RU2745728C1 - Method of forming a loop double-barreled ileostomy - Google Patents

Abstract

FIELD: medicine and abdominal surgery.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. The ileal loop is withdrawn, avoiding a 180° turn. Then a hypoallergenic tube or plastic stick is passed along the base of the loop perpendicular to the intestine in the avascular zone of the mesentery. Further, the adducting and educting knees of the ileum are stitched together and to the skin with a single suture to form a spur, and after tying, in the second stage, a tube or a plastic stick is fixed with the ends of the same thread. Then the intestine is additionally sutured to the skin on both sides of the tube with three horizontal U-shaped sutures, and then the intestinal lumen is opened with a longitudinal incision of 2-3 cm along the antimesenteric edge.

EFFECT: said invention allows reducing the time of stoma formation, reducing the risks of stoma retraction into the abdominal cavity, creating conditions for closing the ileostomy in 3/4 without resorting to resection of the small intestine, reducing postoperative complications and thereby reducing the time of medical and social rehabilitation and increasing effectiveness of treatment.

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Description

The proposed invention relates to medicine, namely to abdominal surgery, and can be used in the formation of a double-barreled loop ileostomy if it is necessary to disable the passage of intestinal contents along the distal intestine.

The formation of a double-barreled loop ileostomy is one of the important components in the spectrum of surgical interventions for various benign and malignant diseases of the colon, requiring the shutdown of the passage of feces to the underlying departments. The formation of a loop preventive double-barreled ileostomy is used for low anterior resection of the rectum with the formation of a colorectal anastomosis, as well as for colproctomy with the formation of an ileo reservoir to "turn off" the section of the intestine with an anastomosis and create the best conditions for it for correct and faster healing, as well as reducing the consequences leakage of the anastomosis.

A known method of forming a double-barreled ileostomy according to Catell, when the ileum is removed from the abdominal cavity through an oblique incision in the right iliac region and crossed. The prepared ends of the intestines are brought out to different corners of the wound - leading to the lower, abducting - to the upper. The removed sections of the intestine are sutured to the parietal peritoneum, the space between them is sutured. Further, serous-musculocutaneous sutures are applied along the perimeter, the threads of which are then sutured to the free edge of the intestine, turning it inside out, creating a column 3-4 cm high. [Mikhailova E.V., Petrov V.P., Perehodov S.N. Intestinal stomas. Moscow: Nauka, 2006, pp. 35-36.].

The disadvantage of this method is the high risk of postoperative complications: ischemia and necrosis of the removed portion of the ileum, from which the stoma is formed; with the severity of subcutaneous adipose tissue, tension of the sutures between the skin and the parietal peritoneum is possible, which can lead to tissue ischemia, eruption of sutures and the development of infection in the form of an abscess or parastomic phlegmon;

There is a known method of forming an ileostomy according to Thornball, taken as the closest analogue, when the ileal loop is selected, a gauze holder is passed through the mesentery and with its help the loop is brought out through the circular ileostomy opening onto the anterior abdominal wall so that the adducting end is on top and the outgoing end is below, by turning the intestine 180 °. Then, around the circumference, the intestine is sutured with interrupted sutures to the skin so that there are 4-5 ligatures at the distal end of the loop, and 1-2 ligatures on the mesentery on both sides at the proximal end of the loop 5-7. The ligatures are not cut off. A transverse incision is cut through the intestine 1/2 -3/4 of the circumference closer to the abducent end of the loop, the wall of the proximal knee of the intestine is turned outward, and the left ligatures are used to stitch the edges of the incision of the intestinal wall through all layers. [Vorobiev G.I., Tsar'kov P.V. Basics of intestinal stoma surgery. / P.V. Vorobiev, G.I. Tsarkov, Stolny grad :, 2002. 115-118 p.].

