RU2793389C1 - Method for closing a single-barrel ileostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin is excised with two bordering incisions around the ileostomy, subcutaneous fat - with excision of scar tissue between the intestinal wall and the skin. The distal end of small intestine is isolated in the form of a "proboscis" 4 cm long with mucosa inverted and blood supply preserved, which is sutured with single-row interrupted serous-muscular sutures transversally to the wall of the large intestine with invagination of the "proboscis" into the lumen of the colon through a 2.5-cm long transverse incision 0.5 cm away from the line of previously applied sutures. Single-row interrupted serous-muscular sutures are applied around the formed anastomosis.

EFFECT: method ensures reduction of the surgery time and its traumatism, prevention of reflux of large intestine contents into the small intestine, reduces postoperative complications due to preservation of blood supply to the intestinal wall, prevents stenosis and scarring of the anastomosis.

1 cl, 3 dwg, 1 ex

Description

SUBSTANCE: invention refers to medicine, namely to surgery of the large and small intestine, and concerns methods for forming invaginated areflux small-colon anastomoses, and can be used to eliminate functioning ileostomies.

A revolution in the technique of forming loop ileostomies occurred in 1952, when Brooke applied and subsequently published a technique for removing and disassembling the ileostomy so that the intestinal part of the small intestine protruded several centimeters above the level of the skin, creating a "column". For this, the method of comparing the serous membranes of the excreted small intestine and its evagination was used, followed by suturing of the mucous membrane of the small intestine to the skin of the anterior abdominal wall.

Medical rehabilitation of patients who have undergone various surgical interventions is one of the priority tasks of modern surgery. A special position is occupied by the problem of surgical rehabilitation of stoma patients.

The elimination of intestinal stomas is a key moment that allows the patient to cross the barrier of psycho-social discomfort and return to their usual way of life and work.

The existing opinion about the satisfactory function of the most commonly used in clinical practice longitudinal, and even more so end-end ileotransversal anastomoses (ITA) is very erroneous, as evidenced by the studies of many authors [Ya.D. Vitebsky 1973; A.G. Nikitenkov 2004: N.A. Nikitin 2012: A.V. Plekhov 2009]. Removal of the ileocecal region, which in its essence is a valvular apparatus of absolute barrier action, which regulates the portioning of the flow of small intestine contents into the large intestine and protects the small intestine from reflux of aggressive colonic contents saturated with bacterial flora, leads to serious violations of the functions of the digestive tract: the development of secondary enteritis, dysbacteriosis , the occurrence of syndromes of excessive colonization of the small intestine and malabsorption [E.A. Belousov 2009: G.S. Mikhailyants 2015]. Restoration of continuity of the intestinal tube is due not only to the risk of developing traditional complications (insufficiency of anastomotic sutures, intestinal obstruction), but also to the likelihood of microbial colonization of the small intestine. In the long term, these patients complain of frequent loose stools, bloating, loss of appetite and body weight. These phenomena are due to the damaging effect of reflux of colonic contents on the mucous membrane of the small intestine with the development of reflux enteritis [S.B. Abuzhabbarov 2006: S.S. Maskin, V.I. Egorov, A.I., Starovidchenko 2000: S.N. Navruzov. S.B. Abdujabborov 2003: S.Anwar, S.Hughes, AJ.Eadie 2004].

There are three main ways to form an anastomosis between the small and large intestine - end to side, side to side, end to end (Kulikov V.P. Sazhin V.P., Baglikov V.D. et al. Comparative analysis of various options for small intestine anastomoses / / Russian Journal of Oncology 2001, No. 1. S. 29-32). At the same time, many authors talk about disorders that occur in the small intestine due to the ingress of aggressive colonic contents into it.

Small-colonic anastomosis with right-sided hemicolectomy is the most difficult of all types of inter-intestinal fistulas, as it involves the connection not only of two intestines that are different in function and diameter, but also, to some extent, replenishment of the function of the remote ileocecal valve. Most authors have now come to understand the need to create a damper function in the formation of the small-colonic fistula.

