RU2556552C1 - Method for creating ileocolonic anastomosis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: right-sided hemi-colectomy is performed. A spout with a feed mesenteric vessel is formed at a distal end of the small intestine. A colonic wall is incised transversally. An anterior and then posterior lips of the anastomosis are formed with one-row interrupted sutures. Creating an ileotransversoanastomosis with an absorbable suture involves pricking a needle into an enteric wall at 2.0-2.5 cm from the edge from a mucous membrane, moved through a muscular layer, a submucous layer and pricked out onto the enteric mucosa at 1.0-1.5 cm from the edge. The needle is pricked in from the enteric mucosa at 0.5-0.8 cm from the edge, and a free end of the spout is inserted into a point between the submucous and muscular layers of the small intestine. Inside out, the needle is pricked into a point between the submucous and muscular layers of the large intestine and brought out onto the serous layer at 0.25-0.3 cm from the edge. The sutures are crossed over and held tight. The ectopic excess enteric mucosa and submucous layer are put inside to form antireflux valve leaflets. The serous layers of the small and large intestines are aligned to make the anastomosis leak-proof. A blind part of a proximal end of the large intestine is underrun above the anastomosis with interrupted seromuscular sutures to cover the anastomosis additionally.EFFECT: method enables providing the reliable homeostasis, leak-tightness, the adequate valve function of the end-to-side transversal invaginated ileocolonic anastomosis ensured by the precise alignment of the intestinal wall layers.1 ex, 2 dwg

Description

The invention relates to medicine, namely to surgery, and can be used in surgical interventions requiring the connection of the small and large intestines.

The closest in technical essence to the proposed method is a method of forming a small intestinal anastomosis, including right-sided hemicolectomy, then applying a small intestinal anastomosis by forming on the distal section of the anastomosed small intestine "proboscis" with a length of 3.5-4 cm with a portion of the mesentery and terminal feeding vessel (see RF patent No. 2373872, publ. 11/27/2009). According to the method, the colon wall is transversely dissected. The small intestinal "proboscis" is invaded into its lumen with the fixation of the latter to the walls of the colon with interrupted sutures. At the same time, invagination of the small intestine "proboscis" into the lumen of the colon is performed simultaneously with its controlled inversion and full adaptation of the mucous-submucous layers of the small and large intestines due to the use of single-row nodal sutures. Each of the seams is formed as follows. The first step is the longitudinal sero-muscular flashing of the wall of the small intestine with a width of 0.5-0.6 cm along the proximal border of the "proboscis". The second stage at a distance of 0.5-0.6 cm from the free edge of the "proboscis" is carried out serous-submucosal flashing of the intestinal wall with a puncture in the free edge of the "proboscis". The third step is to capture the colon wall in the suture with marginal submucosal serous stitching 0.5-0.6 cm wide.

The disadvantages of this method is the lack of valve function of the anastomosis, feces can be thrown into the small intestine with increased pressure in the large intestine. These shortcomings in the postoperative period contribute to the development of reflux enteritis and dysbiosis.

The objective of the invention is the development of a method of forming a small intestinal anastomosis with obtaining a technical result that allows to ensure the reliability of hemostasis, tightness, sufficient valve function of the anastomosis.

The technical result is achieved by the fact that the method includes performing a right-sided hemicolectomy, forming in the distal section of the anastomosed small intestine a “proboscis” with a length of the mesentery and the feeding end vessel, a transverse section of the colon wall.

The peculiarity is that the anastomosis is formed by single-row interrupted sutures, each of which is applied as follows: when the ileotransverse anastomosis is formed by an absorbable thread, the needle is injected into the wall of the distal end of the small intestine at a distance of 2.0-2.5 cm from the edge from the side of the serous membrane, they pass through the muscle membrane, submucosa and make a needle puncture the serous membrane of the small intestine at a distance of 1.0-1.5 cm from the edge, then inject the needle from the serous membrane of the small intestine and at a distance of 0.5-0.8 cm from the edge and lead to the free edge of the "proboscis" to a point located between the submucosal and muscle membranes of the small intestine, then from the inside out the needle is pierced to a point located between the submucosa and muscle membranes of the colon, and withdrawn on its serous membrane, departing from the edge by 0.25-0.3 cm, then the filaments cross each other and pull in opposite directions, while the excess of the mucosa and submucous small intestine, turned outward, is tucked inward, forming the valves of the areflux valve and serosis the small membranes of the small intestine are precisely matched to each other, ensuring the tightness of the anastomosis, with the indicated sutures, the anastomosis is formed first, then the posterior lips of the anastomosis, then the blind part of the proximal end of the colon is sutured over the anastomosis with the small intestine by nodular serous-muscular sutures forming the second row of sutures additionally covering anastomosis.