The disadvantages of this method is a longer and technically more difficult stage of the ileostomy formation; in the absence of a fixation tube passed through the mesentery, there is a risk of suture eruption that fix the intestinal wall to the skin, which can lead to retraction of the stoma into the abdominal cavity; the inability to close the ileostomy with the formation of ileoileoanastomosis in 3/4, due to the reversal of the intestine and the formation of evaginate due to eversion of the intestinal mucosa.

Objectives: simplifying the formation and shortening the time of stoma formation, reducing the risks of stoma retraction into the abdominal cavity, creating conditions for closing the ileostomy in 3/4 without resorting to resection of the small intestine, reducing postoperative complications and thereby reducing the time and increasing the effectiveness of treatment, reducing the time medical and social rehabilitation, labor costs of medical personnel.

The essence of the invention is that the loop of the ileum is withdrawn avoiding a 180 ° turn, then perpendicular to the intestine, a rigid hypoallergenic tube or a plastic stick is passed in the avascular zone of the mesentery along the base of the loop to eliminate mobility and the risk of intestinal retraction into the abdominal cavity, then it is sutured using 2 sutures, each of which fixes the adduction and discharge knee of the intestine between each other and to the skin with the formation of a "spur", and after tying, in the second stage, the ends of the same thread fix the tube, then between these sutures the intestine is additionally sutured to the skin from both the sides of the tube with three horizontal U-shaped sutures, to create additional tightness between the skin wound and the intestinal wall, and after that with a longitudinal incision of 2-3 cm along the antimesenteric edge, the intestinal lumen is opened, while the intestine is not inverted and the edges of the intestinal incision are not fixed to the skin in order to create conditions for the formation of an anastomosis in 3/4 with the subsequent closure of the sludge eostomes.

EFFECT: during the formation of a preventive double-barreled ileostomy due to the absence of bowel reversal when the loop is removed and with the opening of the bowel lumen in the longitudinal direction without eversion and without fixing the edges of the bowel incision, the time of removal and formation of the stoma is reduced, as well as the creation of conditions for the formation of an anastomosis 3/4 during its subsequent closure, the use of 2 sutures, each of which fixes the adductor and discharge knee of the intestine between each other and to the skin with the formation of a "spur", and then the tube, the use of horizontal U-shaped sutures helps to achieve a better tight fit between a skin wound and intestinal wall, thereby reducing the number of sutures formed, which leads to a reduction in the time of surgical intervention, as well as a decrease in the percentage of early postoperative complications and the time of medical and social rehabilitation of the patient.

For clarity, there is a table of comparative analysis of the results of approbation of the method on 84 patients

For better understanding, the method is shown in: FIG. 1 - bringing the loop of the ileum to the anterior abdominal wall with a rigid hypoallergenic tube,

FIG. 2, FIG. 3, FIG. 4, FIG. 5, Fig. 6, FIG. 7 - the stages of fixing the adducting and abducting knees between themselves and to the skin,

FIG. 8 - Fixation with the ends of the same thread of a hypoallergenic tube,

FIG. 9, Fig. 10, Fig. 11, Fig. 12, Fig. 13 - the stages of additional suturing of the intestine to the skin from tube to tube on opposite sides with three horizontal U-shaped sutures,

FIG. 14 - open lumen of the intestine,

where item 1 is the loop of the ileum,

p. 2 - rigid hypoallergenic tube.

p. 3 - bowel adductor

p. 4 - bowel abduction knee

p. 5 - fixing the leading and abducting knees between themselves and to the skin with the formation of a "spur"

p. 6 - tube fixation

p. 7 - additional sutures fixing the intestine to the skin

p. 8 - the open lumen of the intestine.

