RU2445022C2 - Method of preventing failure of entero-entero anastomosis sutures - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for extraperitonisation of entero-entero anastomosis. Laparotomy is carried out. Resection of necrotised part of small intestine is performed. Entero-entero anastomosis is applied. Dissection of all layers of abdominal wall is performed and cavity whose walls are formed by parietal peritoneum, muscles, subcutaneous fatty cellular tissue and skin. Into formed in such way cavity laid is interintestinal anastomosis with hermetisation and its fixation to parietal peritoneum.

EFFECT: method makes it possible to prevent development of peritonitis in case of failure of anastomosis sutures.

3 ex, 1 dwg

Description

The invention relates to medicine, namely to abdominal surgery, can be used in surgical treatment of patients with the aim of preventing insolvency of sutures of enteroenteroanastomosis after resection of the small intestine with its diseases and injuries.

The main indications for using the claimed method are the prevention of inconsistency of sutures of enteroenteroanastomosis in acute adhesive intestinal obstruction, thrombosis of mesenteric vessels, strangulated hernia of the abdominal wall, injuries of the small intestine, especially in cases of widespread peritonitis, necrosis or rupture of jejunum, and also in cases inter-intestinal anastomosis.

One of the main directions in the prevention of gastrointestinal suture failure is the creation of optimal conditions for healing of sutures and anastomoses of the gastrointestinal tract, which in turn improves the immediate and long-term results in abdominal surgery [Chernousov AF Prevention of gastrointestinal anastomosis failure. / A.F. Chernousov, T.V. Khorobrykh, O.N. Antonov // Surgery. - 2005. - No. 12. - S.25-29]. It is known that the failure of the sutures of the gastrointestinal tract occurs due to the imperfection of techniques for sealing anastomoses of the gastrointestinal tract [Mateshuk V.P. The method of healing wounds of the intestine. / V.P. Mateshuk, I.I. Vasilevsky // West. surgery. - 1963. - No. 1. - S. 36-38].

For the prevention of insolvency of the sutures of the gastrointestinal tract, the anastomosis zone is delimited from the free abdominal cavity [Milonov OB Postoperative complications and dangers in abdominal surgery: a guide for doctors. / O. B. Milonov, K. D. Toskin, V. V. Zhebrovsky // M .: Medicine. - 1990. - 186 s]. One of the important and promising areas of prevention of intestinal suture insolvency is to strengthen the suture line by various means, which include a large omentum, parietal peritoneal flap, autodermal implant, dura mater, demucosized small intestine transplant, various polymer films, fibrin glue, TachoComb [Dibirov M.D. The use of surgical glue - "Bioclay-Lab", for the prevention of insolvency of anastomoses in the organs of the gastrointestinal tract. / M.D.Dibirov, B.S. Briskin, I.E. Rodionov, B.C. Hakobyan // Annals of Surgery. - 2008. - No. 2. - S.31-34]. If the colon is damaged, in order to prevent suture failure, the damaged area is removed through contraperture on the anterior abdominal wall [Kalanov R.G. Minimally invasive surgery in coloproctology. / R.G. Kalanov, D.I. Mehdiev, I.M. Urazbakhtin // Materials of the All-Russian Conference endoscopically assisted operations. - Yekaterinburg. - 1999. - S.93-94]. In case of injuries of the colon, occupying no more than 1/2 of the circumference, the damaged area is excised with subsequent suturing, after which extraperitonization of the sutured area is carried out with a tubular drainage to it [Kozlov I.Z. Abdominal injuries. / I.Z. Kozlov, S.Z. Gorshkov, B.C. Volkov // M .: Medicine. - 1988. - 224 p.].

The closest technical solution is the method of applying coloenteroanastomosis, at the first stage of which a double-barreled colostomy is placed in the channel between the skin and the peritoneum, and at the second stage, coloenteroanastomosis is formed [see RF patent application No. 1142110, published 02/28/1985; IPC A61B 17/00, A61B 17/11].

The main disadvantage of this method is the invasiveness, as well as the possible development of joint failure with the development of peritonitis in the second stage, with the formation of coloenteroanastomosis.

The aim of the invention is to prevent the development of inconsistency of sutures of enteroenteroanastomosis, improving the results of surgical interventions for diseases and injuries of the small intestine.

This goal is achieved by the method of extraperitonization of enteroenteroanastomosis in patients, which consists in the fact that after laparotomy, resection of the necrotic part of the small intestine, application of enteroenteroanastomosis, all layers of the abdominal wall are dissected, forming a cavity with parietal peritoneum, muscles, and subcutaneous fat skin, an interintestinal anastomosis is placed in the cavity formed in this way with sealing and fixing it to the parietal peritoneum.

The method of extraperitonization of enteroenteroanastomosis is illustrated in figure 1., where the inter-intestinal anastomosis 7 is placed in the formed cavity, the walls of the cavity thus formed are skin 1, subcutaneous fatty tissue 2, muscle tissue 3, aponeurosis 4 and preperitoneal fatty tissue 6, with its sealing and fixation to the parietal peritoneum 5.

The method is illustrated by examples of its specific implementation.

