis side-by-side, where: 1 V lumbar vertebra, 2 sacrum, 3 sigmoid colon, 4 rectum, 5 left edge of the dissected peritoneum, 6 right edge of the dissected peritoneum, 7 anal channel, 8 uterus, 9 utero-rectal pocket of the peritoneum, 10 ileum, 11 ileorectoanastomosis.

The method is as follows. After performing a wide median laparotomy and revision of the abdominal cavity organs, scissors are longitudinally dissected along its transitional fold along the right edge of the rectum from the sacral promontory (promontory) down to the pelvic floor. In the region of this incision, the parietal peritoneum and subperitoneal tissue are shifted to the sides with a tuffer, thereby exposing the front surface of the V lumbar vertebra, sacrum and coccyx. By sipping the sigmoid (and, accordingly, the rectum) gut, an excessively deep rectovesical or utero-rectal pocket of the peritoneum is straightened in the proximal direction and the rectum is removed from the pelvic cavity as high as possible. In this position, the rectum along its right lateral edge is sutured with four interrupted sutures to the anterior longitudinal ligament of the spine in the region of the body of the V lumbar vertebra, the periosteum of the promontory and the upper and middle third of the sacrum (Fig. 1). These seams also capture the inner (left) edge of the dissected parietal peritoneum. Suture threads tighten and tie knots, starting from the bottom seam. The free right (lateral) edge of the dissected parietal peritoneum is sutured to the right anterolateral surface of the rectum, which ensures its additional fixation in the optimal position (figure 2). An excessively deep utero-rectal (rectovesical in men) peritoneum pocket is sutured with two purse-string sutures with the capture of the sacro-uterine ligaments and the posterior surface of the uterus (in women), the parietal peritoneum on the front surface of the rectum. First, a purse string suture is applied to the deepest part of the peritoneal pocket in the region of its bottom, this suture is tightened and tied. 4 cm higher (proximal) of this suture, a second purse string suture is applied, tightened and tied, thereby completely covering the utero-rectal (rectovesical) peritoneal pocket (Fig. 3). Then the entire colon is mobilized by dissection of its ligaments and mesentery, starting from the terminal ileum and cecum and ending with the rectosigmoid division. The ileum is crossed with a stapler 10 cm proximal to the ileocecal angle. At the level of the rectosigmoid division, the colon is also crossed with a stapler. Thus, the entire colon is removed. The stitch seams on the stumps of the ileal ampoule of the rectum are peritonized with nodular serous-muscular sutures. Impose isoperistaltic ileorectoanastomosis side-by-side with two rows of nodal sutures (figure 4).

The effectiveness of the proposed operation is determined by the fact that it provides: 1) elimination of a practically useless huge reservoir in the form of a non-restorative elongated, enlarged, and atonic colon due to its total resection and the possibility of free passage of semi-fluid contents from the ileum through ileorectoanastomosis to the rectum, which eliminates the possibility occurrence of constipation, but at the same time provides regular soft or semi-liquid stools; 2) moving from the pelvic cavity in the proximal direction of the abnormally lowered rectum and thereby eliminating the pathological submucosal-mucous fold in its lumen (internal prolapse or internal invagination), which helps to prevent recurrence of anorectal obstruction; 3) elimination of an excessively deep rectovesical (in men) or utero-rectal (in women) peritoneal pocket, which helps to prevent recurrence of prolapse and prolapse of the rectum and delay the passage of contents along it.

Clinical examples.

Example 1. Patient MA., 37 years old, medical history No. 2394. Received December 17, 2001. With complaints of chronic constipation - an independent stool once every 5-6 days, the department during defecation of a small amount of feces of high density and dryness, fragmented (like a "sheep"), injuring the anus, no the feeling of complete bowel movement after defecation, the presence of a feeling of stopping the contents in the rectum during straining, despite prolonged regular intake of laxatives. She had a history of back colporaphia in 2000, levatoroplasty for rectocele, and in 2001 for left-sided hemicolectomy for dolichocolon, chronic cologenic constipation. These operations did not bring relief. Examination results: with digital rectal examination, sphincter tone is normal. With sigmoidoscopy - signs of internal rectal prolapse. Irrigosocpy revealed a right-sided dolichocolon, transversoptosis, hypomotor dystonia of the remaining part of the colon, megacecum, and ileocecal valve insufficiency. The diagnosis was established: “Condition after left-sided hemicolectomy for dolichocolon. Functional intestinal obstruction. Internal prolapse of the rectum. Chronic coloproctogenic colostasis. "

