RU2489098C1 - Method of sphincterolevatoroplasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. Triangular flap with base on perineum and apex in vagina is excised. First puncture of needle with ligature is performed in the area of angle near triangle base. Ligature is passed through tissues of perineum and front portion of sphincter with puncture out in the middle part of triangle base. Second puncture in is made in wall of vagina in the middle of triangle lateral side. Needle is passed to the top of triangle with grip of levator and front wall of rectum. Third puncture in is made in the apex of triangle. Ligature is passed with grip of levator with puncture out in the middle of the other side of triangle. Fourth puncture in is made in the middle part of triangle base. Needle with ligature is passed through anterior portions of sphincter with puncture out in the other angle of triangle base.

EFFECT: method reduces duration of restoration of perineum anatomical structures with one suture.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to coloproctology and can be used in the surgical treatment of rectocele, anal sphincter insufficiency, rectovaginal fistula and cloaca, as well as the consequence of birth tears of the perineum, sexual discomfort due to the discrepancy between the levators and the expansion of the genital gap.

Currently, there are many methods for surgical correction of pelvic floor insufficiency, rectocele, rectovaginal fistula. Despite the abundance of methods, a high percentage (about 60%) of unsatisfactory results remains. This is primarily due to the desire for reliable suturing of tissues, which leads to anemia, necrosis and an unsatisfactory result.

A known method proposed by G.I. Vorobyov, including the restoration of the anatomical structures of the perineum, with preliminary separation of tissues by incision and their subsequent stitching (see, Surgery, 1994, No. 4, p. 35-37).

The tissue stitching in the known method is carried out floor by stage with the capture of the previous layer, namely, after mobilization of the rectal wall and excision of the scars, the own fascia is opened longitudinally and catgut sutures are applied transverse to the rectal wall at a distance of 1.5-2 cm from each other . The next row of sutures sutures the posterior fascia leaves of the levators, fixing the anterior rectal wall to them. Then sutured the muscles that raise the anus with the front leaves of their fascia. Separate catgut sutures No. 5 suture the edges of the isolated sphincter - first a deep, and then a subcutaneous portion of it. Subcutaneous tissue (or the back wall of the vagina in women) is sutured with catgut, and the skin is sutured with silk in the anteroposterior direction.

The known method has significant morbidity and the duration of the operation is 1.5-2 hours.

Floor-wise stitching of tissues with the capture of the previous layer leads to tissue ischemia, which contributes to suppuration of the surgical wound and unsatisfactory treatment results. In addition, the known method helps to leave ligatures in the tissues and the formation of ligature fistulas.

Catgut sutures contribute to the formation of eosinophilic granulomas and suppuration of the surgical wound and relapse of the rectal obstruction apparatus.

The known method adopted as a prototype, including the restoration of the anatomical structures of the perineum, with preliminary separation of tissues by incision and their subsequent stitching (see the description of the invention to the patent of the Russian Federation No. 2103923, IPC АВВ 17/00, publ. 02.10.1998).

In the known method, the separation of the perineal tissue is produced by a transverse or arcuate incision. They mobilize the wall of the rectum to a depth of 5-6 cm, economically excise scars, highlight the edges of the sphincter for 1.5-2 cm and levators so that they can be reduced to the midline of the perineum without tension. After this, the own fascia of the levators is longitudinally opened. When stitching tissues, a needle with strong suture material (nylon, lavsan) is carried out sequentially through the levator and its fascia, the back wall of the vagina without trapping the mucosa, the levator with its fascia on the opposite side. The second seam is applied to the levators with the capture of their own fascia of the anterior intestine, corrugating it. So they form the anal canal.

Stitching of the sphincter with the formation of a duplicate of its ends is carried out by the third suture.

After pulling up, the ligatures are tied, bringing the stitched fabrics together until they are in close contact. Sutures are sutured on the skin with subcutaneous tissue. The slit-like space above the levators is drained by flowing drainage in the transverse direction.

In the known method, the use of several sutures on the muscular structures of the pelvic floor, which leads to their ischemia and increase the likelihood of necrosis and suppuration of the suture.

The known method does not provide surgical correction of the obturator apparatus of the rectum, providing restoration of the anatomical structures of the perineum.

In addition, the duration of the operation in a known manner is 0.5-1.0 hours, and after wound healing, the sutures are removed for 7-8 days.

The technical objective of the proposed method is to improve the method of surgical correction of insufficiency of the obturator apparatus of the rectum, providing restoration of the anatomical structures of the perineum and reducing the duration of the operation.

The technical problem is solved in that the method of sphincterolevatoroplasty involves the restoration of the anatomical structures of the perineum, with preliminary separation of the perineal tissue by an incision and their subsequent stitching, while the incision is made in the form of a triangle with a base on the perineum and apex in the vagina, above the excess of the mucous membrane of the posterior vaginal wall, and restoration of the anatomical structures of the perineum is carried out with one suture, consisting of successive injections and punctures with a variable direction, and with subsequent grave, starting a needle injection at one corner at the base of the triangle, covering the damaged anterior portion of the sphincter, passing through the perineal tissue and leaving the middle of the base of the triangle, the second injection is performed in the frontal plane, in the middle of one side of the triangle, bypassing one levator with fascia , by capturing the muscle layer of the anterior wall of the rectum and exiting at the apex of the triangle, the third injection is performed at the apex of the triangle, bypassing the other levator with fascia and leaving the triangle in the middle of the other side a, and the fourth injection is performed in the middle part of the base of the triangle, capturing the damaged structures of the anterior portion of the sphincter and going to another angle at the base of the triangle. The seam is performed with a double prolene thread.

