RU2444313C2 - Method of restoring of large intestine continuity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for restoration of large intestine continuity. Mucous membrane of anal canal is separated on silicone tube anteriorly on posterior semicircle. Overlying large intestine is brought down and fixed in anal canal with separate sutures. Septum, formed between stump of rectum and brought down large intestine, is dissected.

EFFECT: method makes it possible to reduce risk of developing anastomosis strictures, reduce operation trauma.

2 ex, 3 dwg

Description

The invention relates to medicine, namely to Oncology, and can be used to restore the continuity of the colon after Hartmann surgery for cancer of the rectum and sigmoid colon. Restoring the continuity of the colon after Hartmann's surgery presents significant technical difficulties, since the anastomosis is formed under conditions of scarred tissue of the bottom of the pelvic cavity. The most difficult step is the isolation of the rectal stump. In a whole series of cases, it is not possible to isolate the stump and differentiate it from the wall of the bladder (in men) or the posterior wall of the vagina (in women).

A known method of restoring the continuity of the colon with the hardware formation of an anastomosis after Hartmann's surgery (Banerjee S, Leather AJ, Rennie JA, Samano M, Gonzalez JG, Papagrigoriadis S: Feasibility and morbidity of reversal of Hartmann's. Colorectal Dis 2005, 7: 454-459) . The essence of the method is to connect the stump of the rectum with the leading section of the colon using a stapler. The stump of the rectum is partially mobilized, a stapler is inserted into it. The removable head of the device is fixed with a purse string suture in the lumen of the overlying colon, connected to the main body of the device in the stump of the rectum, then flashing is performed and the anastomosis is automatically formed by clips.

The disadvantages of the method are the need to allocate at least one of the walls of the stump of the rectum for the formation of anastomosis, which presents significant technical difficulties in the conditions of scarred tissues, and the technical impossibility of such an operation with a short stump of the rectum.

A known method of restoring the continuity of the colon performed during Duhamel’s operation (Duhamel, B .: A New Operation for the Treatment of Hirschsprung's Disease. Arch. Dis. Child., 35:38, 1960. B. Duhamel, Rectorectal and transanal pull-through as treatment for Hirschsprung's disease, Dis. Colon Rectum 7 (1964)). This method was proposed in pediatric surgery for Hirschsprung disease. The essence of the method is to lower the overlying colon through the channel laid between the sacrum and the stump of the rectum to connect with the latter. The rectal mucosa is peeled off, retreating 0.5-1.0 cm from the transitional fold along the posterior semicircle of the anal canal in the upper direction by 1.5-2.0 cm. Above this area, the rectum is dissected through all layers, including the dissection of part of the internal sphincter rectum and anal-coccygeal ligament, thereby forming a space for lowering the overlying colon in the presacral region. The overlying colon is lowered into this space and is fixed by separate sutures.

The disadvantage of this method is the need to intersect the internal sphincter and the anal-coccygeal ligament, which in the long term can lead to cicatricial stenosis of the formed anastomosis.

Closest to the claimed invention in technical essence and the achieved result is a method for restoring the continuity of the colon with the formation of invagination colorectal anastomosis proposed by G.V. Bondar (Gulmamedov F.I. et al. Materials of the X Congress of Ukrainian Oncologists on October 10-12, 2001) . The essence of the method lies in the circular demucosis of the anal canal at a distance of 5-6 cm from the transitional fold and lowering the overlying colon into the formed channel. The first team of surgeons from the side of the abdominal cavity from all sides mobilizes the stump of the rectum and the reduced colon. The second team of surgeons performs circular demucosis of the rectal stump on a silicone tube, then at a height of 5-6 cm, the demucosal stump is dissected through all layers, bringing the reduced colon to it. Anastomosis is formed externally after inversion of the demucosal stump of the rectum.

The disadvantages of the prototype are a high risk of developing anastomotic strictures after circular rectal demucosis of the rectum, the technical complexity of the operation, its invasiveness, and the inability to form an anastomosis when the length of the rectal stump is less than 8 cm.

The objective of the invention is the development of a new effective method for restoring continuity of the colon after Hartmann surgery, having better functional results compared to the prototype, reducing the morbidity and risk of anastomotic strictures in patients with rectal stump length less than 8 cm.

