RU2709831C1 - Method of surgical treatment of rectal tumors - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to surgery, and can be used in oncoprotrology in surgical treatment of rectal tumors. Anterior rectal resection is performed and a stump is formed by applying a linear mechanical suture. Head of stapling apparatus is introduced and fixed in adducting department of large intestine. Base portion of the suturing apparatus is introduced transanally into the lumen of the rectal stump. Suture of the stapling apparatus is drawn from a lumen of the rectal stump into a small pelvis cavity. Single U-suture is applied on the rectal stump at 1 cm to both sides of the stylet in a sagittal direction. For this purpose needle prick-in is performed on posterior surface of rectal stump at point at distance of at least 1 cm from linear mechanical suture. Needle is pricked out on a forward surface of a stump of a rectum in a point spaced at the distance of not less than 1 cm from a linear mechanical suture. Needle prick-in is performed on the rectal stump front surface, prick-out on its posterior surface. Base portion of the stapling apparatus is removed from the cavity of the rectum at a distance of not less than 2 cm. U-shaped suture is tightened around the stylet, bringing the edges of the linear mechanical seam closer to the inner diameter of the base portion of the stapling apparatus. U-shaped suture assembly is tied, the ligature ends are cut off. Base of the stapling apparatus is repeatedly inserted into the cavity of the rectal stump and connected to its head. Instrumental circular anastomosis is applied, after which the stapling apparatus is removed from the rectum.EFFECT: method provides higher effectiveness of surgical treatment of rectal tumors, virtually ruling out inconsistencies of anastomosis and infection of a small pelvis cavity in the postoperative period due to U-shaped suture.1 cl, 2 ex

Description

The invention relates to surgery and can be used in oncology in the surgical treatment of both benign and malignant tumors of the rectum.

Surgical treatment of colorectal tumors is a complex and urgent task in colorectal surgery. Among sphincter-preserving surgeries, anterior rectal resection with a tumor (Park JS, Choi GS, Kim SH, et al. Multicenter analysis of risk factors for anastomotic leakage after laparoscopic rectal cancer excision: the Korean laparoscopic colorectal surgery study group // Ann. Surg. - 2013. - No. 257. - P. 665-71). One of the crucial and difficult stages of such surgical intervention is the application of a colorectal anastomosis in the pelvic cavity. Anastomosis failure in the surgical treatment of colorectal tumors is one of the most serious complications and occurs from 1.5 to 21% of cases, and the associated postoperative mortality reaches 6.0-39.3% (Popov D.E. Risk factors for the failure of colorectal anastomoses in patients with colorectal cancer // Coloproctology. - 2014. - No. 2 (48). - P. 48-56). Numerous data from modern multicenter studies do not reveal a significant tendency to a decrease in the incidence of anastomotic insolvency in the postoperative period, which remains at a fairly high level from 5 to 9% (Hirst NA, Tiernan JP, Millner P.A. et al. Systematic review of methods to predict and detect anastomotic leakage in colorectal surgery. // Colorectal Disease. - 2014; 16 (2): 95-109).

Dissatisfaction with the results of modern methods of surgical treatment of rectal tumors requires the development of new highly effective methods of surgical interventions.

Conducted a search in the scientific and patent literature found various methods of surgical treatment of tumors of the rectum.

A known method of surgical treatment of a tumor of the rectum, described in the patent of the Russian Federation No. 2567917 "Method for the prevention of insolvency of apparatus colorectal anastomosis", (publ. 10.11.2015., Bull. No. 31). The method is as follows. Perform anterior resection of the rectum with the tumor. In the operating room, transrectal ultrasound is performed at a height of 2 cm above the dentate line with a 7.5 MHz transrectal sensor and the rectal wall thickness is measured. Then intraoperatively using a fingertip pulse oximeter measure the level of saturation in the distal and proximal stumps of the intestine. After this, a hardware colorectal anastomosis is applied. With a wall thickness of the rectum of more than 3.5 mm and with a saturation level in the distal and proximal stumps of the intestine less than 70, an ileostomy is removed.