The novelty of the invention lies in the fact that sphincterolevatoroplasty is performed with one suture with its alternating direction, which reduces the duration of the operation to 0.5 hours. The proposed method provides a comparison of homogeneous tissues and the absence of ischemia, which eliminates the possibility of suppuration and relapse of the obstruction of the rectum.

Since the proposed method allows you to restore the anatomical structure of the perineum, it can be applicable both in operations with rectocele, and in case of damage to the anterior portion of the sphincter, with the formation of incontinence, as well as in the complete absence of rectovaginal septum.

The inventive step is confirmed by the fact that the solution was not obvious to specialists and has not been applied to date.

The proposed method is reproduced in specialized proctological departments as such a need arises.

Performing an incision in the form of a triangle with a base on the perineum and apex in the vagina above the excess of the mucosa of its posterior wall and restoration of the anatomical structures of the perineum with one suture with its alternating direction allows:

- bring together the edges of the damaged sphincter;

- bring together the front levators;

- bring together the levators and the front portion of the sphincter;

- Compare the edges of the skin and mucous wounds, forming a full crotch;

- to provide prevention of the formation of ligature fistulas.

The proposed method of sphincterolevatoroplasty provides anatomical comparison of the muscles of the pelvic floor, maintaining blood circulation in them, and also forms a full crotch with high cosmetic and functional effect.

The method of sphincteroleoplasty is illustrated by drawings, where in Fig.1 shows a section made in the form of a triangle; figure 2 - implementation of jabs-jabs; figure 3 - made seam.

The proposed method is implemented as follows.

An incision 1 is made in the form of a triangle with the base on the perineum and the apex in the vagina above the excess of the mucous membrane of its posterior wall (Fig. 1).

The restoration of the anatomical structures of the perineum is carried out by one suture, consisting of successive injections and punctures, with their alternating direction (figure 2). The seam is made with a double prolene thread 2. The prolene thread 2 has a smooth surface and, when tightened, slips better in the tissues, bringing them closer, and the use of a double thread reduces the effect of “teething”.

Initially, the needle is injected into one of the corners at the base of the triangle, covering the damaged anterior portion of the sphincter 3, passing through the perineal tissue, and the injection is carried out in the middle part of the base of the triangle.

After the injection, the second injection is performed in the middle part of one side of the triangle, in the frontal plane, bypassing one levator 4 and its fascia, capturing the front wall of the rectum (muscle layer), and the injection is carried out at the apex of the triangle. The third injection is performed at the apex of the triangle bypassing the other opposite levator 5 with fasciae and the injection is performed in the middle of the other side of the triangle.

After this injection, the fourth injection is performed in the middle part of the base of the triangle, into the horizontal section of section 1, capturing the damaged structures of the anterior portion of the sphincter 6 and going to another angle at the base of the triangle.

Then the entire seam 7 is simultaneously tightened, bringing together the edges of the damaged sphincter 3 and 6, the levators 4 and 5, comparing the edges of the skin and mucous wounds, and forming a full crotch (Fig. 3). The edges of the skin and mucosa are fixed with interrupted sutures.

The proposed method of sphincterolevatoroplasty provides anatomical comparison of the muscles of the pelvic floor, maintaining blood circulation in them, and forms a full crotch with a high cosmetic and functional effect.

Example

Patient, 39 years old, May 10, 2011 complained of incontinence of liquid feces and gases.

On examination, it was revealed: in the perineum, postoperative scars, rectovaginal septum thinned, genital gap. The formation of cystocele and rectocele is noted. On palpation in the perineum, muscle tissue is absent. 1/3 sphincter defect, levators dispersed to the walls of the pelvis.

DS: Pelvic floor muscle deficiency. Continent I degree. Rectocele I degree. Cystocele.

05/24/2011, anterior sphincterolevatoroplasty was performed using one seam with a variable direction. After 7 days, the sutures on the skin were removed - healing by primary intention, a satisfactory function of the sphincter and anus levators was noted. The patient was discharged in satisfactory condition.

Claims (2)

1. The method of sphincterolevoplasty, including the restoration of the anatomical structures of the perineum, with preliminary separation of the perineal tissue by an incision and their subsequent stitching, characterized in that the incision is made in the form of a triangle with a base on the perineum and apex in the vagina above the excess of the mucous membrane of the posterior vaginal wall, and restoration of the anatomical structures perineum is carried out with one suture, consisting of consecutive injections and punctures with their alternating direction, and with subsequent tightening, starting needles in one corner at the base of the triangle, covering the damaged anterior portion of the sphincter, passing through the perineal tissue and leaving the middle part of the base of the triangle, the second injection is performed in the frontal plane, in the middle part of one side of the triangle, bypassing one levator with fascia, capturing the muscle layer the front wall of the rectum and exiting at the apex of the triangle, the third injection is performed at the apex of the triangle, bypassing the other levator with fascia and leaving in the middle of the other side of the triangle, and the fourth injection at They are performed in the middle part of the base of the triangle, capturing the damaged structures of the anterior portion of the sphincter and going to another angle at the base of the triangle. 2. The method of sphincteroleoplasty according to claim 1, characterized in that the suture is performed by a double prolene thread.

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