RU2790526C1 - Single-bore intestinal stoma forming method - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to colorectal surgery. Stoma canal is created through anterior leaflet of rectus abdominis vagina, thickness of rectus abdominis muscle while maintaining integrity of posterior leaflet of rectus abdominis vagina at equal distance from white and semilunar lines and equal distance from the adjacent tendinous bridges of rectus abdominis muscle. The rectus abdominis vagina lateral wall is dissected. The space between the internal oblique and transverse abdominal muscles is created up to the level of the anterior axillary line where the stoma canal internal opening is formed and mobilized intestine is passed to the anterior abdominal wall via the opening.

EFFECT: invention provides for avoiding parastomal hernia formation without using mesh implants, preserving the anterior abdominal wall muscular-aponeurotic framework structures, ensuring the intestinal stoma proper functioning, improving quality of patient's life.

1 cl, 1 ex

Description

The invention relates to medicine, namely to colon surgery, and can be used in the formation of a permanent terminal intestinal stoma.

Despite the dynamic development of colorectal surgery and the introduction of sphincter-preserving methods of surgical treatment, at least 11% of patients with colorectal cancer (CRC) end up with permanent colostomy. The main complication of permanent terminal intestinal stoma is parastomal hernia (PSH) with a development rate of about 50%. According to specialized literature, at least half of PSG occurs within the first 2 years after surgery, while the risk of hernia development remains high throughout the patient's life.

Parastomal hernia is a factor that complicates the care of intestinal stoma, reduces the quality of life of patients, and often leads to impaired bowel function. In addition, like all ventral hernias, parastomal hernias can lead to strangulation of the intestine in the hernial sac, often requiring emergency surgery.

In order to prevent parastomal hernia, Goligher J.C. in 1958 he proposed a method for the formation of an extraperitoneal end intestinal stoma, which consisted in the formation of a retroperitoneal stoma canal [1]. In this case, intra-abdominal pressure does not push the intestine into the stomal canal, but rather presses it against the anterior abdominal wall. In addition, the length of the stomal canal is significantly increased, to the walls of which the intestine carrying the stoma is additionally fixed. This technical solution has significantly reduced the number of parastomal hernias [2].

The significance of the density of fixation of the intestine carrying the stoma in the stomal canal is noted by many experts. In this regard, the technique of forming the stomal canal through the thickness of the rectus abdominis muscle (“transrectal stoma”) has become widespread. Meta-analysis data did not reveal the advantages of this approach [3].

Critically considering the described approaches, it should be noted that their implementation still retains the main factor in the formation of parastomal hernia - the presence of a through defect in the anterior abdominal wall, which in essence is a model of a hernia ring.

A common drawback of the known methods of forming intestinal stomas is the search for a technical solution that takes into account the distribution of intra-abdominal pressure only in the sagittal projection, while according to Laplace's law, the pressure is distributed in three projections. The muscles of the abdominal wall are interconnected by tendon sprains, balancing each other from opposite sides. From the point of view of clinical anatomy, the most critical points of the structural integrity of the anterior abdominal wall are the linea alba and lunate and the points of attachment of the tendon bridges of the rectus muscles to them.

The desire to be as sparing as possible to the muscular-aponeurotic skeleton of the anterior abdominal wall, as the main factor preventing the formation of parastomal hernias, was reflected in the method of Hamada M., et al. [4]. which became the prototype of the proposed method. The authors formed the stomal canal transrectally, while the posterior leaf of the sheath of the rectus abdominis muscle was preserved and only its lateral wall was dissected. Despite the attractiveness of this method, it is necessary to take into account the fact that the length of the retromuscular stomal canal increases slightly, by only 5-7 cm. through stomal canal.

The purpose of the invention:

- to improve the quality of life of patients with single-barreled (terminal) intestinal stomas by reducing the risk of developing parastomal hernias.

This goal is achieved by bringing the intestine to the anterior abdominal wall through the stomal canal, formed in the horizontal direction from the anterior axillary line to a point located at an equal distance between the semilunar line and the median line, and also at an equal distance between the two tendon bridges of the rectus abdominis muscle. In this case, the stomal canal is formed in the avascular space between the internal oblique and transverse abdominal muscles, as well as between the posterior leaf of the sheath of the rectus abdominis muscle and the rectus abdominis muscle itself. Preservation of the main elements of the muscular-aponeurotic skeleton of the anterior abdominal wall, as well as the preservation of the neurovascular structures of the anterior abdominal wall, can significantly reduce the risk of developing parastomal hernia.

Operation technique:

In the preoperative period, the place of removal of the terminal intestinal stoma is marked on the skin, in the place most convenient for fixing the colostomy bag and direct visual control of the stoma by the patient. Then, an ultrasound examination of the anterior abdominal wall is performed, in which the semilunar line, midline and tendon bridges of the rectus abdominis are marked. After that, the place of passage of the intestine through the rectus abdominis muscle is marked at a point located at an equal distance between the tendon bridges of the rectus abdominis muscle - in the vertical direction and between the midline of the abdomen and the semilunar (spigelian) line - in the horizontal direction. The location of the stomal opening and the transrectal stomal canal may not coincide, since the first is usually located closer to the lateral edge of the rectus abdominis muscle, and the second is located in the middle of the distance between the midline and semilunar lines.

