RU2737911C1 - Method for introduction of preventive double-barley ileostomy in rectal resection or in colproctectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to colorectal surgery. Macropreparation is removed through the minilaparotomy incision. At distance of 15–20 cm from the caecum, and after a colproctectomy - from the point of planned anastomosis with a rectum, the ileum is captured and brought into the same minilaparotomic wound with the condition that the loop is next output at the point of the formed stoma above the skin level. It is followed by two ligatures of different colours under the loop for marking the leading and abducting intestine. One-color ends of the ligatures are fastened above the wall of the intestine by three-four nodes. Loop is immersed into abdominal cavity, minilaparotomic wound is closed. Then the marked loop is moved laparoscopically into the formed stoma zone, fixed, its lumen is opened and a colostomy bag is installed.

EFFECT: method enables reducing the time of stoma withdrawal and formation, excluding damage to the intestinal wall during its formation, as well as reducing postoperative complications and time of medical and social rehabilitation of the patient.

1 cl, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to colorectal surgery and can be used in the formation of a laparoscopic double-barreled intestinal stoma if it is necessary to disable the passage of intestinal contents through the colon.

Since the beginning of the 1990s. In colorectal surgery, laparoscopic technologies are introduced to reduce surgical trauma, including the imposition of a double-barreled intestinal stoma after rectal surgery in order to “turn off” the anastomotic bowel section and provide it with optimal conditions for normal healing in the absence of passage of feces.

Known laparoscopic method of imposing an intestinal stoma by capturing the bowel loop with a working tool through the trocar and removing the bowel loop through the trocar opening. A circular incision of the skin around the trocar is performed, a loop of the intestine is brought out through this opening onto the anterior abdominal wall, after which gas is desuflated, instruments are removed from the abdominal cavity, and the intestine is fixed with separate interrupted sutures to the skin [Fuhrmann G.M., Ota D.M. Laparoscopic intestinal stomas. Dis. Colon Rectum, 1994, v. 37, p. 444-447].

The disadvantages of this method are the process of searching for the necessary section of the loop of the ileum in the conditions of imposed carboxyperitoneum, followed by the determination of the adducting and abducting sections of the intestine, which requires time and lengthening of the surgical intervention, as well as torsion of the stoma around the mesentery in the absence of preliminary marking of the intestine, which leads to a violation of intestinal patency and intestinal ischemia in the postoperative period.

There is a known method of forming a laparoscopic double-barreled intestinal stoma, taken as the closest analogue, including the formation of a hole for the introduction of a trocar in the abdominal wall, removal of the bowel loop through the formed hole, opening its lumen with the formation of a column by fixing the edges of the incision to the skin. After the formation of the opening from the side of the abdominal cavity in the direction corresponding to the position of the adductor intestine, the parietal peritoneum and transverse fascia are dissected by 2-4 cm, and after removing the intestinal loop, the adductor intestine is fixed to one of the edges of the incision along its entire length, stitching the peritoneum with a seizure transverse fascia [Vorobiev G.I. "Method for the formation of a laparoscopic double-barreled intestinal stoma" / Shelygin Yu.A., Frolov S.A. et al., / patent No. 2294711 Bull. No. 7 dated 10.03.2007 p. 4].

The disadvantages of this method are: the process of searching for the required section of the loop of the ileum in conditions of imposed carboxyperitoneum with the subsequent determination of the adducting and abducting sections of the intestine, which requires additional time and lengthening of the surgical intervention, as well as possible torsion of the stoma around the mesentery due to the lack of preliminary marking of the intestine, which leads to a violation of intestinal patency and intestinal ischemia in the postoperative period.

Objectives : simplifying the formation and shortening the formation time of the stoma, reducing postoperative complications and thereby reducing the time and increasing the effectiveness of treatment, reducing the time of medical and social rehabilitation, labor costs of medical personnel.

The essence of the invention is that through the minilaparotomic incision, a macrodrug is removed at the distance closest to the cecum, and after colproctomy - from the place of the planned anastomosis with the rectum, a section of the ileum is captured and taken out into the same minilaparotomic wound with the condition of the subsequent exit of this loop into place of the formed stoma above the level of the skin, then under the loop, two ligatures of different colors are made to mark the adducting and efferent bowel sections, with three or four knots the one-color ends of the ligatures are tied over the intestinal wall, the loop is immersed in the abdominal cavity, the minilaparotomic wound is sutured, and then the marked loop is moved into the zone of the formed stoma laparoscopically, fix it, open its lumen and install a colostomy bag.

The technical result due to the pre-marking the selected section of the small intestine in deriving preventive double-barreled ileostomy is decreasing clearance time and the formation of a stoma, with the exception of damage of the intestinal wall in the formation of a stoma, reducing surgery time, as well as the reduction of postoperative complications and the time of medical and social rehabilitation sick.