The disadvantages of this method: 1. The technical complexity of the method, as it requires the availability of special equipment and a specialist in ultrasound diagnostics. 2. In the remote postoperative period, a second operation is required to close the ileostomy.

A known method of surgical treatment of a tumor of the rectum, described in the article Abelevich. A.I. "Low anterior resection of the rectum in malignant neoplasms." // Medical Almanac No. 1 (10), 2010, p. 173-176.

The method is as follows. Perform anterior resection of the rectum with the tumor. The rectum is crossed with a linear stapler. The excess linear mechanical suture is immersed in the lumen of the stump of the rectum with two half-mesh sutures. Then form a hardware circular anastomosis using a stapler.

The disadvantages of this method are: 1. There is a risk of anastomotic insolvency, since the application of two half-mesh sutures on the stump leads to significant deformation of the rectal stump wall in the area of colorectal anastomosis by the stapler. 2. The technical complexity of the method, since it is necessary to impose half-mesh seams evenly and symmetrically in the narrow space of the pelvic cavity.

A known method of surgical treatment of tumors of the rectum, described in the book of V.B. Aleksandrova “Rectum cancer” 1977, pp. 94-106. The method is as follows. Perform anterior resection of the rectum. A L-shaped clamp is applied along the resection line. The intestine is cut off immediately under the clamp, the walls of the rectum are captured with long clamps Alice. A double-row colorectal anastomosis is applied with single interrupted sutures. Nodal sutures are applied so that the nodules of threads are located on the side of the mucous membrane.

The disadvantages of this method are: 1. There is a risk of infection of the pelvic cavity, due to its possible contamination by microorganisms, as the lumen of the rectal stump is opened. 2. The technical complexity of the method since the application of a manual colorectal anastomosis in the narrow space of the pelvic cavity is a difficult task.

A known method for the surgical treatment of tumors of the rectum, described in the patent of the Russian Federation No. 2556618 (publ. 07/10/2015, Bull. No. 19) "Method for the surgical treatment of colon cancer." The method is as follows. A section of the colon with a tumor is resected. The stump of the rectum is stitched with a linear stapler. The overlying colon is mobilized for releasing. Behind the stump of the rectum, a tunnel is formed from the side of the anus as close as possible to the oral end of the stump. An opening is formed on the back wall of the rectal stump with an electric knife, through which the mobilized colon is brought down using a conductor. The intestine is fixed to the edges of the hole with four sutures. The excess intestine is removed through the anus and fixed to the skin of the perineum. The stump of the rectum is washed daily with antiseptic solutions until the excess intestine is cut off for 10-14 days.

The method has disadvantages. 1. There is a risk of infection of the pelvic cavity due to the ingress of microorganisms into it when opening the lumen of the rectal stump. 2. The method is complicated in execution and requires repeated manipulations on 10-14 days of the postoperative period.

The closest technical result, taken as a prototype, is the "Method of surgical treatment of tumors of the rectum" described in the patent of the Russian Federation No. 2469655 (publ. 12/20/2012, Bull. No. 35) "Method for treating the stump of the lower ampullar rectum." The method is as follows. An anterior resection of the rectum is performed, its stump is formed by applying a linear mechanical suture, the head of the stapler is inserted and fixed in the adducting section of the colon. The base part of the stapler is introduced transanally into the lumen of the stump of the rectum, its stylet is drawn from the lumen of the stump of the rectum into the pelvic cavity, and the base part of the stapler is connected to its head. A hardware circular anastomosis is then applied and the stapler is removed from the rectum. After applying a linear mechanical suture, the center of the mechanical suture of the rectal stump with a single ligature is additionally sutured, passing it under the suture brackets. Pull the seam up. Cut 1 cm of the mechanical seam directly under the brackets 5 mm to the right and left of the ligature. The hole formed is sutured with single sutures perpendicular to the axis of the mechanical suture.

