RU2734595C1 - Method for intestinal stoma formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, coloproctology. After the laparotomy is performed on the side of presumed stoma removal, the skin and subcutaneous fat is mobilized from the midline of the abdomen and an anterior wall of rectus abdominis muscle along the length of the laparotomy wound. Mobilized skin-subcutaneous flap is formed laterally from its edge. Intersection of the intestine with a mesentery is made between the edges of a dissected aponeurosis of a white abdominal line and is brought out through a skin opening formed in the skin-subcutaneous flap. Intestine is fixed on the skin by means of an elastic hypoallergenic tube drawn through the mesentery. Abdominal cavity is closed by suturing skin edges medial to the formed stoma.

EFFECT: method provides the possibility of excretion of the intestinal stoma without mesentery tension with limited mobility of the intestinal loops, enables to prevent the disturbed blood supply in the mesentery, preserving integrity of muscular-aponeurotic structures of the abdominal cavity, reducing the length of treatment from the moment of applying stoma to its closure and improving the patient's quality of life after the operation.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery - methods of forming intestinal stomas.

A known method of forming an ileostomy [1] by removing the ileum through a circular opening in the anterior abdominal wall together with the mesentery, perpendicular to the mesentery in the avascular zone, an elastic hypoallergenic tube is passed, which is fixed to the skin of the anterior abdominal wall with separate interrupted sutures.

The disadvantage of this method is the impossibility of conducting the intestine together with the mesentery through all layers of the abdominal wall: the peritoneum, preperitoneal tissue, the posterior aponeurosis of the rectus abdominis muscle, the rectus abdominis muscle, the anterior aponeurosis of the rectus abdominis muscle, subcutaneous tissue and skin, if due to inflammatory infiltrate and / or adhesions, the intestine and its mesentery are fixed deep in the abdominal cavity.

A known method of forming an intestinal stoma [2], in which the formation of an intestinal stoma is carried out by passing a section of the intestine through a circular opening in the skin and subcutaneous tissue of the anterior abdominal wall together with the mesentery, perpendicular to which in the avascular zone is installed a hypoallergenic tube, fixed to the skin with separate interrupted sutures, characterized in that after performing a laparotomy, the skin and subcutaneous tissue are mobilized from the anterior leaflet of the aponeurosis of the rectus abdominis muscle, at the selected place of removal of the intestine to the abdominal wall, a transverse intersection of the anterior leaflet of the sheath of the rectus abdominis muscle, the rectus abdominis muscle itself and its posterior leaflet, formed in this way is carried out the upper portion of the rectus muscle is displaced cranially or to the middle, or to the edge of the spigel line of the abdomen, and the lower portion is displaced caudally or to the middle, or to the edge of the spigel line of the abdomen, into the formed wide window in the musculo-aponeurotic layer of the abdominal wall, the mobilized skin is displaced from the subcutaneous fatty tissue, which is supplied to the transected intestine fixed in the depth of the abdominal cavity and through the channel formed in the skin and subcutaneous tissue, the intestine is brought out to the anterior abdominal wall.

The disadvantage of this method is the need to intersect the aponeurosis and the area of the rectus abdominis muscle to form a window through which the cutaneous-subcutaneous flap is brought to the intestine, fixed in the depth of the abdominal cavity. This further complicates the performance of the operation aimed at closing the defect in the abdominal wall. This method is taken as a prototype.

The aim of the invention is to provide a method for the formation of an intestinal stoma.

This goal is achieved by the fact that after performing a laparotomy on the side of the proposed removal of the stoma, the skin and subcutaneous tissue are mobilized from the midline of the abdomen and the anterior wall of the rectus sheath along the length of the laparotomic wound; a hole is formed in the mobilized skin-subcutaneous flap, retreating laterally from its edge; the transected intestine with the mesentery is carried out between the edges of the dissected aponeurosis of the white line of the abdomen and is brought out through the hole formed in the skin-subcutaneous flap onto the skin; the abdominal cavity is closed by suturing the edges of the skin medially to the formed stoma.

The method provides the possibility of removing the intestinal stoma without tension of the mesentery with limited mobility of intestinal loops due to inflammation and adhesions in the abdominal cavity, which is achieved by mobilizing subcutaneous tissue from the anterior sheath of the rectus abdominis muscle. Conducting an intestinal stoma only through a skin-subcutaneous flap prevents a violation of the blood supply in the mesentery and preserves the integrity of the musculo-aponeurotic structures of the abdominal wall. The above actions technically simplify the operation to restore the continuity of the gastrointestinal tract and the anatomical integrity of the anterior abdominal wall during repeated reconstructive surgery, reduce the treatment time from the moment of stoma placement to its closure, and improve the patient's quality of life after surgery.

The method is carried out as follows. After performing a laparotomy on the side of the intended removal of the stoma, the skin and subcutaneous tissue are mobilized from the midline of the abdomen and the anterior wall of the vagina of the rectus abdominis muscle along the length of the laparotomic wound, a hole is formed in the mobilized skin-subcutaneous flap, retreating laterally from its edge, and then the transected intestine with the mesentery carried out between the edges of the dissected aponeurosis of the white line of the abdomen and brought out through the hole formed in the cutaneous-subcutaneous flap onto the skin and fix the intestine on it with the help of an elastic hypoallergenic tube passed through the mesentery, and then the abdominal cavity is temporarily closed by suturing the edges of the skin medially of the formed stoma ...

