RU2743882C1 - Method of single-stem decompression ileostoma application in patients with adiposity 3-4 degrees - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to miniinvasive abdominal surgery, oncology. Mini-approach to the operated tissues on the anterior abdominal wall at the border of the middle and right one-third of the bispinal line is performed. Round incision is made with diameter of 3-4 cm. Skin flap together with the subcutaneous fat is incised to an aponeurosis; a cruciate incision of the aponeurosis is performed; abdominal muscles are separated; the peritoneum is dissected. Using the retractor, the wound diameter is increased, the ileocecal angle is measured, the ileocele is retracted by 5-7 cm, the ileum is transected by means of an electrosurgical apparatus with preserving the vascular arcade. Distal end of the small intestine is closed with two-row sutures, a portion of a leading loop of the ileum of the required size is mobilized, which is brought out on the anterior abdominal wall and a single-stem ileostoma is formed in the place of mini-access.

EFFECT: method enables reducing tissue injuries, reducing the length of surgical intervention, postoperative rehabilitation, reducing a risk of postoperative complications such as a commissural process in the abdominal cavity, fistula formation, hernia.

1 cl, 2 dwg

Description

The invention relates to medicine, namely to minimally invasive abdominal surgery and can be used to treat colon cancer complicated by acute colonic obstruction in patients with severe subcutaneous fat, when the removal of the ileal loop to the anterior abdominal wall is not possible or questionable.

There is a known method of imposing an end enterostomy (game-like anastomosis of a crossed bowel loop) according to Maidl (Source: https://na-bolnichniy.ru/lechenie/enterostomiva-po-majdlyu-vitczelvu-tomb, date of treatment 09/16/2020).

The essence of the method lies in the fact that after the laparotomy, the small intestine is crossed 30 cm from the Treitz ligament. The proximal end of the intestine is anastomosed end to side with the small intestine 20 cm below the intersection. The distal end is passed in an oblique direction, removed through a separate incision in the anterior abdominal wall and fixed to the skin.

The disadvantage of this analogue is the laparotomy, the need for an additional incision on the abdominal wall for the stoma, the imposition of an interintestinal anastomosis at the initial stage, which in the future, possibly threatens the development of anastomotic leakage, an increase in the duration of the surgical intervention, and, in addition, this method does not exclude the passage of the intestinal contents along the bowel discharge loop.

Of the known technical solutions, the closest in purpose and technical essence to the claimed invention is the imposition of an end ileostomy according to Brook (Source: https://meduniver.com/Medical/Xirurgia/koncevaia_ileostomia_ikolostomia.html, date of treatment 09/16/2020).

This method includes the following steps: midline laparotomy, mobilization of the terminal part of the ileum so that it can be freely withdrawn outside the abdominal wall in the place planned for the stoma, excision of the skin in the form of a disc in the place chosen for the stoma: not more than the diameter of the small intestine, dissection of the subcutaneous fat and cruciate dissection of the aponeurosis of the rectus abdominis muscle, longitudinal dilution of the fibers of the rectus abdominis muscle and opening the posterior leaf of its vagina and peritoneum, formation of the opening, removal of the intestine through the opening and fixation to the aponeurosis 3-4 serous-muscular sutures, suturing laparotomic wounds or ports.

The disadvantage of the prototype is the need to perform a midline laparotomy, the possible development of bleeding (associated with surgical intervention): for example, during traction for the mesenteric vessels, the risk of fistula formation, stoma retraction with pronounced subcutaneous fat (obesity), stoma necrosis (insufficient mobilization, strangulation) , stricture (nadaponeurotic necrosis) or peritonitis (subgaponeurotic necrosis), volvulus of the small intestine around the segment of the intestine carrying the stoma, prolapse, hernia.

The purpose of the invention is to minimize complications (during surgery and in the postoperative period) in the treatment of colon cancer complicated by acute colonic obstruction in patients with grade 3-4 obesity.

The claimed invention is aimed at solving the problem of creating a method of imposing a single-barreled decompression ileostomy through a mini-access for the treatment of colon cancer complicated by acute colonic obstruction in patients with grade 3-4 obesity.

