RU2441606C1 - Allograft proctoperineoplasty for rectocele correction in patients with impaired motor-evacuation function of the large intestine with descending perineum syndrome and pelvic organs fixation disorders - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to surgery and may be applied to rectocele therapy. The posterior vaginal wall graft shall dissected from its lower third, from the vulval vestibule to the protrusion head. The rectovaginal septum and anterior rectum wall grafting shall be reinforced by a Ç£cross-shapedÇ polypropylene wide-meshed graft to the pouch of Douglas. The anterior rectum wall shall be stretched transversely on the mesh. The lateral edges of the Ç£cross-shapedÇ graft shall be fixed to levator muscles in the place of their fixation to the pubic bones. The upper edge shall be fixed via a counteropening in the posterior vaginal vault. It's only the anterior levator muscle portion Ç£legsÇ that are to be taken in together with the polypropylene graft apex. The wound shall be stitched up in the lower and in the upper vaginal thirds. ^ EFFECT: method allows to enhance the reliability of graft fixation, improve the functional outcome. ^ 1 dwg, 1 ex

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, to keep 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 vaginal wall remains (may form after levatoroplasty) (it is important to emphasize that complaints of prolapse of the posterior vaginal wall 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;

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

- When using circular staplers (mucous-submucosal resection), in addition to the above drawbacks, the size of the removed section of the anterior rectal wall is limited by the capabilities of the working part of the apparatus, while the length of the intestinal wall forming the rectocele is much larger and averages at least 9 cm.

4. Plastic surgery of the rectovaginal septum with a transplant allows to strengthen the rectovaginal septum and eliminate the rectocele. The disadvantages of this method are:

• Lack of fixation of the upper pole of the graft can lead to its displacement after activation of the patient.

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

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 is 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, the flap of the posterior wall of the vagina is excised in its lower third from the vestibule to the apex of the protrusion.

Then, through a cut in the lower third of the vagina, the rectovaginal septum is cleaved to the level of the pelvic peritoneum, mobilization of the posterior wall of the vagina to the posterior fornix, mobilization of the anterior wall of the rectum, and the front portions of the levator muscles. Then, a cross-shaped polypropylene graft of “cruciform” shape is freely placed on the front wall of the rectum. Next, the polypropylene graft without tension is fixed to the muscles of the levators at the corners of the mesh with two sutures (Polysorb 03) in the place of their attachment to the pubic bones.

Then, an additional incision is made of the vaginal wall in the region of the posterior fornix. The upper end of the "cross-shaped" graft is carried out through the created counter-hole and is fixed.

Then, with separate sutures (Polysorb 03), only the legs of the front portions of the levator muscles are sutured with the capture of the top of the polypropylene graft (1-2 sutures). Wounds in the lower and upper third of the vagina are sutured without tension.

Thus, the proposed method allows to eliminate the excess wall of the vagina. 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 in 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 and its reliable fixation through contraperture in the posterior vaginal fornix strengthens the pelvic floor.

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.

Clinical example

Patient Zh., 39 years old, IS No. 2034-10, 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 coitus.

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 prolapse of the perineum in the stage of subcompensation of the muscles of the pelvic floor.

In a functional study of the obturator apparatus of the rectum, electrophysiological indicators of the contractility of the muscles of the external sphincter within the lower limit of the norm. Reflex responses saved.

The patient was diagnosed with rectocele 3 degrees.

February 24, 2010, the patient underwent surgery by the proposed method. The postoperative period was uneventful. There was no pain. Postoperative wounds in the vagina healed by first 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

- improve functional results;

- perform pelvic floor plasty with reliable fixation of the graft in the rectovaginal septum.

Information sources

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 large-mesh "cross-shaped" polypropylene transplant, characterized in that a flap of the posterior vaginal wall is excised in its lower third from the vestibule to the apex of protrusion, and rectovaginal anterior septum and reinforcement are strengthened rectum "cross" polypropylene coarse graft to Douglas space, stretch the front wall straight of the intestine in the transverse direction on the grid, the lateral ends of the “cruciform” graft are fixed to the muscles of the levators at the place of their attachment to the pubic bones, and the upper end is fixed through contraperturation in the posterior vaginal fornix, only the legs of the front portions of the levator muscles are sutured with the capture of the top of the polypropylene graft, sutured wounds in the lower and upper third of the vagina.