Indications for the use of the proposed method are: the presence of a short stump of the rectum less than 8 cm, the inability to differentiate the tissues of the small pelvis after radiation or chemoradiotherapy.

The problem is solved in that the overlying colon is lowered into the tunnel between the mucous membrane and the muscle layer of the lower ampullar part of the rectum and anal canal, which was formed after separation of the mucous membrane in the posterior semicircle of the anal canal. The reduced colon is fixed with individual sero-muscular sutures, restoring the continuity of the colon without mobilizing and isolating the stump of the rectum.

The method is as follows.

After a laparotomy and opening of the sacral space, the canopy of the rectal stump is determined using an instrument or a finger. Then, from the perineal side, the mucous membrane is dissected on the silicone tube along the posterior semicircle of the anal canal, backing 2-3 cm above the transitional fold. Next, the mucous membrane of the anal canal is separated anteriorly to the dome of the rectal stump and a tunnel is formed between the separated mucous membrane and the muscle layer of the wall of the lower ampullar section of the rectal stump (Fig. 1). Then, the dome of the rectal stump is dissected through all layers in the continuation of the formed tunnel. The overlying colon is brought down into the formed tunnel and fixed in the anal canal by separate serous-muscular sutures (figure 2). Between the stump of the rectum and the reduced colon, as a result, a septum forms due to the anterior semicircle of the wall of the reduced colon and the anterior mucous membrane of the stump of the rectum separated (Fig. 3). The septum is dissected throughout, without imposing additional sutures. The mucous membrane of the anal canal and the reduced colon as a result form a single space. The sphincter apparatus is not damaged during surgery.

The invention is illustrated by the following figures.

Figure 1 presents the sagittal section of the stump of the rectum. From the perineum, along the posterior semicircle of the stump of the rectum, the mucous membrane is separated from the muscle membrane to form a tunnel (the projection of the tunnel is a solid line with an arrow).

Figure 2 presents the sagittal section of the stump of the rectum after being lowered into the formed tunnel of the overlying colon, which is fixed to the stump of the rectum by individual serous-muscular sutures.

Figure 3 presents a cross section of the stump of the rectum after lowering the overlying colon. The septum formed by the anterior wall of the reduced colon and anteriorly mucous membrane of the rectal stump is then dissected.

Examples of the application of the proposed method

Patient Sh., 1940, and.b. No. 99/9939

Clinical diagnosis: Stage IIIb rectal cancer, T3N1M0.

Histological diagnosis: moderately differentiated adenocarcinoma with the germination of all layers of the intestinal wall, cancer metastases in 2 lymph nodes.

Hartmann's operation from 02.06.99, 4 courses of chemotherapy according to the Mayo scheme.

12.24.99 surgery to restore continuity of the colon according to the claimed method. The postoperative period is smooth.

The function of the anastomosis is not impaired, the function of holding feces is satisfactory.

Patient I., born in 1950, and. No. 08/19,500

Clinical diagnosis: Cancer of the sigmoid colon T3N1M0.

Histological diagnosis: moderately differentiated adenocarcinoma.

12.22.08 - obstructive resection of the sigmoid and rectum, supravaginal amputation of the uterus with appendages, resection of the cecum dome, appendectomy. Postoperative radiation therapy SOD 60 Gray, 6 courses of chemotherapy according to the XELOX regimen.

12/07/2009, the operation was performed according to the claimed method.

The postoperative period without complications, fecal retention function is satisfactory.

According to this method, 10 surgical interventions. In one patient, a moderate stricture of the colanal anastomosis was revealed 6 months after the operation, and in one patient - a partial necrosis of the reduced intestine, a second operation was performed.

Technical result

The inventive method allows to simplify the restoration of continuity of the colon after Hartmann's surgery, to make it possible to perform such an operation with a rectal stump less than 8 cm in length without damaging the sphincter apparatus, reduce the invasiveness of the operation and the risk of developing strictures, and improve the quality of life of cancer patients.

Claims (1)

A method of restoring the continuity of the colon by lowering the overlying colon into the formed tunnel, characterized in that the mucosa of the anal canal is separated on the silicone tube anteriorly in the posterior semicircle, the overlying colon is reduced and fixed in the anal canal with separate sutures, the septum formed between the rectum stump is dissected. and the reduced colon.

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