The method is carried out as follows

Through the formed ileostomy opening, the selected loop of the ileum is brought out to the anterior abdominal wall (item 1) 3-4 cm above the skin level, avoiding a 180 ° turn, then perpendicular to the intestine, a rigid hypoallergenic tube (p .2) or a plastic stick to exclude mobility and the risk of retraction of the intestine into the abdominal cavity (Fig. 1), then suture it (Fig. 2) using 2 sutures, each of which fixes the adductor (Fig. 3, item 3 ) and the abducting knee (Fig. 4, p. 4) of the intestine between themselves and to the skin (Fig. 2, Fig. 5, Fig. 6, Fig. 7) with the formation of a "spur" (Fig. 7, p. 5) , and after tying, in the second stage, the ends of the same thread fix the tube (Fig. 8, item 6), then between these sutures the intestine is additionally sutured to the skin on both sides of the tube (item 7) with three horizontal U-shaped sutures ( Fig. 9, Fig. 10, Fig. 11, Fig. 12, Fig. 13), to create additional tightness between the skin wound and the intestinal wall, and after this, with a longitudinal section of 2-3 cm along the antimesenteric edge, the intestinal lumen is opened (Fig. 14, item 8), while the intestine is not inverted and the edges of the intestinal incision are not fixed to the skin in order to create conditions for the formation of an anastomosis in 3/4 with the subsequent closure of the ileostomy.

Example 1

Patient K., 63 years old, was admitted to the clinic with a diagnosis of Cancer of the lower neo-ampullar rectum. On October 22, 2018, the patient underwent surgery: Low anterior rectal resection with total mesorectumectomy, with the formation of an end-to-end sigmoidorectal anastomosis and the formation of a preventive loop extraperitoneal ileostomy. After processing the operating field with an incision from the xiphoid process to the pubis up to 40.0 cm long, the abdominal cavity was opened layer by layer. With the help of electrocoagulation along the interfascial spaces, the rectum is mobilized to the pelvic diaphragm along the posterior surface, lateral and, last of all, along the front (total mesorectumectomy). The neoplasm occupies the lumen of the lower ampullar rectum. Immediately behind the lower pole, an L-shaped clamp is applied to the rectum, the rectum is washed with 1000 ml of an antiseptic solution. A linear stapler is placed below the clamp. After suturing and crossing the rectum, the macro-preparation was removed as a single block. After mobilization of the left flexure of the colon, the stump of the sigmoid colon freely reaches the stump of the rectum. Through the end of the sigmoid colon, the anvil rod of the circular stapler stapler is held, reinforced with a purse string suture. With the help of an assistant anal sphincter divulsion. A circular stapler is inserted through the anus into the rectum. The stem is pushed through the center of the purse-string suture of the rectal stump. The anvil is attached to the stem. Anvil and head are brought together, staple seam. As a result, an end-to-end sigmoidorectal anastomosis is formed. In the right iliac region (in the middle of the distance between the umbilicus and the anterior superior spine of the ileum), at the outer edge of the rectus abdominis muscle of a rounded shape, the skin and subcutaneous tissue, aponeurosis, and peritoneum are dissected with a cut up to 2.5 cm in diameter. The loop of the ileum through the formed ileostomy opening was extracted into the wound to the anterior abdominal wall 4 cm above the skin level, without turning by 180 °, then perpendicular to the intestine, in the avascular zone of the mesentery along the base of the loop a rigid hypoallergenic tube was passed. The leading and abducting knees of the ileum are stitched together on both sides and to the skin with the formation of a spur with a single suture, which, after tying, the ends of the thread of the same suture fix the tube. The intestine is additionally fixed to the skin on both sides of the tube by three horizontal U-shaped sutures. The laparotomic wound was sutured tightly in layers, the aponeurosis with a continuous suture. Alcohol on the skin. Aseptic dressing. A longitudinal incision of 2 cm along the antimesenteric edge opened the lumen of the ileostomy. Installed colostomy bag. The postoperative period was uneventful, the small intestine peristalsis was restored and the intestinal contents entered six hours after the operation, the patient was activated on the 2nd day after the operation and moved freely on the 5th, minor pain syndrome in the early postoperative period was stopped by non-narcotic analgesics and by 8 -day the patient was discharged home in satisfactory condition. With further follow-up for 1.5 months, no complications (evagination, infringement of the stoma, parastomal hernia) from the side of the formed preventive double-barreled ileostomy were detected. 12/10/2018 surgical treatment - closing a loop double-barreled ileostomy with the formation of an anastomosis at 3/4.