The disadvantages of the prototype are: 1. There is a risk of anastomotic insolvency, since superimposed single nodal sutures on the formed hole in the perpendicular direction of the axis of the mechanical suture do not properly remove the entire line of the mechanical suture from the linear apparatus from the zone of the proposed circular colorectal anastomosis. 2. There is a risk of infection of the pelvic cavity, as the lumen of the rectal stump is opened by cutting 1 cm of the mechanical suture directly under the brackets 5 mm to the right and left of the ligature. 3. The complexity of the technical execution of the method, since in the narrow space of the pelvic cavity there is a restriction of movements for many surgical procedures.

The objective of the invention is the development of a highly effective method for the surgical treatment of tumors of the rectum.

The technical result of the proposed method is to reduce the risks of developing anastomotic insolvency, infection of the pelvic cavity and simplifying the implementation of the method.

The technical result of the proposed method for the surgical treatment of a tumor of the rectum is achieved by performing anterior resection of the rectum and forming its stump by applying a linear mechanical suture. Introduce and fix the head of the stapler in the adducting section of the colon. The base of the stapler is transanally inserted into the lumen of the rectal stump. The stylet of the stapler is carried out from the lumen of the rectal stump into the pelvic cavity. A single U-shaped suture is applied to the stump of the rectum at a distance of 1 cm on both sides of the stylet in the sagittal direction. To do this, a needle injection is performed on the posterior surface of the rectal stump at a point spaced at least 1 cm from the linear mechanical suture. The needle is punctured on the front surface of the rectal stump at a point spaced at least 1 cm from the linear mechanical suture. The subsequent injection of the needle is performed on the front surface of the stump of the rectum, the injection - on its back surface. The base part of the stapler is removed from the cavity of the rectal stump at a distance of at least 2 cm. The U-shaped seam is pulled around the stylet of the stapler, bringing the edges of the linear mechanical suture closer to the inner diameter of the base part of the stapler. The knot of the U-shaped seam is tied, the ends of the ligature are cut off. The base part of the stapler is reintroduced into the cavity of the rectal stump and connected to its head. A hardware circular anastomosis is applied, after which the stapler is removed from the rectum.

Detailed description of the method:

In the operating room under endotracheal anesthesia in the position of the patient lying on his back with legs apart, the skin is treated with antiseptic solutions. Perform median laparotomy. An audit of the abdominal organs is carried out, the exact location of the tumor is determined. An anterior resection of the rectum is performed and its stump is formed by applying a linear mechanical suture, for example, with a CONTOUR linear stapler manufactured by JOHNSON & JOHNSON (USA). The head of the stapler (for example, EEA 31, Covidien, USA) is inserted into the adduction section of the colon and fixed with a purse string suture, for example, Proline 2/0 with a 1/2 needle. The base portion of this stapler (EEA apparatus 31, Covidien, USA) is transanally inserted into the lumen of the rectal stump. The stylet of the stapler (apparatus EEA 31, Covidien, USA) is carried out from the lumen of the rectal stump into the pelvic cavity. A single U-shaped suture is applied to the stump of the rectum at a distance of 1 cm on both sides of the stylet in the sagittal direction, for example, Biosin 3/0 with a 1/2 needle. To do this, a needle injection is performed on the posterior surface of the rectal stump at a point spaced at least 1 cm from the linear mechanical suture. The needle is punctured on the front surface of the rectal stump at a point spaced at least 1 cm from the linear mechanical suture. The subsequent injection of the needle is performed on the front surface of the stump of the rectum, the injection - on its back surface. The base part of the stapler is removed from the cavity of the rectal stump at a distance of at least 2 cm.The U-shaped seam is pulled around the stylet of the stapler (EEA apparatus 31, Covidien, USA), bringing the edges of the linear mechanical suture closer to the inner diameter of the base part of the stapler ( EEA apparatus 31, Covidien, USA). The knot of the U-shaped suture is tied up, the ends of the ligature are cut off. The base part of the stapling apparatus (EEA apparatus 31, Covidien, USA) is reintroduced into the cavity of the rectal stump and connected to its head. A circular anastomosis is applied to the apparatus (apparatus EEA 31, Covidien, USA), after which the stapling apparatus (EEA 31, Covidien, USA) is removed from the rectum. The pelvic cavity is drained with two silicone tubes brought out through separate contrapertures of the anterior abdominal wall in the right and left lateral regions. The laparotomy wound is sutured in layers, an aseptic dressing is applied.

