RU2495632C1 - Method of forming artificial sphincter on brought down to perineum intestine after rectum extirpation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to surgery, and deals with methods of artificial sphincter formation. From iliac intestine separated is 10-12 cm long transplant on feeding pedicle. Counter-mesenteric edge of obtained section is longitudinally cut and demucosation is performed. Ends of transplant are configured in form of "a roll". Anastomosis is applied. Distal area of brought down intestine is enveloped by transplant. Intestine with "neo-sphincter" is fixed to skin of perineum.

EFFECT: elaboration of method of artificial sphincter formation.

1 ex, 1 dwg

Description

The invention relates to medicine, in particular to surgery, and relates to methods for forming an artificial rectal sphincter.

A known method of forming a rectal obturator for cancer. The obturator includes an obturator valve and a rubber main tube, a compression tube with a clamp, an air shutoff valve, and an adjustable stop. The compression tube passes through an adjustable stop and is connected to the air pump. The main rubber tube has a tip, notches and is made with the possibility of attachment to the belt through the crotch. An adjustable stopper is mounted on the main rubber tube with the possibility of movement and fixation by notches (Obturator of the rectum for cancer. // Patent RU No. 2417783, MPK A61F 2/04 (2006.01); A61L 27/06 (2006.01); A61M 25/06 (2006.01 ); А61В 17/60 (2006.01) Aiskhanov S.K. (RU), Bataev D.K. - S. (RU), Mazhiev X.N. (RU), Totikov V.Z. (RU), Bekuzarova S .A. (RU). Publication date 04/20/2011).

The disadvantages of the existing method are the development of necrosis or pressure sores in the intestinal wall due to prolonged exposure (more than 2 hours) to her compression tube.

The closest set of essential features to the claimed invention is a method selected as a prototype. (Primary colonic anastomosis in acute obstructive obstruction. // Patent RU No. 2383306 C1, IPC A61B 17/00 (2006.01). Bashirov S.R. (RU), Bashirov R.S. (RU), Trifonov M.N. ( RU), Pankratov I.V. (RU), Gaidash A.A. (RU), Semakin R.V. (RU). Publication date 03/10/2010). On the anti-mesenteric section of the intestine in the transverse direction, a dissection of the serous-muscular membrane is performed over a length of 15-18 mm. Dissection is performed 20-30 mm above the smooth muscle pulp cuff. From the vertices of the corners of the planned flap in the proximal direction, two more parallel sections of the serous-muscular membrane 65-70 mm long are made along the right and left sides of the protozoa of the intestine. Cuts are performed along the edge of the mesentery and pendants. The targeted flap from the serous-muscular layer is separated from the underlying submucosa in the direction from the apex in the transverse section to its base at the proximal end. At the same time, the connection between the base of the flap and the intestinal wall is maintained. After suturing the submucosal area in the transverse direction, the intestines are reduced. Anastomosis is formed in the perineum. By abdominal access, a sero-muscular flap is fixed with 2-4 interrupted sutures to the pelvic peritoneum along the anterior semicircle of the small pelvis, respectively, of the projection of the lop-rectum loop. The method allows to create a holding mechanism after extended resections of the rectum with removal of the internal sphincter, portions of the external sphincter of excision of levators by forming a levator to create an anorectal angle between the pelvic and perineal sections of the reduced intestine.

The disadvantage of the existing method is that smooth muscle pulp and smooth muscle flaps fixed to the pelvic peritoneum, due to poor blood supply, are replaced with time by connective or scar tissue, which leads to cicatricial stricture of the reduced intestine, which complicates the method.

EFFECT: creation of an elastic cuff preventing arbitrary bowel movement and simplification of the method.

The technical solution of the claimed object is that from the ileum, a graft is isolated on the feeding leg with a length of 10-12 cm from the ileum, the mesenteric edge of the obtained area is longitudinally dissected and demucosed, the ends of the graft are configured as a “roll”, so that between the layers there were no free spaces; the leading and outlet sections anastomose; the formed graft covers the distal portion of the reduced intestine 2-3 cm above the edge, the intestine with the “nephosphincter” is lowered into the pelvis and fixed to the skin of the perineum.