The invention is illustrated by drawings.

FIG. 1 illustrates the opening of the lumen of the colon in the transverse direction, the beginning of the formation of the anastomosis with single-row interrupted sutures, where:

1 - small intestine,

2 - colon

3 - the opening of the colon 2 in the transverse direction,

4 - injection needle into the wall of the distal end of the small intestine 1 at a distance of 2.0-2.5 cm from the edge from the side of the serous membrane,

5 - serous membrane of the small intestine 1,

6 - muscle membrane of the small intestine 1,

7 - submucous membrane of the small intestine 1,

8 - puncture needle on the serous membrane of the small intestine 1 at a distance of 1.0-1.5 cm from the edge,

9 - injection into the wall of the distal end of the small intestine 1 at a distance of 0.5-0.8 cm from the edge from the side of the serous membrane,

10 - a puncture in the free edge of the "proboscis" to a point located between the submucosa 7 and muscle 6 of the small intestine 1,

11 - injection into a point located between the submucosa and muscle membranes of the colon 2,

12 - the mucous membrane of the small intestine 1,

13 - the blind part of the proximal end of the colon 2.

FIG. 2 illustrates the formed lateral invagination transverse small intestinal anastomosis and suturing of the blind part 13 of the proximal end of the colon 2 over the small intestinal anastomosis with nodular sero-muscular sutures, where:

14 - nodular serous-muscular sutures,

15 - lateral invagination transverse small intestinal anastomosis

The method is as follows.

Perform right hemicolectomy. Then, on the anastomosed distal end of the small intestine 1, a "proboscis" is formed with a length of 3.0-3.5 cm with a section of the mesentery and a feeding end vessel. The wall of the colon 2 along the line of the future anastomosis is dissected strictly in the transverse direction with the formation of the hole 3 by a length exceeding the width of the small intestine "proboscis" by 0.1-0.2 cm (when performing resection interventions on the colon, the distance from the blind part of the proximal end of the colon intestines to the line of the anastomosis should be 6.5-7.5 cm).

They begin to form an anastomosis with single-row interrupted sutures, each of which is imposed as follows: when an ileotransversoanastomosis is formed with an absorbable thread, 4 needles are injected into the wall of the distal end of the small intestine 1 at a distance of 2.0-2.5 cm from the edge from the side of the serous membrane 5; through the muscular membrane 6, the submucosa 7 and make an injection 8 of the needle on the serous membrane of the small intestine 1 at a distance of 1.0-1.5 cm from the edge, then inject 9 needles from the side of the serous membrane 5 of the small intestine 1 at a distance of 0.5 -0.8 cm from the edge and lead to the free edge of the "proboscis" at point 10, located between the submucosa 7 and muscle 6 of the small intestine 1, then from the inside out the needle is pierced at point 11, located between the submucosa and muscle of the large intestine 2 and it is excreted on its serous membrane, departing from the edge by 0.25-0.3 cm, then the threads cross each other and stretch in opposite directions, while the excess of the mucosa 12 and submucous 7 of the small intestine 1, turned outward, is tucked inward, forming sashes areflux valve, and oznye thin shell 1 and the large intestines 2 accurately and reliably correlated with each other, providing a leak anastomosis. The width between the following seams is 0.3-0.4 cm.

The next step, these seams form first the front, then the back lips of the anastomosis. Then the blind part 13 of the proximal end of the colon 2 is sutured over the anastomosis with the small intestine 1 with serous-muscular muscle sutures 14, forming the second row of sutures that additionally cover the anastomosis. As a result, a lateral invagination transverse small intestinal anastomosis 15 is formed, which has the reliability of hemostasis, tightness and sufficient valve properties.

Clinical example.

Patient N., 56 years old, was admitted to the surgery department of the State Central Clinical Hospital of Ulyanovsk with complaints of cramping pains throughout the abdomen, nausea, vomiting, and stool and gas retention for 2 days. Over the past three months, notes a decrease in appetite, weight loss, constipation. During the examination: on a survey radiography of the abdominal cavity, multiple small intestinal and colonic Kloiber bowls.