Example 2

Patient A., 56 years old, was admitted to the clinic with a diagnosis of Cancer of the mid-ampullar rectum. On August 14, 2019, the patient underwent surgical treatment: Low anterior rectal resection with total mesorectumectomy, with the formation of a sigmoidorectal anastomosis end-to-end and the formation of a preventive loop extraperitoneal ileostomy.

After processing the operating field with an incision from the xiphoid process to the pubis up to 30.0 cm long, the abdominal cavity was opened layer by layer. With the help of electrocoagulation along the interfascial spaces, the rectum was mobilized to the pelvic diaphragm along the posterior surface, lateral and anterior (total mesorectumectomy). The neoplasm occupies the lumen of the mid-ampullar rectum. Immediately behind the lower pole, an L-shaped clamp is applied to the rectum, the rectum is washed with 1000 ml of an antiseptic solution. A linear stapler is placed below the clamp. After suturing and crossing the rectum, the macro-preparation was removed as a single block. Without mobilization of the left flexure of the colon, the stump of the sigmoid colon freely reaches the stump of the rectum. Through the end of the sigmoid colon, the anvil rod of the circular stapler stapler is held, reinforced with a purse string suture. With the help of an assistant anal sphincter divulsion. A circular stapler is inserted through the anus into the rectum. The stem is pushed through the center of the purse-string suture of the rectal stump. The anvil is attached to the stem. Anvil and head are brought together, staple seam. As a result, an end-to-end sigmoidorectal anastomosis is formed. In the right iliac region (in the middle of the distance between the navel and the anterior superior spine of the ileum), at the outer edge of the rectus abdominis muscle of a rounded shape, the skin and subcutaneous tissue, aponeurosis, and peritoneum are dissected with a cut up to 2 cm in diameter. The loop of the ileum through the formed ileostomy opening was extracted into the wound on the anterior abdominal wall 3 cm above the skin level, without turning by 180 °, then perpendicular to the intestine, in the avascular zone of the mesentery along the base of the loop, a plastic stick was held. The leading and abducting knees of the ileum are stitched together on both sides and to the skin with the formation of a spur with a single suture, which, after tying, the ends of the thread of the same suture fix the tube. The intestine is additionally fixed to the skin on both sides of the tube by three horizontal U-shaped sutures. The laparotomic wound was sutured tightly in layers, the aponeurosis with a continuous suture. Alcohol on the skin. Aseptic dressing. A longitudinal incision of 3 cm along the antimesenteric edge opened the lumen of the ileostomy. Installed colostomy bag.

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 7 -day the patient was discharged home in satisfactory condition. With further follow-up for 2 months, no complications (evagination, infringement of the stoma, parastomal hernia) from the side of the formed preventive double-barreled ileostomy were detected. 10/16/2019 surgical treatment - closure of the loop double-barreled ileostomy with the formation of an anastomosis at 3/4.

Claims (1)

A method of forming a loop preventive double-barreled ileostomy, including the removal of the loop of the ileum to the anterior abdominal wall, characterized in that the loop of the ileum is removed, avoiding a 180 ° turn, then perpendicular to the intestine in the avascular zone of the mesentery, a hypoallergenic tube is passed along the base of the loop, then a plastic stick is passed the adducting and abducting knees of the ileum are stitched together and to the skin with a single suture to form a spur, and after tying, in the second stage, a tube or a plastic stick is fixed with the ends of the same thread, then the intestine is additionally sutured to the skin on both sides of the tube with three horizontal p- shaped sutures, and then with a longitudinal incision of 2-3 cm along the antimesenteric edge, the intestinal lumen is opened.

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