The practical feasibility of the proposed method is confirmed by the following clinical examples.

Example 1: patient N., 63 years old, was admitted to the surgical department of Rostov State Medical University (Rostov State Medical University) with a clinical diagnosis of colorectal cancer T3N0M0 stage 2, 2 cells. Group.

In the operating room under endotracheal anesthesia in the position of patient N. lying on his back with legs apart, the skin was treated with antiseptic solutions. A median laparotomy was performed up to 30 cm long. The abdominal organs were revised and the exact location of the tumor was determined. The rectum tumor was located 9 cm from the anus, of a dense consistency, tuberous, measuring 4 × 4 × 3 cm. There were no signs of tumor invasion into the surrounding tissues and organs. The rectum with the tumor was mobilized. Patient N. was performed surgical treatment of a tumor of the rectum according to the claimed method. An anterior resection of the rectum was performed and its stump was formed by applying a linear mechanical suture with a CONTOUR linear stapler manufactured by JOHNSON & JOHNSON (USA). The head of the stapler EEA 31, manufactured by Covidien, USA, was fixed in the adducting section of the colon by applying a purse string suture with Proline 2/0 thread with a 1/2 needle. The base portion of the EEA 31 stapler, Covidien, USA, was transanally inserted into the lumen of the rectal stump. The stylet of the stapler EEA 31, manufactured by Covidien, USA, was carried out from the lumen of the rectal stump into the pelvic cavity. A single U-shaped suture with Biosin 3/0 thread with a 1/2 needle was applied to the stump of the rectum at a distance of 1 cm on both sides of the stylet in the sagittal direction. For this, injections of the needle were performed on the posterior surface of the stump of the rectum at a point spaced 1.5 cm from the linear mechanical suture. The needle was punctured on the front surface of the rectal stump at a point spaced 1.5 cm from the linear mechanical suture. A subsequent injection of the needle was performed on the front surface of the rectal stump, and the injection was performed on its posterior surface. The base of the stapler EEA 31, from Covidien, USA, was removed from the cavity of the rectal stump at a distance of 2 cm. The U-shaped suture was pulled around the stylet of the apparatus EEA 31 from Covidien, USA, bringing the edges of the linear mechanical suture closer to the inner diameter of the base of the stapler EEA 31, company Covidien, USA. The knot of the U-shaped seam was tied, the ends of the ligature were cut off. The base of the stapler EEA 31, Covidien, USA, was reintroduced into the cavity of the rectal stump and connected to its head. A hardware circular anastomosis was applied using an EEA 31 apparatus from Covidien, USA, after which the stapler was removed from the rectum. The pelvic cavity was drained by two silicone tubes, brought out through separate contrapertures of the anterior abdominal wall in its right and left lateral regions. The laparotomy wound was sutured in layers, an aseptic dressing was applied. The postoperative period was uneventful, without complications. Drains removed on the 5th and 6th day. Sutures were removed on the 9th day. The patient was discharged from the hospital on the 10th day.

In the postoperative period, patient N. was not found to have failed for colorectal anastomosis and infection of the pelvic cavity.

Example 2: Patient C, 49 years old, was admitted to the surgical department of Rostov State Medical University with a clinical diagnosis of a tubulo-villous tumor of the rectum.