The invention is carried out in the following way, from the ileum by transplantation, a graft is isolated on the feeding leg with a length of up to 10-12 cm (which is sufficient for the formation of a neosphincter in it later, while maintaining the blood supply to the graft), the leading and outlet sections of which are anastomosed. The anti-mesenteric edge of the obtained area is longitudinally dissected, and its demucosis is performed. Then the ends of the graft are configured in the form of a “roll”, so that there is no free space between the layers.

Formed graft 2-3 cm above the edge cover the distal section of the reduced intestine, obturating its lumen. The intestine with the “nephosphincter” descends into the pelvis and is fixed to the skin of the perineum. The result is an elastic cuff that prevents involuntary bowel movements.

The essence of the method is confirmed graphically, where figure 1 shows an artificial sphincter of the rectum. 1 - large intestine; 2 - sphincter "roll" from the small intestine; 3 - perineum.

According to the information available to the authors, the set of essential features characterizing the essence of the claimed invention is not known, which allows us to conclude that the invention meets the criterion of "novelty."

According to the authors, the essence of the claimed invention does not follow for experts explicitly from a known level of medicine, since the above possibility of creating a similar artificial rectal sphincter is not revealed from it, which allows us to conclude that the criterion is “inventive step”.

The set of essential features characterizing the essence of the invention, in principle, can be repeatedly used in medicine to obtain a result consisting in the creation of a similar artificial sphincter of the rectum, which allows us to conclude that the invention meets the criterion of "industrial applicability".

The method is introduced into the clinic and is used in patients with colorectal cancer.

Clinical example:

Patient S., 56 years old, was hospitalized in a surgical hospital on 05/23/2011 with a clinic of acute intestinal obstruction. In the course of studying the medical history of the disease, it was revealed that already in the last month, the patient has noted an alternation of diarrhea and constipation with the inconstant appearance of impurities of red blood in the feces. About 2 days before admission, bloating, violation of stool and gas, pain, nausea, general weakness began to be noted.

Examination:

General blood test (05/23/2011): Hb 112 g / l .; erythritol. 3.4 "1012 / l; col.poof 0.8; retic .; thrombus. 286.3; lake. 6.4'109 / l; n 6%; with 53%: e 1%; l 36%; m 4%; ESR 25 mm per hour. Survey radiography of the abdominal cavity (05/23/2011)

Conclusion: signs of acute colonic obstruction. Ultrasound of the abdominal organs (05/23/2011) Conclusion: the phenomenon of colonic obstruction.

Perrectum examination: (05/23/2011). At a distance of 4 cm from the anus, a circular tumor is determined that stenoses the lumen of the intestine. Sigmoidoscopy: (23.05. 2011). At a distance of 4 cm from the anus, a circular tumor is determined, stenosing the lumen of the intestine up to 1.5 cm, the length of the tumor stricture is up to 4 cm. During the manipulation, it was possible to establish silicone drainage through the tumor channel and decompress the proximal colon. A biopsy has been performed. Conclusion: moderately differentiated adenocarcinoma.

Decompression and infusion therapy was prescribed, against which acute obstructive colonic obstruction resolved, which was confirmed clinically and radiologically. After resolving the obstruction and conducting the necessary preoperative preparation, the patient was operated on in a delayed manner. Under general anesthesia on 05/31/2011, the patient underwent lower middle laparotomy. When revising the abdominal organs, data for regional and distant spread of the tumor process were not found. Given the low localization of the cancerous tumor, it was decided to perform abdominal-perineal extirpation of the rectum with the formation of a colostomy according to the method developed in the clinic. At the base of the sigmoid colon, the peritoneum is dissected from both sides by a lyre-shaped incision. Distal to the discharge of the left colon artery, the inferior mesenteric artery is bandaged. The sigmoid colon is mobilized from the vessels of the mesentery for 5 cm to the entrance to the small pelvis and is crossed. Next, the fascial membranes at the base of the mesentery of the distal loop of the crossed sigmoid colon are dissected. The posterior semicircle of the rectum between its own fascia and the anterior fascia of the sacrum to the coccyx is highlighted in a sharp way. The rectum is mobilized with surrounding fiber to the anal canal with suturing and intersection of the middle rectal arteries.