Operation December 22, 2001: Kümmmel-Zerenin rectectomy, suturing of the utero-rectal pocket of the peritoneum, total colectomy, ileorectostomy. Operation description. Wide median laparotomy with bypass of the navel on the left along the old scar. Dissection of adhesions, revision. The cecum and ascending colon are significantly enlarged. In the region of the hepatic angle, the large intestine forms an additional loop. The transverse colon is significantly elongated, sagging in the pelvis. The splenic angle, the descending colon and the proximal 2/3 of the sigmoid colon are absent; there is end-to-end transverse sigmoid anastomosis. The recto-uterine peritoneal pocket is deep, sagging deep into the utero-rectal space along with the partially invaginated rectal walls. The uterus is lowered with an anterior bend. Considering the clinical data, examination results and intraoperative findings (dolichocolon, delayed transit through the colon, signs of anorectal obstruction against the background of internal prolapse of the rectum), it was decided to perform rectopexy in combination with the elimination of the utero-rectal pocket, total colectomy with the formation of ileorectoanastomosis. In the Trendelenburg position, the loops of the small intestine are laid up. Sipping the distal sections of the sigmoid colon straightened the utero-rectal pocket, visualized the pelvic floor. Starting from the promontorium, to the right of the rectum, longitudinally down to the pelvic floor, the peritoneum covering the intestine is dissected in the area of transition to the posterior wall of the pelvis. With the help of a tupfer, the front surface of the Vth lumbar vertebra, promontorium, sacrum and tailbone is released. 4 sutures were laid with prolen thread (1/0) on the anterior oblong ligament of the spine, periosteum of the promontorium and the proximal and middle third of the sacrum strictly along the midline. By maximally stretching the rectum in the proximal direction, these threads sutured its right mesenteric edge with the capture of the free left edge of the dissected peritoneum. The threads are tightened and knots tied, starting from the bottom seam. The free right edge of the dissected peritoneum is sewn with several interrupted sutures to the anterolateral surface of the rectum. After visualization of the ureters, two purse string sutures (two floors, thread - prolene 1/0) eliminated an excessively deep utero-rectal pocket of the peritoneum. The distance between the purse string sutures is 4 cm. The sacro-uterine ligaments, the peritoneum of the anterior surface of the rectum and the posterior surface of the uterus are captured in the sutures. Then mobilization of the colon began. Dissection of the transitional folds of the peritoneum of the right lateral canal liberated the dome of the cecum, the terminal ileum. The ascending intestine and the hepatic angle of the colon are mobilized. Mobilization of the transverse colon began with the intersection of the gastrointestinal ligament. At the level of the rectosigmoid department, after stitching with a linear stapler, a resection was performed. Also, with the help of a stapler, the terminal part of the ileum was crossed, departing from the ileocecal angle by 10 cm. The stumps of the intestines were peritonized with gray-serous sutures. Then an isoperistaltic ileorectoanastomosis side-by-side with 2 rows of sutures is formed. Nodal sutures sutured the window in the mesentery in the area of the anastomosis. The posterior sheet of the parietal peritoneum is partially captured in the sutures. Drainage into the lateral canals and pelvis through separate punctures in the iliac areas. Layered seams on the wound.

The postoperative period was uneventful. Bowel function recovered on the 3rd day. Discharged January 14, 2002 in a satisfactory condition, at discharge the chair 4 times a day, half-decorated. Examined after 1, 3, 6 months, 1, 3, 6 years after surgery: half-formed stool in the first 3 months was observed 3-4 times a day; by 6 months and in subsequent years after surgery - 2 times a day, regular (morning and evening). The result is recognized as good.

Example 2. Patient MA., 37 years old, medical history No. 2394. Received December 17, 2001. With complaints of chronic constipation - an independent stool once every 5-6 days, despite prolonged regular intake of laxatives. A history of 2000 was posterior colporaphia, levatoroplasty for rectocele, in 2001 for left-sided hemicolectomy for dolichocolon, chronic cologenic constipation. These operations did not bring relief. Examination results: with digital rectal examination, sphincter tone is normal. With sigmoidoscopy - signs of internal rectal prolapse. Irrigosocpy revealed a right-sided dolichocolon, transversoptosis, hypomotor dystonia of the remaining part of the colon, megacecum, and ileocecal valve insufficiency. The diagnosis was established: “Condition after left-sided hemicolectomy for dolichocolon. Functional intestinal obstruction. Internal prolapse of the rectum. Chronic coloproctogenic colostasis. "

Operation December 22, 2001: Kümmmel-Zerenin rectectomy, suturing of the utero-rectal pocket of the peritoneum, total colectomy, ileorectostomy. The postoperative period was uneventful. Bowel function recovered on the 3rd day. Discharged January 14, 2002. In satisfactory condition, upon discharge, the chair 4 times a day, half-decorated. Examined after 1, 3, 6 months, 1, 3, 6 years after surgery: half-formed stool in the first 3 months was observed 3-4 times a day; by 6 months and in subsequent years after surgery - 2 times a day, regular (morning and evening). The result is recognized as good.

