RU2575311C2 - Method for colon resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, surgery. A colonic anastomosis is formed. Walls of afferent and efferent intestines are separated. Serous surfaces of the expected anastomosis are cleaned throughout 1.5-2.0 cm. The anastomosed intestinal segment are placed with their mesentetic edges facing each other. They are sutured together with one or two ligatures at the mid-distance between mesenteric and anti-mesenteric edges from both sides. That is followed by uniform lateral and longitudinal extension and underrunning with a mechanical suture at a stitch pitch of 1-1.5 mm. Forceps are used with removing the intestinal segment to be excised. All layers of front walls of the afferent and efferent intestines are dissected by 70-80% of their width at 3-5 mm from the mechanical suture line. An anterior anastomosis line is applied by a single-suture continuous suture at a pitch of 2-3 mm with synthetic absorbable material and 4/0-5/0 non-traumatic needle. The suture is applied at 3-5 mm from an edge of the intestinal wall at a stitch pitch of 2-3 mm with covering serous-muscular-subserous layers of the afferent and efferent loops.

EFFECT: method provides increasing the anastomosis reliability, reducing the risk of postoperative complications by simplifying the colonic anastomosis technique and reducing the time of creation.

3 ex

Description

The invention relates to medicine, namely to surgery, and can be used for resection of the colon with the imposition of colonic anastomosis.

A known method of forming an antireflux invagination of small intestinal anastomosis (1 - RF patent No. 2456944 A61B 17/11, 2006 - analogue). According to the analogue, the ends of the small and large intestines, captured by polypotome loops, are combined so that the mesentery of both intestines are located relative to each other at an angle of 45 ° and a first row of nodular serous-muscular sutures is placed between them along the perimeter. Polypotome loops are deployed in one direction with the stumps oriented toward the colon and the following three rows of nodular serous-muscular sutures are sequentially applied along the perimeter, which invaginate the stump of the small intestine into the lumen of the colon. Electrosurgical cutting off of the stumps of both intestines captured by polypotome loops is performed.

There is also a method of applying a compression colonic anastomosis, adopted as a prototype (2 - RF patent No. 2301635, A61B 17/11, 2006). In the prototype method, a triangular platform is formed, directed by the apex to the mesenteric edges, by applying three serous-muscular sutures. Two punctures of the intestinal wall are formed in the middle of the base of the obtained triangular platform. A nickel-titanium spiral with shape memory is introduced through the punctures. A second row of anastomotic sutures is applied at the level of the triangular site. However, the reliability of the prototype method is relatively limited.

The purpose of the invention is to increase the reliability of anastomosis and reduce postoperative complications, simplify the technique of applying colonic anastomosis, reduce the time of its application.

The technical result of the proposed method is achieved by isolating the wall of the adducting and abducting intestines with the release of serous surfaces of the future anastomosis for 1.5-2.0 cm, anastomosed sections of the intestine have mesenteric edges to each other, stitched with one or two ligatures in the middle of the distance between the mesenteric and anti-mesenteric edges on both sides, uniformly stretch in the transverse and longitudinal directions and simultaneously stitched with a seam step of 1-1.5 mm mechanical seam; retreating 3-5 mm from the line of the mechanical suture, cut all the layers of the anterior walls of the intestines to 0.7-0.95 of their width, carry out through stitching of the edges of the mechanical suture, tie a knot from the side of the intestinal lumen, immerse the angle of the mechanical suture with serous-muscular sutures then, with a continuous twisting seam with a step of 2-3 mm, the anastomosis front lip is formed with a synthetic absorbable suture material 4 / 0-5 / 0 with an atraumatic needle, capturing the serous-muscular-submucous layers of the leading and outlet loops, with a comparison of the layers, the formation of an anastomosis complete by immersion of the second angle of the mechanical seam.

The invention is illustrated as follows. In surgical practice, different types of sutures are used to connect the walls of the colon - colonic anastomoses: manual one- two-, three-row, continuous and nodular, apparatus - using linear and circular staplers with one, two and three rows of staples. The most widely used in our country are manual, often double-row nodal, and hardware using circular staplers with two rows of staples (company Auto Suture) (Zoltan J. Operational technique and optimal wound healing conditions. Budapest. 1983). A single-row continuous serous-submucosal suture is gaining an increasing number of supporters (VN Egiev, “Single-row continuous suture of anastomoses in abdominal surgery”, Moscow, 2001). With the comparable effectiveness of various methods of anastomoses, they have the following disadvantages: 1) The need for testing and scrupulous observance of the technique of applying a manual suture, a significant time for applying a manual colonic anastomosis. 2) The high cost of apparatus for applying circular anastomoses, allowing to standardize and simplify the technique, significantly reduce the time of application of the anastomosis.

The method is implemented as follows.