Simultaneously with the allocation of the anterior semicircle of the intestine of the perineal side, the anus was sutured and excised with two bordering incisions. After crossing and ligation of the posterolateral portions of the levators, the anterior semicircle of the rectum is separated from the posterior wall of the vagina. The anterolateral portions of the levators were dissected and the remaining fixed sections of the rectum were mobilized. The intestine is removed through the perineal wound. Hemostasis. Remediation and drainage of the pelvic cavity with the removal of drainage tubes through contrapertures to the perineum. Then, a transplant was isolated from the ileum by crossing on a feeding leg up to 10 cm long, the leading and taking parts of which were anastomosed. The anti-mesenteric edge of the obtained area is longitudinally dissected and demucosized. Then the ends of the graft are configured in the form of a “roll”, so that there is no free space between the layers.

Formed graft 2-3 cm above the edge covered the distal section of the reduced intestine, obturating its lumen. The intestine with the “nephosphincter” is lowered into the pelvis and fixed to the skin of the perineum. The result is an elastic cuff that prevents involuntary bowel movements. Recovery of the pelvic peritoneum, layer-by-layer suturing of the abdominal cavity.

The drug: a removed rectum with pararectal tissue and lymph nodes. At 4 cm from the anus in the lower ampullar region, a circular tumor is determined that infiltrates the wall of the rectum.

Diagnosis: cancer of the lower ampulla of the rectum T4N0MO

In the postoperative period, for 3 days, flow-through and washing drainage of the pelvic cavity was performed through the installed drainage tubes on the perineum, which were removed on the 4th day. Chair for 4 days. Healing of a laparotomy wound by primary intention, sutures were removed on the 10th day.

The patient was discharged on the 18th day in satisfactory condition under the supervision of an oncologist at the clinic.

Three months later, on September 10, 2011, patient S., 56 years old, was hospitalized in the clinic for follow-up examination and to study the functional results of the formation of the developed nephosphincter. She does not complain, she is satisfied with the results of treatment, considers herself socially rehabilitated. Continental sphincter function is satisfactory. Emptying does not occur more often 1-2 times a day with formed bowel movements by introducing a tube. During the survey, data for the generalization of the main process were not found. The patient was discharged in satisfactory condition under the supervision of an oncologist at the clinic. Examination: General blood test (September 10, 2011) Hb 135 g / l; erythrocytes 4.4 ^# 1012 / L; col. indicator 0.9; white blood cells 4.8 "109 / l; the wand. 5; segment 42; e. one; lymphocytes 44; monocytes 9; ESR 18 mm per hour. Biochemical blood test (09/10/11) General. protein 70 g / l; glucose 4.5 mmol / l; total bilirubin 8.5 mmol / l; creatinine 57 mmol / l; cholesterol 3.5 mmol / l; AcAT 0.33 μmol / L; AlAT 0.29 μmol / L. Coagulogram (09/10/2011) PTI 94%; fibrinogen 4.11 g / l: et. testotr. ECG (09/10/2011). Sinus rhythm, heart rate of 68 per min, the electrical axis of the heart is deflected to the left, signs of left ventricular myocardial hypertrophy. Irrigography (09/11/2011) By introducing 300 ml of contrast medium through an artificial anus, the reduced section of the colon is filled for 30-40 cm. The retaining function of the pulp is satisfactory: after removing the probe, as well as in a sitting position and standing barium leakage from the newly formed anus not marked. An accumulation of contrast is noted in the region of the distal part of the extracted loop, where the extension of the loop of 9 × 6 cm in the form of a reservoir is determined. Emptying the contrast was noted with an increase in intra-abdominal pressure and ghosts of the knees to the stomach.

Thus, the simplicity and effectiveness of the proposed method can improve the "quality" of life and the results of medical and social and labor rehabilitation of "colostomized" patients.

Claims (1)

The method of forming an artificial sphincter on the intestine reduced to the perineum after extirpation of the rectum, characterized in that a transplant is isolated from the ileum by crossing on a feeding leg 10-12 cm long; the anti-mesenteric edge of the obtained area is longitudinally dissected and demucozed, the ends of the graft are configured as a “roll” so that there are no free spaces between the layers; the leading and outlet sections anastomose; the formed graft covers the distal portion of the reduced intestine 2-3 cm above the edge, the intestine with the “nephosphincter” is lowered into the pelvis and fixed to the skin of the perineum.

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