In the operating room under endotracheal anesthesia in the position of the patient S. lying on the back with legs apart, the skin was treated with antiseptic solutions. A median laparotomy was performed up to 25 cm long. The abdominal organs were revised and the exact location of the tumor was determined. The tumor of the rectum was located 10 cm from the anus, dense-elastic consistency, 4 × 5 × 4 cm in size. There were no signs of tumor invasion into the surrounding tissues and organs. The rectum with the tumor was mobilized. Patient C. Surgical treatment of a rectal tumor was performed according to the claimed method. An anterior resection of the rectum was performed and its stump was formed by applying a linear mechanical suture with a CONTOUR linear stapler manufactured by JOHNSON & JOHNSON (USA). The head of the stapler EEA 31, manufactured by Covidien, USA, was fixed in the adducting section of the colon by applying a purse string suture with Proline 2/0 thread with a 1/2 needle. The base portion of the EEA 31 stapler, Covidien, USA, was transanally inserted into the lumen of the rectal stump. The stylet of the stapler EEA 31, manufactured by Covidien, USA, was carried out from the lumen of the rectal stump into the pelvic cavity. A single U-shaped suture with Biosin 3/0 thread with a 1/2 needle was applied to the stump of the rectum at a distance of 1 cm on both sides of the stylet in the sagittal direction. To do this, injections of the needle were performed on the posterior surface of the rectal stump at a point spaced 1 cm from the linear mechanical suture. The needle was punctured on the front surface of the rectal stump at a point spaced 1 cm from the linear mechanical suture. A subsequent injection of the needle was performed on the front surface of the rectal stump, and the injection was performed on its posterior surface. The base part of the stapler EEA 31, Covidien, USA, was removed from the cavity of the stump of the rectum at a distance of 2.5 cm.The U-shaped suture was pulled around the stylet of the apparatus EEA 31, Covidien, USA, bringing the edges of the linear mechanical suture closer to the inner diameter of the base part stapler EEA 31, company Covidien, USA. The knot of the U-shaped seam was tied, the ends of the ligature were cut off. The base of the stapler EEA 31, Covidien, USA, was reintroduced into the cavity of the rectal stump and connected to its head. A hardware circular anastomosis was applied using an EEA 31 apparatus from Covidien, USA, after which the stapler was removed from the rectum. The pelvic cavity was drained with two silicone tubes, brought out through separate contrapertures of the anterior abdominal wall in its right and left lateral regions. The laparotomy wound was sutured in layers, an aseptic dressing was applied. The postoperative period was uneventful, without complications. Drainages removed on the 4th day. Sutures were removed on the 8th day. Patient S. was discharged from the hospital on the 9th day.

In the postoperative period, patient S. did not have an inconsistency of the colorectal anastomosis and infection of the pelvic cavity.

Surgical treatment of 11 patients with rectal tumors was performed in the surgical department of the Rostov State Medical University clinic, of which 8 were patients with malignant tumors and 3 with benign tumors. In the early and long-term postoperative periods, none of these patients showed anastomotic insufficiency and infection of the pelvic cavity.

Thus, the proposed method is simple, allows you to increase the effectiveness of surgical treatment of tumors of the rectum, virtually eliminating in the postoperative period, cases of failure of the anastomosis and infection of the pelvic cavity.

Claims (1)

A method of surgical treatment of a rectal tumor, including anterior resection of the rectum, formation of its stump by applying a linear mechanical suture, insertion and fixation of the head of the stapler in the adducting section of the colon, insertion of the base part of the stapler transanally into the lumen of the rectal stump, conducting its stylet from the lumen stump of the rectum into the pelvic cavity, the connection of the base part of the stapler with its head, the application of a hardware circular anastomosis and removal of the staple a rectum parataque, characterized in that after the stitching of the stapler in the pelvic cavity, a single U-shaped suture is placed on the rectum stump at a distance of 1 cm on both sides of the stylet in the sagittal direction, for this, the needle is punctured on the posterior surface of the stump of the rectum at a point spaced at least 1 cm from the linear mechanical suture, punctured on its front surface at a point spaced at least 1 cm from the linear mechanical suture, subsequent injection of the needle is performed on the same surface of the rectal stump, punctured on its posterior surface, after which the base part of the stapler is removed from the cavity of the rectal stump at a distance of at least 2 cm, the U-shaped suture is tightened around the stylet, bringing the edges of the linear mechanical suture closer to the inner diameter of the base part the stapler, the knot of the U-shaped suture is tied, the ends of the ligature are cut off, the base part of the stapler is reintroduced into the cavity of the rectal stump, connecting with its head.