The removed portion of the colon is mobilized by dividing its mesentery. Carefully isolate the wall of the adducting and abducting intestines with the release of serous surfaces of the future anastomosis for 1.5-2.0 cm. Anastomosed sections of the intestine are placed in the form of a "double-barreled gun" with the mesenteric edges to each other, sewn with one or two ligatures in the middle of the distance between the mesenteric and the mesenteric edges on both sides. Intestinal walls evenly stretch in the transverse and longitudinal direction. Both intestines are simultaneously flashed with a UO-60 type stapler with a seam pitch of 1-1.5 mm with a mechanical seam. A crushing clamp is applied to the resected area of the intestine and it is cut off along the edge of the stapler. Hemostasis of the anterior lip of the anastomosis is performed by electrocoagulation or by stitching of bleeding vessels. Retreating 3-5 mm from the line of the mechanical suture, dissect all layers of the anterior walls of the intestines by 0.7-0.95 of their width using electrocoagulation for hemostasis. A through stitching of the edges of the mechanical suture is carried out and a knot is tied from the side of the intestinal lumen. Stitching the intestine outward from the mechanical suture, immerse its angle with serous-muscular sutures. Then, the front lip of the anastomosis is formed with a continuous absorbent suture with a synthetic absorbable suture 4 / 0-5 / 0 with an atraumatic needle, while the serous-muscular-submucous layers of the leading and outlet loops are captured, with a comparison of the layers. The suture is applied at a distance of 3-5 mm from the edge of the intestinal wall, the step of the suture is 2-3 mm. Sutures necessarily capture the submucosal layer, which is the most durable layer of a hollow organ. The formation of the anastomosis is completed by immersion of the second angle of the mechanical suture.

To increase the density of matching, the walls of the stitched intestines are strengthened with additional nodal or continuous sutures with the same suture material, covered with fat pendants.

The method is further explained by examples of its implementation.

Example 1

Patient Yu., 79 years old, was admitted with complaints of general weakness, decreased performance. Upon admission, anemia, weight loss, pallor of the integument, streaks of blood in the feces are noted, dark clots, constipation, and calaniform form occasionally appear.

With fibrocolonoscopy, contact bleeding is noted, in the splenic corner there is a bulging of the mucous membrane with a tuberous surface and vascular injection, which indicates the presence of cancer of the splenic angle of the colon. A histological examination will determine a highly differentiated adenocarcinoma.

Performed left-sided hemicolectomy.

Mobilization of the removed portion of the colon by dividing its mesentery after iliac-paraaortic lymphadenectomy. The walls of the adducting transverse colon and abduction sigmoid colon were isolated with the release of serous surfaces of the future anastomosis for 1.5 cm. Anastomosed sections of the intestine are located in the form of a "double-barreled gun" with mesenteric edges to each other, sewn together with ligatures at the middle of the distance between the mesenteric and mesenteric edges two sides. The intestinal walls are evenly stretched in the transverse and longitudinal directions. Both guts were simultaneously stitched with the UO-60 device with a 1.5 mm suture step. A crushing clamp is applied to the resected area of the intestine, with its subsequent cutting off along the edge of the stapler. Hemostasis was performed by electrocoagulation of bleeding vessels. Departing 3 mm from the mechanical suture of the anastomosis, all layers of the anterior walls of the intestines were dissected by 70-80% of their width using an electric knife for hemostasis. A through stitching of the edge of the mechanical suture was performed and a knot was tied from the side of the intestinal lumen. Stitching the intestine outward from the mechanical suture, its angle is immersed in serous-muscular sutures. Then, the front lip of the anastomosis with a synthetic absorbable suture 4 / 0-5 / 0 with an atraumatic needle was formed with a continuous twisting seam, while serous-muscular-submucous layers of the leading and outlet loops were captured, with a comparison of the layers. The suture is applied at a distance of 3-5 mm from the edge of the intestinal wall, the step of the suture is 2-3 mm. The formation of the anastomosis is completed by immersion of the second angle of the mechanical suture. On the third day after surgery, the patient began to eat. On the fourth day - an independent chair. After receiving the conclusion of the pathoanatomical study, he was discharged under the supervision of an oncologist.

During the follow-up examination after a year with FCC, the line of the anastomosis is poorly traced. There are no violations of the passage of feces.

Example 2

Patient C, 31 years old, was admitted with complaints of pain in the lower abdomen on the left, in the lower back against a background of constant constipation.

For a long time suffers from constipation. During the year, it is treated by a gastroenterologist with a low effect. Complies with a constantly sparing diet and fractional diet. Colonoscopy and irrigography revealed dolichosigma with torsion of additional loops and impaired passage of barium at this level. Due to the difficulties of conservative therapy, the gastroenterologist is focused on surgical treatment.

Resection of the sigmoid colon was performed.