Known "proboscis" anastomoses M.A. Kimbarovsky (M.A. Kimbarovsky // Surgery. - 1950, No. 9. - S. 26-29; A.M. Ganichkin. Colon cancer. - L., 1970), submersible anastomoses of Ya.D. Vitebsky (Ya.D. Vitebsky. Essays on surgery of the ileocecal intestine. M., 1973). In 2003 Tretyakov A.A., Kagan I.I., Nikitenkov A.G. proposed end-to-side invaginated ileotransverse anastomosis (patent for invention No. 2215482 dated 11/10/2003) and end-end invaginated ileotransversoanastomosis (patent for invention No. 2218100 dated 10.12.2003). In 2009, Nikitin N.A. and Plekhov A.V. a method was proposed for the formation of an invaginated ileotransverse anastomosis, in which the intussusception of the "proboscis" of the small intestine is carried out with its controlled eversion and complete adaptation of the mucous layers of the small and large intestine through the use of single-row three-stitch sutures (Nikitin A.V., Plekhov A.V. Method of formation small-colonic anastomosis // Patent for the invention of the Russian Federation No. 2373872 dated 11/27/2009). The method for the formation of ileotransverse anastomosis, proposed by V.I. Onopriev and described in the monograph by Yu.S. Gilevich and V.I. Onoprieva [Yu.S. Gilevich, V.I. Onopriev. Anastomoses in abdominal surgery. - Stavropol book publishing house, 1978. - p. 148-168]. The anastomosis was formed within the haustra of the transverse colon, at least 4 cm in transverse size. Anastomosis is performed in the haustra between the free and omental bands with a 3-row precision serous-muscular-submucosal suture.

There is also a known method for the formation of ileotransverse anastomosis according to Nikitin. Immediate results of the use of various methods for the formation of ileotransverse anastomosis in right-sided hemicolectomy in oncological practice (Glushkov E.A., Nikitin N.A., Ivanov A.D., Kislichko S.A.). The method was performed as follows. On the distal part of the anastomosed small intestine, a "proboscis" 3.5-4 cm long with a portion of the mesentery and a terminal feeding vessel was formed. The colon was transversely dissected between the tenia to a length exceeding the diameter of the small intestine by 2-3 mm. Small intestinal "proboscis" was invaginated into the lumen of the colon with fixation of the latter to the walls of the colon with interrupted sutures. At the same time, intussusception of the small bowel "proboscis" into the lumen of the colon was performed simultaneously with its controlled eversion and complete adaptation of the muco-submucosal layers of the small and large intestines through the use of single-row three-stitch invaginating interrupted sutures. Each of the seams was formed as follows. The first stage was longitudinal serous-muscular suturing of the small intestine wall 0.5-0.6 cm wide along the proximal border of the proboscis. The second stage at a distance of 0.5-0.6 cm from the free edge of the "proboscis" was carried out serous-submucosal stitching of the intestinal wall with a puncture into the free edge of the "proboscis". At the third stage, the wall of the large intestine was captured into the suture with marginal submucosal-serous stitching 0.5-0.6 cm wide. As the first sutures, two sutures were placed on both sides of the proboscis mesentery and one suture was placed along its protivomesenteric edge. Then formed the anterior and posterior lips of the anastomosis. Known methods have a number of disadvantages: - three-row sutures, even precision ones, can disrupt adequate blood supply to the intestinal wall in the area of the intestinal wound, which leads to the formation of necrosis areas, creates conditions for the penetration of microflora into the anastomosis zone. The invaginated valve in some cases undergoes scarring, wrinkling, which ultimately leads to stenotic deformation of the anastomosis or amputation of the valve (the invaginated area of the ileum). As a prototype, we adopted the method of forming a transverse invagination small-colonic anastomosis end-to-side according to Ya.D. Vitebsky (Ya.D. Vitebsky. Valve anastomoses in surgery of the digestive tract. M., 1988). To apply this anastomosis, the end of the small intestine is placed on the anterior wall of the large intestine. The walls of the intestines are sutured with two gray-serous sutures, which are fixed near the mesenteric and anti-mesenteric edges of the small intestine. Then intermediate sutures are applied. From the edge of the stump to the anastomosis there should be a distance of 8-10 cm. The length of the small intestine "proboscis" is 4 cm in an adult. Parallel to the first row of gray-serous silk sutures, a second row of gray-serous sutures is applied with atraumatic needles. Before opening the lumen of the large intestine, two “traps” sutures are performed that connect the anterior walls of the future anastomosis. The large intestine is dissected strictly transversely at a distance exceeding by 0.1 cm in both directions the semicircle of the small intestine. The free end of the small intestine (“proboscis” is immersed in the large intestine, after which it is immediately tightened and sutures - “traps” are tied. Synthetic sutures - “traps” are supplemented with intermediate sutures, after which the anastomosis is completed with the second floor of silk knotted sutures.

The prototype has several disadvantages:

- the use of 2- and 3-row sutures promotes ischemia of the intestinal wall in the anastomosis zone and healing proceeds according to the secondary type;

- on the serous membrane of the ileum, immersed in the lumen of the colon, an inflammatory process develops, after which relief, scar tissue forms in the anastomosis zone, a rough rigid ring is formed, narrowing the lumen of the anastomosis and violating not only its areflux function, but also complicating the evacuation of the contents.