Inspection: general condition is serious; the skin is moist, pale; pulse of weak filling and tension - 112 beats per minute; blood pressure - 100/60 mm Hg

The tongue is dry, coated with a white coating. The abdomen is swollen, symmetrical, is not involved in the act of breathing. Palpation is intense and sharply painful in all departments. Hepatic dullness is present. Dullness over the bosom. Intestinal motility is weakened. The symptom of Shchetkin-Blumberg is positive in all departments.

Diagnosed with Acute obstructive intestinal obstruction. Secondary disseminated peritonitis. "

Operation: Mid-median laparotomy. Intraoperatively revealed a tumor of the cecum, obstructive intestinal obstruction. Secondary disseminated peritonitis.

Performed right hemicolectomy. Then, at the anastomosed distal end of the small intestine, a "proboscis" was formed with a length of 3.0 cm with a section of the mesentery and a feeding end vessel. The wall of the colon along the line of the future anastomosis was dissected strictly in the transverse direction to a length exceeding the width of the small intestine "proboscis" by 0.1 cm (the distance from the blind part of the proximal end of the colon to the anastomosis line was 6.5 cm). An anastomosis was formed with single-row interrupted sutures, each of which was applied as follows: during the formation of ileotransversoanastomosis with an absorbable thread, the needle was inserted into the wall of the distal end of the small intestine at a distance of 2.0 cm from the edge from the side of the serous membrane, passed through the muscular membrane, submucosal base and displayed on the serous the membrane of the small intestine at a distance of 1.0 cm from the edge, then the needle was pierced from the serous membrane of the small intestine at a distance of 0.5 cm from the edge and displayed in the free edge " ka ”to a point located between the submucosa and muscle of the small intestine, then from the inside out the needle was pierced to a point located between the submucosa and muscle of the large intestine and displayed on its serous membrane, departing from the edge by 0.25 cm, then the threads crossed and pulled in opposite directions, while the excess of the mucous and submucous small intestines, turned outward, tucked inward, forming the valves of the areflux valve, and the serous membranes of the small and large intestines accurately and reliably correlated nested with each other, ensuring the tightness of the anastomosis. The width between the following seams is 0.3 cm.

The next step, the indicated sutures formed first the front, then the back lips of the anastomosis. Then, the blind part of the proximal end of the colon was sutured over the anastomosis with the small intestine with nodular serous-muscular sutures, forming the second row of sutures, additionally covering the anastomosis.

Abdominal drainage, layer-by-layer suturing of the abdominal wall wound. The postoperative period was uneventful. Drains removed on the 6th day. Healing by first intention. Discharged in satisfactory condition on the 14th day after surgery. Examined after 6 months. He made no complaints, he tries to adhere to diets, works in his specialty, and evaluates the result of the operation as good.

Thus, the proposed method of ileotransverse anastomosis in conditions of peritonitis, intestinal obstruction allows the formation of an anastomosis with different diameters of the small and large intestines, the intestinal membrane in the anastomosis zone accurately and reliably correlate with each other, ensuring tightness of the anastomosis, sufficient valve function of the anastomosis, eliminating the risk of bleeding, reflux enteritis and dysbiosis.

Claims (1)

A method of forming a small bowel anastomosis, including performing a right-sided hemicolectomy, forming a “proboscis” in the distal section of the anastomosed small intestine with a length of the mesentery and a supply terminal vessel, a transverse section of the colon wall, characterized in that the anastomosis is formed by single-row interrupted sutures, each as follows: during the formation of ileotransverse anastomosis with an absorbable thread, the needle is injected into the wall of the distal end t of the intestine at a distance of 2.0-2.5 cm from the edge from the side of the serous membrane, is passed through the muscle membrane, submucosal base and the needle is punctured on the serous membrane of the small intestine at a distance of 1.0-1.5 cm from the edge, then needle injection from the side of the serous membrane of the small intestine at a distance of 0.5-0.8 cm from the edge and lead to the free edge of the "proboscis" at a point located between the submucosa and muscle membranes of the small intestine, then from the inside out the needle is punctured at a point located between submucosal and muscle membranes of the colon and in lead on its serous membrane, 0.25-0.3 cm backward from the edge, then the threads cross each other and pull in opposite directions, while the excess of the mucosa and submucous small intestine, turned outward, is tucked inward, forming the valves of the areflux valve, and the serous membranes of the small and large intestines are precisely matched to each other, ensuring the tightness of the anastomosis, these sutures form the front, then the posterior lips of the anastomosis, then the blind part of the proximal end of the colon is sutured over the anastomosis with small intestine with nodular sero-muscular sutures, forming the second row of sutures, additionally covering the anastomosis.

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