For clarity, there is a table of comparative analysis of the results of testing the method on 48 patients

Table

No. Technical indicators of the closest analogue Result Technical indicators of the proposed method Result Additional technical effect one Time of removal and formation of the stoma 20-30 minutes Time of removal and formation of the stoma 10-15 minutes fifty% 2 Damage to the intestinal wall during stoma formation 6% Damage to the intestinal wall during stoma formation 0% one hundred% 3 The effectiveness of the treatment ++ The effectiveness of the treatment
(see technical result) +++ twenty% 4 Labor costs of medical personnel ++ Labor costs of medical personnel +++ twenty%

The method is carried out as follows

Through the minilaparotomic approach, a macrodrug is removed and through it, a section of the ileum is captured and removed, starting with the choice of the loop closest to the cecum, and after colproctomy, the closest to the anastomosis with the rectum. The smallest distance from the site of the supposed ileostomy to the caecum or intestinal anastomosis is 15-20 cm. A prerequisite for choosing a loop is the ability to pull it to the anterior abdominal wall to the place of its withdrawal 3-4 cm above the skin level. After choosing the loop, under it through its mesentery in the avascular zone is carried out by two ligatures of different colors, which are used to mark the adducting and efferent parts of the intestine. Three or four knots of the same color ends of the ligatures are tied over the intestinal wall, then the loop is immersed back into the abdominal cavity. After suturing the minilaparotomic wound, carbon dioxide is injected into the abdominal cavity. Trocars are inserted into the previously established places: the first trocar is installed along the midline in the supra-umbilical region for a video camera, the second - at the site of formation of the intestinal stoma, 1-2 working trocars are inserted on the side opposite to the site of removal of the intestinal stoma (with ileostomy after resection of the rectum - in left iliac region, and after colproctomy it is possible to remove it in the right iliac region). Laparoscopically, the marked section of the intestine is intended for the formation of a stoma. The ligatures are grasped with a Babcock forceps passed through the second trocar. Gas desoflation is performed. Trocars are removed, the wound above the Babcock forceps is expanded to 3-4 cm. A bowel loop is inserted into the wound with the forceps 3-4 cm above the skin level. Instead of ligature holders, to exclude the mobility of the intestine and reposition it into the abdominal cavity, a fixing plastic stick is introduced, used for temporary fixation of a looped stoma, which is fixed from both ends to the skin with interrupted sutures. After that, the intestine is fixed to the skin, its lumen is opened and a colostomy bag is installed.

Example 1.

Patient M., 65 years old, was admitted to the hospital with a diagnosis of Cancer of the mid-ampullar rectum. On December 18, 2017, the patient underwent surgery: Laparoscopic low anterior rectal resection with total mesorectumectomy, with the formation of a descendorectal anastomosis end-to-end and the formation of a preventive loop extraperitoneal ileostomy.

After processing the operating field above the navel, puncture the abdominal cavity with a Veress needle. CO ₂ insufflation. Four-port access to the abdominal cavity. Interfascial, the left half of the colon and rectum are mobilized to the pelvic floor. A linear stapler was placed on the rectum below the lower pole of the neoplasm by 5.0 cm. The rectum is sutured and transected. The rectal stump is about 4.0 cm. A lower midline mini-laparotomy up to 5.0 cm long was performed. A protective sleeve was inserted into the wound and the proximal rectal stump with a tumor and the left half of the colon was brought out to the anterior abdominal wall. The mesentery of the descending and sigmoid colon is excised to the parallel vessels. At the level of the upper third, the sigmoid colon is transected. The macro specimen was removed. A purse-string suture is applied to the proximal end of the sigmoid colon, and the incus of the circular stapling apparatus is immersed in the intestinal lumen. After tightening the purse string suture, the incus and sigmoid colon are immersed in the abdominal cavity. Then, through the minilaparotomic wound, a section of the ileum was captured and removed, choosing a loop 20 cm from the cecum. The loop is freely pulled onto the anterior abdominal wall to the place of its withdrawal 4 cm above the skin level.After choosing the loop, two ligatures of different colors are held under it through its mesentery in the avascular zone, which serve to mark the adductor and efferent bowel sections. The ends of the ligatures are tied with three knots over the intestinal wall, then the loop is immersed back into the abdominal cavity. The minilaparotomic wound was sutured in layers. Insufflation of carbon dioxide into the abdominal cavity. Trocars were inserted into previously established places: the first trocar was installed in the midline in the supra-umbilical region for a video camera, the second - at the site of formation of the intestinal stoma, one working trocar was inserted on the side opposite to the site of removal of the intestinal stoma in the left iliac region. The stump of the sigmoid colon freely reaches the stump of the rectum. Formed hardware sigmoidorectal anastomosis end-to-end. Control of the tightness of the anastomosis: physiological solution was introduced into the small pelvis, 200.0 ml of air was introduced into the rectum. The anastomosis is sealed. Laparoscopically revealed a marked section of the intestine intended for the formation of a stoma. The ligatures were grasped with a Babcock forceps and passed through the second trocar. The gas was desuflated. The trocars were removed, the wound over the Babcock forceps was expanded to 3 cm. A loop of the ileum was brought into the wound together with the forceps 4 cm above the skin level. Instead of ligature holders, to exclude the mobility of the intestine and reposition it into the abdominal cavity, a fixing plastic stick is introduced, which is used to temporarily fix a looped stoma, which is fixed at both ends to the skin with interrupted sutures. After that, the intestine was fixed to the skin, its lumen was opened and the colostomy bag was installed.