The objective of the invention is to develop a design of small-colonic anastomosis, which has an areflux function, while not disturbing the blood supply to the intestinal wall, not causing stenosis and scarring of the anastomosis.

The aim of the invention is to reduce the time of the operation and its trauma, to prevent the reflux of colonic contents into the small intestine.

This goal is achieved by excising the skin, subcutaneous fat with excision of scar tissues between the intestinal wall and skin with two bordering incisions around the ileostomy, isolating the distal small intestine in the form of a "proboscis" 4 cm long with everted mucosa and preserved blood supply, which is sutured single-row interrupted serous-muscular sutures in the transverse direction to the wall of the colon with invagination of the "proboscis" into the lumen of the colon through a transverse incision 2.5 cm long at a distance of 0.5 cm from the line of previously applied sutures, followed by the imposition of single-row nodal serous-muscular sutures around the formed anastomosis.

The novelty in the method is that the stump of the small intestine in the form of an already formed "proboscis" with preserved blood supply is freely immersed in the lumen of the colon and one row of serous-muscular sutures is applied, which reduces the operation time.

This method of forming an invaginated small-colonic anastomosis has high mechanical and biological tightness, the healing of the anastomosis occurs by primary intention, the isolated ileostomy is a ready-made “proboscis” with everted mucosa and adequate blood supply, which, when immersed in the transverse colon, plays the role of a valve that prevents reflux contents of the large intestine into the small intestine.

When performing small-colonic anastomosis, adequate blood supply to the stump of the small intestine is achieved.

The stated essence of the invention is illustrated by drawings, where:

Fig. 1 - isolation of the ileostomy in the form of a finished "proboscis".

Fig. 2 - suturing of the isolated ileostomy with single-row interrupted serous-muscular sutures in the transverse direction to the wall of the colon.

Fig. 3 - invagination of the "proboscis" into the lumen of the colon through a transverse incision with the imposition of single-row interrupted serous-muscular sutures around the formed anastomosis.

The proposed method was operated on 5 patients in the surgical department of CHUZ KB "RZD-Medicine", Astrakhan.

Examples of the clinical implementation of the method: Example No. 1. Patient P., aged 62, was hospitalized in the surgical department of the CHUZ "KB" RZD-Medicine ", Astrakhan. She was admitted with complaints about the presence of a functioning single-barrel ileostomy. Decreased quality of life. From the anamnesis: operated a year ago for perforation of the terminal ileum. Resection of the distal small intestine and removal of the ileostomy in the right half of the abdominal wall were performed. The protocol of the operation: under anesthesia with two bordering incisions around the ileostomy, the skin and subcutaneous fat were excised to the intestinal wall, followed by its mobilization from cicatricial adhesions (Fig. 1). The dome of the caecum is brought into the wound. The distal small intestine in the form of a finished "proboscis" 4 cm long, bearing a labial fistula in the form of a "papilla" with preserved blood supply, is sutured with single-row interrupted serous-muscular sutures in the transverse direction to the wall of the large intestine (Fig. 2) with invagination of the "proboscis" in the lumen of the colon through a transverse incision 2.5 cm long at a distance of 0.5 cm from the line of previously applied sutures, followed by the application of single-row interrupted serous-muscular sutures around the formed anastomosis (Fig. 3). Stitches on the wound. The postoperative period proceeded without complications. The sutures were removed on the 8th day. Discharged for outpatient observation in a satisfactory condition.

The proposed method of closing the ileostomy has an advantage over the known ones, it eliminates the reflux of the contents into the small intestine, thereby preventing the development of postoperative complications. This anastomosis is technically simpler and less traumatic. Using the method allows to improve the immediate results of the operation: to prevent the development of anastomosis. When using the method, the long-term results of the operation are also improved: reflux of the contents of the large intestine into the small intestine and the development of cicatricial changes in the anastomosis zone are excluded.

There were no anastomotic leaks in the operated patients; all the imposed anastomoses performed an areflux function, which was confirmed by X-ray and endoscopic studies.

The proposed method can be recommended for use in clinical practice to eliminate a functioning ileostomy.

Claims (1)

A method for closing a single-barrel ileostomy, including the formation of an invaginated areflux small-colonic anastomosis, characterized in that two fringing incisions around the ileostomy excise the skin, subcutaneous fat with excision of scar tissues between the intestinal wall and skin, and allocate the distal small intestine in the form of a "proboscis" 4 cm long with inverted mucosa and preserved blood supply, which is sutured with single-row interrupted serous-muscular sutures in the transverse direction to the wall of the colon with invagination of the "proboscis" into the lumen of the colon through a transverse incision 2.5 cm long at a distance of 0.5 cm from the line previously applied sutures, followed by the imposition of single-row interrupted serous-muscular sutures around the formed anastomosis.

Images