The method is illustrated by graphic material

Figure 1 shows the anterior abdominal wall (1) after laparotomy, mobilization of the cutaneous-subcutaneous flap (2) on the left, the small intestine (3) with the mesentery (4) is drawn between the edges (5) of the aponeurosis and brought out through the opening (6) into the cutaneous a subcutaneous flap (2) on the skin surface in the form of a stoma (7), fixed on the skin with an elastic hypoallergenic tube (8), passed through the mesentery (4) of the small intestine (3).

Figure 2 shows the abdominal wall (1) after the completion of the operation, which shows an intestinal stoma (7), brought out through a skin-subcutaneous flap (2) to the surface of the skin, and sutures (9) are placed medially on the edges of the skin to close the abdominal cavity , under which drainage (10) is installed according to Redon.

The proposed method is implemented as follows. After performing a laparotomy, an infiltrate is determined in the abdominal cavity, in which the loops of the small intestine are involved. The infiltrate is separated by crossing the adductor section of the small intestine, the distal end is sutured, and the proximal end is prepared for removal onto the skin in the form of an intestinal stoma. To do this, on the left, a skin-subcutaneous flap is mobilized from the midline of the abdomen and the anterior wall of the vagina of the rectus abdominis muscle, in which an opening is formed.

The intestine is passed between the edges of the aponeurosis, and then the intestine is passed through a hole in the skin-subcutaneous flap, which is fixed on the skin with an elastic hypoallergenic tube passed through the mesentery, and then the abdominal cavity is closed by suturing the edges of the skin of the laparotomic wound, under which drainage according to Redon is installed ...

The method of forming an intestinal stoma is illustrated by an example. Patient S., 27 years old, 04/29/2017, was admitted to the Samara Regional Clinical Hospital named after V.I. V.D. Seredavina. Diagnosis: progressive peritonitis after surgery for a shot gunshot wound of the abdominal cavity with damage to the colon and liver, with the location of the wound canal in the left hypochondrium.

During relaparotomy, it was found that in the abdominal cavity there is a clinical picture of widespread purulent-fibrinous fecal peritonitis, paralytic acute intestinal obstruction, stage IIb. In the right hypochondrium and subhepatic space there is a fibrinous-purulent infiltrate around the end colostomy brought out to the anterior abdominal wall. Mesacolon is involved in the infiltrate. Under these conditions, the patient is shown resection of the ascending colon, elimination of the colostomy with the removal of the terminal ileostomy.

Under the prevailing conditions of gross changes in the anterior abdominal wall in the area of the wound channel after a gunshot wound in the left hypochondrium, in the presence of an infiltrate at the site of a previously removed colostomy, in conditions of an adhesions in the abdominal cavity, limiting the mobility of the small intestine, removal of an ileostomy through all layers of the anterior abdominal wall impossible. In this regard, our method was applied to form a stoma.

Intraoperatively, it was possible to remove the ileostomy without tension of the mesentery, to preserve the blood supply to the latter and not to disrupt the integrity of the musculo-aponeurotic structures of the anterior abdominal wall. In the postoperative period, the stoma retained its viability and functioned. No complications were observed in the long-term period. After 6 months, the patient was able to perform a reconstructive operation to restore the integrity of the gastrointestinal tract and plastic anterior abdominal wall in a combined way without technical difficulties.

The proposed method for the formation of an intestinal stoma can be used in surgical departments in the treatment of patients with surgical pathology in the abdominal organs.

Sources of information

1. Patent for the invention of a method for forming an ileostomy No. 2320278 dated 27.03.2008, authors: Belokonev Vladimir Ivanovich, Zhitlov Andrey Gennadievich.

2. Patent for the invention of a method for the formation of an intestinal stoma No. 2532304 dated 10.11.2014, the authors Belokonev Vladimir Ivanovich, Fedorin Alexander Ivanovich, Medvedchikov-Ardiya Mikhail Alexandrovich, Gorbunov Yuri Valentinovich.

Claims (1)

A method of forming an intestinal stoma by removing the ileum through a circular opening in the anterior abdominal wall together with the mesentery, holding and fixing an elastic hypoallergenic tube perpendicular to the mesentery in its avascular zone, characterized in that after performing a laparotomy on the side of the intended removal of the stoma, the skin and subcutaneous tissue are mobilized from the midline of the abdomen and the anterior wall of the vagina of the rectus abdominis muscle along the length of the laparotomic wound; a hole is formed in the mobilized skin-subcutaneous flap, retreating laterally from its edge; the transected intestine with the mesentery is carried out between the edges of the dissected aponeurosis of the white line of the abdomen and is brought out through the hole formed in the skin-subcutaneous flap onto the skin; the abdominal cavity is closed by suturing the edges of the skin medially to the formed stoma.

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