After resection of the colon, an intestinal segment is formed of sufficient length, at least 20 cm, with adequate blood supply and mobility for free removal to the anterior abdominal wall.

An incision is made in the skin and subcutaneous tissue in a previously determined place of the stomal opening, with a length corresponding to the diameter of the intestine displayed on the anterior abdominal wall. After that, the wound is displaced medially with Farabef hook retractors, to the projection of the previously marked transrectal stomal canal. Here, the anterior leaf of the sheath of the rectus muscle is dissected in the vertical direction over an extent equal to the diameter of the intestine brought to the anterior abdominal wall with the preserved part of the mesentery. The fibers of the rectus muscle are separated by a clamp along the incision of the anterior leaf of the sheath of the rectus abdominis muscle and its posterior leaf is preserved. The retractor-hooks of the Farabeus are inserted into this defect and the lateral portion of the rectus abdominis muscle is taken up and towards the semilunar line, exposing the lateral edge of the sheath of the rectus abdominis muscle. Then it is dissected frontally, penetrating into the avascular space between the transverse abdominal muscle and the internal oblique muscle of the abdomen and, further, forming the stomal canal in this space in the lateral direction to the anterior axillary line with a width sufficient for free passage of the intestine with the adjacent part of the preserved mesentery. A Luer clamp is inserted into the formed stomal canal and, at the level of the anterior axillary line from the side of the abdominal cavity, the peritoneum and transverse fascia are dissected in the horizontal direction, and then the fibers of the transverse abdominal muscle are moved apart for an extent sufficient to pass the intestine with the mesentery. The Luer clamp from the stoma canal penetrates into the abdominal cavity, they capture the mobilized segment of the colon and bring it to the anterior abdominal wall. Assess the blood supply of the withdrawn segment and the absence of its tension. The removed intestine is opened and skin-intestinal sutures are applied.

Clinical example:

Patient N was admitted with complaints of red blood discharge during defecation.

According to the clinical and instrumental examination, the patient was diagnosed with cancer of the lower ampullar rectum T ₄ N _x M ₀ with the transition to the anal canal.

The patient underwent surgery in the amount of extralevator abdominoperineal extirpation, the terminal stoma was formed by the proposed method. The postoperative period proceeded without complications. There was no pain syndrome at the site of removal of the stoma and the stomal canal. Postoperative wounds healed by primary intention. The stoma functioned well. Was discharged on the 12th day.

The observation period was 6 months. The function of the stoma is satisfactory. There are no data for parastomal hernia and recurrence of the disease.

The proposed method, in comparison with the known methods of forming single-barreled intestinal stomas, makes it possible to maximally preserve the structures of the muscular-aponeurotic frame of the anterior abdominal wall, reduce the risk of developing parastomal hernia and ensure the normal function of the intestinal stoma.

Bibliography:

1. Goligher J.C. Extraperitoneal colostomy or ileostomy. BrJ Surg. 1958;46:97-103.

2. Wang FB, Pu YW, Zhong FY, Lv XD, Yang ZX, Xing CG. Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route versus transperitoneal route. A meta-analysis of stoma-related complications. Saudi Med J. 2015 Feb;36(2):159-63. doi: 10.15537/smj.2015.2.10203. PMID: 25719578; PMCID: PMC4375691.

3. Kroese LF, de Smet GH, Jeekel J, Kleinrensink GJ, Lange JF. Systematic Review and Meta-Analysis of Extraperitoneal Versus Transperitoneal Colostomy for Preventing Parastomal Hernia. Dis Colon Rectum. 2016 Jul;59(7):688-95. doi: 10.1097/DCR.0000000000000605. PMID: 27270522.

4. Hamada M, Nishioka Y, Nishimura T, Goto M, Furukita Y, Ozaki K, Nakamura T, Fukui Y, Taniki T, Horimi T. Laparoscopic permanent sigmoid stoma creation through the extraperitoneal route. Surg Laparosc Endosc Percutan Tech. 2008 Oct;18(5):483-5. doi: 10.1097/SLE.0b013e3181805729. PMID: 18936671.

Claims (1)

A method for forming a single-barreled intestinal stoma based on exposing the intestine to the anterior abdominal wall, characterized in that the stomal canal is created through the anterior sheet of the sheath of the rectus abdominis muscle, the thickness of the rectus abdominis muscle while maintaining the integrity of the posterior sheet of the sheath of the rectus abdominis muscle at an equal distance from the white and lunate lines and equal distance from adjacent tendon bridges of the rectus muscles, dissect the lateral wall of the sheath of the rectus abdominis muscle, create a space between the internal oblique and transverse abdominal muscles to the level of the anterior axillary line, where an internal opening of the stomal canal is formed, through which the mobilized intestine is passed to the anterior abdominal wall .