Example 3. Patient MA., 33 years old. Medical history No. 2741. Was admitted to the clinic 10/19/2009. Diagnosis: "Dolichocolon. Internal prolapse of the rectum. Chronic coloproctogenic colostasis. " Concomitant disease: Endometrioid ovarian cysts. The patient has constipation since childhood. Complains about the rarity of the stool (less than 3 bowel movements per week), a small amount of feces of the “sheep” type, lack of a feeling of complete emptying of the intestine, a feeling of blockage of contents in the rectum, the need for strong attempts to defecate. Long-term treatment with laxatives and enemas did not bring any effect. After a standard examination (irrigoscopy, sphinctero-manomatometry, defecosphincteromanometry, anoproctometry) was operated on November 3, 2009 - laparotomy, resection of ovarian cysts, Kümmmel-Zerenin rectopexy, total colectomy, ileorectostomy were performed. The postoperative period without complications was discharged on November 14, 2009. On the 11th day after the operation. When examined after a month, the condition is satisfactory, no complaints, stool 2 times a day, half-decorated. When examining 3 months after the operation, the patient's condition is satisfactory, no complaints, stool 2 times a day, half-formed. Thus, the result of the operation is recognized as good.

Information sources

1. Tsvetkova L.N. Prevention and treatment of constipation in children // Questions of modern pediatrics. - 2004. - No. 3. - C.2-7.

2. Locke G.R., Pemberton J.H., Phillips S.F. American Gastroenterologic Association medical position statement: guidelines on constipation // Gastroenterology. - 2000. V.ll9. - P.1761-1778.

3. Longstreth G.F., Thompson W.G., Chey W. D., Houghton L. A., Mearin F., Spiller R. C. Functional bowel disorders // Gastroenterology. - 2006. - V.130. - P.1480-1491.

4. Achkasov S.I. Anomalies in the development and position of the colon. Clinic, diagnosis, treatment. Abstract. dis ... Dr. med. Sciences: 14.00.27 / SSC.- Moscow, 2003-31 p.

5. Yaremchuk A.Ya., Radilsky S.E., Topchiy T.V., Morozova N.L. Chronic colostasis - features of the clinic and diagnosis // Vestn. surgery. - 1990. - No. 7. - C.113-115.

6. Romanov P.A. Clinical anatomy of colon options and abnormalities. - M .: Medicine, 1987 .-- 189 p.

7. Fedorov V.D., Dultsev Yu.V. Proctology. - M.: Medicine, 1984. - 384 p.

8. Vorobiev G.I., Shelygin Yu.A., Titov A.Yu., Kapuller L.L. Clinic and the choice of a method for treating internal prolapse of the rectum (intrectal invagination) // Ann. surgery. - 2000. - No. 6. - S. 34.

8. Vorobiev G.I., Shelygin Yu.A., Titov A.Yu., Kapuller L.L. Clinic and the choice of a method for treating internal prolapse of the rectum (intrectal invagination) // Ann. Surgery. - 2000. - No. 6. - S. 34.

Claims (1)

A method for the surgical treatment of chronic coloproctogenic constipation, including median laparotomy, rectal extension in the proximal direction and straightening of an excessively deep rectovesical or utero-rectal pocket of the peritoneum, dissection of the parietal peritoneum, preparation of the anterior surface of the V lumbar vertebra, sacrum and coccyx, stitching of the rectum the edges of the dissected parietal peritoneum to the anterior longitudinal ligament of the spine in the region of the body of the V lumbar vertebra, tornitsa of promontory and the upper and middle third of the sacrum, suturing of the free edge of the dissected parietal peritoneum to the right anterolateral surface of the rectum, suturing tightly of an excessively deep rectovesical pocket of the peritoneum, characterized in that after suturing of the rectovesical pocket of the peritoneum mobilize the entire colon, starting from the blind and ending with a sigmoid colon, after which complete removal of the mobilized colon and the application of an isoperistaltic ileorectal anastomosis side-by-side are performed.

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