Example 1

Patient A., 69 years old, was admitted to the surgical department with a diagnosis of strangulated postoperative ventral hernia, strangulated intestinal obstruction, widespread peritonitis. The operation was performed - herniolaparotomy, resection of the small intestine due to its necrosis, enteroenterostomy of the type "side to side", closed intubation of the small intestine, sanitation and drainage of the abdominal cavity. Given the prevalence of peritonitis, a high risk of developing inconsistency of the sutures of the intestinal anastomosis, an extraperitonization of the anastomosis was performed. The abdominal wall was dissected layer-by-layer along the front axillary line for 12 cm, a cavity was formed in the thickness of the abdominal wall 4.0 × 4.0 × 10.0 cm in size. An intestinal anastomosis was laid in the formed cavity, sutures were placed on the parietal peritoneum, and the leading and diverting loops of the small intestine over 3 cm in order to create a spur. Wound-reducing sutures with a rubber graduate are applied to the skin. After the surgery, the postoperative period was uneventful. Discharged from the hospital on the 14th day in satisfactory condition. For several months was under the supervision of a surgeon RKB.

Example 2

Patient M., 23 years old, was delivered through the sanitation line with complaints of pain in the area of the postoperative wound, delayed stool, nausea, and dry mouth. 5 days ago, he was operated on at the Central Hospital. An operation was performed - laparotomy, resection of the small intestine, side-to-side enteroenterostomy, sanitation and drainage of the abdominal cavity due to a closed abdominal injury with rupture of the mesentery of the small intestine and necrosis of the small intestine, disseminated purulent peritonitis. An objective examination of the condition is serious, the skin of the physiological color, tachycardia, body temperature 36.7 ° C, dry tongue. The abdomen is involved in the act of breathing, is swollen, tense upon palpation, painful in all departments. Symptom Shchetkina-Blumberg positive in all departments. Peristalsis is not heard, the gases do not go away, there was no stool. Median wound with no signs of inflammation. On drainage from the pelvic cavity there is no discharge.

Diagnosed with Suture failure of enteroenteroanastomosis. Common purulent-fibrinous peritonitis. Relaparotomy was performed, during the audit in the abdominal cavity about 700 ml of intestinal contents were revealed in all departments, the inconsistency of the sutures of the enteroenteroanastomosis of 1.0 × 1.5 cm was diagnosed. Due to the severity of the patient's condition, common peritonitis, it was decided to suture the failure of the sutures of the enteroenteroanastomosis with subsequent extraperitonization. After the abdominal sanitation was performed, suture failure of the enteroenteroanastomosis sutures was performed. The posterior parietal peritoneum was dissected along the posterior axillary line, a cavity of 4.0 × 4.0 × 12.0 cm in size was formed. A small intestine with anastomosis was laid in the formed cavity, and sutures were placed on the parietal peritoneum. Wound-reducing sutures with a rubber graduate are applied to the skin. After repeated surgery, the postoperative period was uneventful. Discharged from the hospital on the 18th day with recovery.

Example 3

Patient T., 47 years old, was delivered through the sanitation line with complaints of pain in the area of the postoperative wound, delayed stool, nausea, repeated vomiting. 7 days ago operated on in the Central Hospital. An operation was performed - laparotomy, resection of the small intestine, side-to-side enteroenterostomy, debridement and drainage of the abdominal cavity due to acute commissural obstruction with necrosis of the small intestine, widespread serous peritonitis. On physical examination, the condition is serious, the skin is pale, tachycardia, body temperature 37.8 ° C, dry tongue. The abdomen is moderately swollen, tense on palpation, painful in all departments. Symptom Shchetkina-Blumberg positive in all departments. Peristalsis is not heard, the gases do not go away, there was no stool. From the lower third of the postoperative wound, intestinal discharge in an amount of 30 ml. Diagnosed with Suture failure of enteroenteroanastomosis. Peritonitis. Relaparotomy was performed, during the audit in the abdominal cavity about 600 ml of intestinal contents were revealed in all departments, the inconsistency of the sutures of enteroenteroanastomosis 1.5 × 2.0 cm in size was diagnosed.In view of the severity of the patient's condition, widespread peritonitis, it was decided to suture the failure of the sutures of enteroenteroanastomosis with subsequent extraperitonization. After the abdominal sanitation was performed, suture failure of the enteroenteroanastomosis sutures was performed. The posterior parietal peritoneum was dissected along the posterior axillary line, a cavity with a size of 4.0 × 5.0 × 13.0 cm was formed. A small intestine with anastomosis was laid in the formed cavity, sutures were placed on the parietal peritoneum. Wound-reducing sutures with a rubber graduate are applied to the skin. After repeated surgery, the postoperative period was uneventful. Discharged from the hospital on day 21 with recovery. For several months was under the supervision of a surgeon RKB.

The advantages of the proposed method is a significant reduction in the likelihood of developing inconsistency of the sutures of the enteroenteroanastomosis due to the reliable sealing of the anastomosis in the formed retroperitoneal cavity. In cases of inconsistency of the sutures of the intestinal anastomosis, a small intestinal fistula is formed, which subsequently closes independently. This technique achieves the main goal of the inadmissibility of the development of peritonitis. All this ultimately leads to an improvement in the immediate and long-term results of surgical interventions for diseases and injuries of the small intestine.

Claims (1)

A method for the extraperitonization of enteroenteroanastomosis in patients, which consists in the fact that after laparotomy, resection of the necrotic part of the small intestine, and the application of enteroenteroanastomosis, all layers of the abdominal wall are dissected, forming a cavity whose walls are parietal peritoneum, muscles, subcutaneous fat tissue and skin and the cavity formed in this way is laid on the interintestinal anastomosis with sealing and its fixation to the parietal peritoneum.

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