The postoperative period was uneventful, the small intestine peristalsis was restored and the intestinal contents entered eight hours after the operation, the patient was activated on the 2nd day after the operation and moved freely on the 4th, minor pain syndrome in the early postoperative period was stopped by non-narcotic analgesics and by 6 -day the patient was discharged home in a satisfactory condition. With further follow-up for 2 months, no complications (evagination, strangulation of the stoma, parastomal hernia) from the side of the formed preventive double-barreled ileostomy were detected.

Example 2.

Patient R., 26 years old, was admitted to the clinic with a diagnosis of Diffuse familial adenomatosis. On June 22, 2016, the patient underwent surgery: Laparoscopic colproctomy with low anterior rectal resection, the formation of a J-shaped ileo-reservoir, with the formation of a reservoir-anal anastomosis laterally to the end and the formation of a preventive loop extraperitoneal ileostomy.

After processing the operating field above the navel, puncture the abdominal cavity with a Veress needle. CO ₂ insufflation. Four-port access to the abdominal cavity. Interfascial right half of the colon, transverse colon, left half of the colon with the rectum are mobilized to the pelvic floor. At the level of the pelvic diaphragm, a linear stapler is placed on the rectum. The rectum is sutured and transected. The rectal stump is about 1 cm. A lower midline mini-laparotomy up to 5.0 cm long was performed. A protective sleeve was inserted into the wound, and the entire macro-preparation with the terminal ileum was brought out to the anterior abdominal wall. The ileum is crossed at the very ileocecal angle between the forceps and the linear stapler. The macro specimen was removed. The end of the ileum is folded into a "J" shape. Through an incision in the area of the top of the future reservoir, a sequentially linear stapler is inserted into both arms of the letter "J" After flashing, the sludge reservoir is formed. In the region of the top of the formed reservoir, the anvil of the circular stapler is immersed. The purse string suture around the anvil stem is tightened and tied. The oil reservoir is immersed in the abdominal cavity.

Further, through the minilaparotomic wound, a section of the ileum was captured and removed, choosing a loop 15 cm from the formed ileoreserver. The loop is freely pulled onto the anterior abdominal wall to the place of its withdrawal 3 cm above the skin level.After choosing the loop, two ligatures of different colors are held under it through its mesentery in the avascular zone, which serve to mark the adductor and efferent bowel sections. The ends of the ligatures are tied with four knots over the intestinal wall, then the loop is immersed back into the abdominal cavity. The minilaparotomic wound was sutured in layers. Insufflation of carbon dioxide into the abdominal cavity. Trocars were inserted into previously established places: the first trocar was installed in the midline in the supra-umbilical region for a video camera, the second - at the site of the intestinal stoma formation, one working trocar was inserted on the side opposite to the intestinal stoma removal site in the right iliac region. The sludge reservoir freely reaches the rectal stump. Formed apparatus reservoir-anal anastomosis side to end. Control of the tightness of the anastomosis: physiological solution was introduced into the small pelvis, 200.0 ml of air was introduced into the intestine. The anastomosis is sealed. Laparoscopically revealed a marked section of the intestine intended for the formation of a stoma. The ligatures were grasped with a Babcock forceps and passed through the second trocar. The gas was desuflated. The trocars were removed, the wound over the Babcock forceps was expanded to 4 cm. A loop of the ileum was inserted into the wound together with the forceps 3 cm above the skin level. Instead of ligature holders, to exclude the mobility of the intestine and reposition it into the abdominal cavity, a fixing plastic stick is introduced, which is used to temporarily fix a looped stoma, which is fixed at both ends to the skin with interrupted sutures. After that, the intestine was fixed to the skin, its lumen was opened and a colostomy bag was installed.

The postoperative period was uneventful, the small intestine peristalsis was restored and the intestinal contents entered ten hours after the operation, the patient was activated on the 2nd day after the operation and moved freely on the 4th, moderate pain in the early postoperative period was stopped by non-narcotic analgesics and by 6 -day the patient was discharged home in a satisfactory condition. With further follow-up for 3 months, no complications (evagination, infringement of the stoma, parastomal hernia) from the preventive double-barreled ileostomy were detected.

Claims (1)

A method for removing a preventive double-barreled ileostomy during rectum resection or colproctomy, including the removal of the ileal loop to the anterior abdominal wall, characterized in that the macro-preparation is removed through the minilaparotomic incision and at a distance of 15-20 cm from the cecum, and after colproctctomy - from the site of the planned anastomosis with the rectum captures a section of the ileum and leads it into the same minilaparotomic wound with the condition of the subsequent exit of this loop in the place of the formed stoma above the skin level, then two ligatures of different colors are made under the loop to mark the adducting and abducting sections of the intestine, with three to four nodes the single-color ends of the ligatures are tied over the intestinal wall, the loop is immersed in the abdominal cavity, the minilaparotomic wound is sutured, and then the marked loop is moved into the zone of the formed stoma laparoscopically, fixed, opened its lumen and installed a colostomy bag.