An oblique variable section in the left inguinal region of 6 cm revealed the abdominal cavity in layers. After dissection of planar adhesions, a loop of the sigmoid colon - a mesentery with a significant scar-adhesion process was removed into the wound. A 40 cm portion of the removed sigmoid colon was mobilized by dividing its mesentery. The walls of the descending intestine and the intestine in the rectosigmoid junction with the release of serous surfaces of the future anastomosis for 1.5 cm were highlighted. Anastomosed sections of the intestine are located in the form of a “double-barreled gun” with mesenteric edges to each other, sewn together with ligatures at the middle of the distance between the mesenteric and marginal mesenteric on both sides. The intestinal walls are evenly stretched in the transverse and longitudinal directions. Both guts were simultaneously stitched with the UO-60 device with a 1.5 mm suture step. A crushing clamp is applied to the resected area of the intestine, with its subsequent cutting off along the edge of the stapler. Hemostasis was performed by electrocoagulation of bleeding vessels. Departing 3 mm from the mechanical suture of the anastomosis, all layers of the anterior walls of the intestines were dissected by 70-80% of their width using an electric knife for hemostasis. A through stitching of the edge of the mechanical suture was performed and a knot was tied from the side of the intestinal lumen. Stitching the intestine outward from the mechanical suture, its angle is immersed in serous-muscular sutures. Then, an anastomosis is formed with a continuous entraining suture with a synthetic resorbable suture 4 / 0-5 / 0 with an atraumatic needle, while serous-muscular-submucous layers of the adductor and abduction loops are captured, with a comparison of the layers. The suture is applied at a distance of 3-5 mm from the edge of the intestinal wall, the step of the suture is 2-3 mm. Anastomosis is completed by immersion of the second angle of the mechanical suture. On the second day after the operation, the gases departed. On the third day after the operation, the patient began to eat and there was an independent chair. On the fifth day after the operating period, she was discharged under the supervision of a polyclinic surgeon. A year after the operation, a regular independent chair.

Example 3

Patient D., 62 years old, was admitted with complaints of pain in the left iliac region.

With a comprehensive examination (FCC, ultrasound, CT), diverticulosis and diverticulitis in the sigmoid colon. After relief of acute inflammatory phenomena, a resection of the sigmoid colon was performed.

An oblique variable section in the left inguinal region of 8 cm revealed the abdominal cavity in layers. A loop of the sigmoid colon was removed into the wound. To it is a fixed strand of the greater omentum - electroadhesiolysis. In the distal part of the sigmoid colon, multiple diverticula of 10-20 mm, one of which is sharply dense, with infiltrated and hyperemic adjacent fatty tissue. Mobilized 30 cm of the removed section of the sigmoid colon by dividing its mesentery. The walls of the leading and outlet sections of the sigmoid colon were isolated with the release of serous surfaces of the future anastomosis for 1.5 cm. The anastomosed sections of the intestine are located in the form of a “double-barreled gun” with mesenteric edges to each other, sewn with ligatures at the middle of the distance between the mesenteric and mesenteric edges on both sides. The intestinal walls are evenly stretched in the transverse and longitudinal directions. Both guts were simultaneously stitched with the UO-60 device with a 1.5 mm suture step. A crushing clamp is applied to the resected area of the intestine, with its subsequent cutting off along the edge of the stapler. Hemostasis was performed by electrocoagulation of bleeding vessels. Departing 3 mm from the mechanical suture of the anastomosis, all layers of the anterior walls of the intestines were dissected by 70-80% of their width using an electric knife for hemostasis. A through stitching of the edge of the mechanical suture was performed and a knot was tied from the side of the intestinal lumen. Stitching the intestine outward from the mechanical suture, its angle is immersed in serous-muscular sutures. Then, an anastomosis is formed with a continuous entraining suture with a 4/0-5 / 0 synthetic absorbable suture material with an atraumatic needle, while serous-muscular-submucous layers of the adductor and abduction loops are captured, with a comparison of the layers. The suture is applied at a distance of 3-5 mm from the edge of the intestinal wall, the step of the suture is 2-3 mm. The continuous suture of the anastomosis is completed by immersion of the second angle of the mechanical suture with serous-muscular sutures and is completed behind it. In the evening on the day of surgery, distinct peristalsis. On the third day after the operation, the gases departed. On the fourth day after the operation, there was an independent chair and the patient began to eat. Two months after surgery, there are no stool disorders.

Claims (1)

A method for resecting the colon with the application of a large intestine anastomosis and performing a suture connection, characterized in that the wall of the adducting and abducting intestines is released with the release of serous surfaces of the future anastomosis for 1.5-2.0 cm, the anastomosed sections of the intestine have mesenteric edges to each other, stitch with one or two ligatures in the middle of the distance between the mesenteric and anti-mesenteric edges on both sides, uniformly stretch in the transverse and longitudinal directions and simultaneously flash in increments seam 1-1.5 mm with a mechanical seam; retreating 3-5 mm from the line of the mechanical suture, cut all the layers of the anterior walls of the intestines to 0.7-0.95 of their width, carry out through stitching of the edges of the mechanical suture, tie a knot from the side of the intestinal lumen, immerse the angle of the mechanical suture with serous-muscular sutures then, with a continuous twisting seam with a step of 2-3 mm, the anastomosis front lip is formed with a synthetic absorbable suture material 4 / 0-5 / 0 with an atraumatic needle, capturing the serous-muscular-submucous layers of the leading and outlet loops, with a comparison of the layers, the formation of an anastomosis complete by immersion of the second angle of the mechanical seam.