The inventive method is carried out as follows and is illustrated by FIG. 1 and FIG. 2. Under general anesthesia on the skin of the anterior abdominal wall at the Lanz point (on the border of the middle and right third of the bispinal line connecting the anterior upper spines of the pelvic wings), they provide mini-access to the tissues to be operated, that is, a rounded incision with a diameter of 3-4 cm is performed, then the skin flap is excised together with the subcutaneous fatty tissue to the aponeurosis. After that, a cruciform incision of the aponeurosis is made, the abdominal muscles are dilated and the peritoneum is dissected. With the help of a retractor, the diameter of the wound is increased, which helps to reduce the thickness of the anterior abdominal wall. Subsequently, the ileocecal angle is determined (4), and 5-7 cm away from it, the ileum is transected using an electrosurgical apparatus, preserving the vascular arcade (2). The abduction loop of the small intestine (3) is sutured with two-row sutures, a section of the adducting loop of the ileum of the required size is mobilized (1), which is brought out to the anterior abdominal wall (6), and a single-barreled ileostomy is formed at the site of the mini-access (7).

Compared with the prototype, the claimed invention has the following distinctive features:

- carry out mini-access to the operated tissues on the anterior abdominal wall at the border of the middle and right third of the bispinal line connecting the anterior upper spines of the pelvic wings (at Lanz's point);

- perform a rounded incision with a diameter of 3-4 cm;

- the skin flap is excised together with the subcutaneous fat to the aponeurosis;

- make a cruciform incision of the aponeurosis;

- dilate the abdominal muscles and dissect the peritoneum;

- with the help of a retractor, the diameter of the wound is increased, which helps to reduce the thickness of the anterior abdominal wall;

- determine the ileocecal angle;

- retreat from the ileocecal angle by 5-7 cm;

- the ileum is crossed with the preservation of the vascular arcade using an electrosurgical apparatus, which is designed to carry out hemostasis in the process of endosurgical mobilization of organs and the closure of large vessels and serves as a universal method for stopping bleeding;

- the outlet end of the small intestine is sutured with double-row sutures;

- a section of the adducting loop of the ileum of the required size is mobilized, which is brought out to the anterior abdominal wall;

- form a single-barreled ileostomy at the site of the mini-access.

Performing a mini-access on the skin of the anterior abdominal wall at the Lanz point (at the border of the middle and right third of the bispinal line connecting the anterior upper spines of the pelvic wings) reduces tissue trauma, shortens the time of surgery, postoperative rehabilitation, and reduces the risk of postoperative complications such as adhesions in the abdominal cavity, the formation of fistulas, hernias, the use of a retractor allows you to increase the diameter of the wound and helps to reduce the thickness of the anterior abdominal wall, which provides proper access to the operated tissues, transection of the ileum using an electrosurgical apparatus, which is designed to carry out hemostasis in the process of endosurgical mobilization of organs, serves as a universal way to stop bleeding when crossing the intestine and is less traumatic for the intestine, mobilization of the adductor loop of the ileum in the described way allows the adductor loop to be removed and formed on the single abdominal wall, single-barreled ileostomy in patients with 3-4 degree of obesity, which is not possible with other methods.

This invention makes it possible to reduce tissue trauma by using a mini-laparotomy and an electrosurgical apparatus, to ensure the removal of the ileal loop in patients with grade 3-4 obesity, which previously did not seem possible or doubtful, to reduce the time of surgery, the period of postoperative rehabilitation, the risk of development postoperative complications, including the risk of developing cicatricial adhesions in the abdominal cavity, bleeding, and, consequently, deaths, as well as improve the quality of life of patients.

Thus, the proposed method is technically less traumatic, can be used in patients with grade 3-4 obesity, when the removal of the loop of the ileum to the anterior abdominal wall is not possible or doubtful, reduces the treatment time, reduces the risk of postoperative complications, postoperative rehabilitation, which cumulatively improves the patient's quality of life.

Claims (1)

A method of imposing a single-barreled decompression ileostomy in patients with grade 3-4 obesity, including laparotomy, dissection of the subcutaneous fat, opening the peritoneum, stoma formation, suturing, characterized in that mini-access to the operated tissues on the anterior abdominal wall at the border of the middle and the right third of the bispinal line, a rounded incision with a diameter of 3-4 cm is performed, the skin flap is excised together with the subcutaneous fat to the aponeurosis, a cruciform incision of the aponeurosis is made, the abdominal muscles are dilated, the peritoneum is dissected, the wound diameter is increased with the help of a retractor, the ileocecal angle is determined , retreat from it by 5-7 cm, cross the ileum with the help of an electrosurgical apparatus while preserving the vascular arcade, the discharge end of the small intestine is sutured with two-row sutures, a section of the adducting loop of the ileum of the required size is mobilized, which is brought out to the anterior abdominal wall and a unilateral ileostoma is formed onplace of mini-access.

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