RU65724U1 - DEVICE FOR THE FORMATION OF ENTEROSYSTURETAL ANASTOMOSIS - Google Patents

Abstract

The utility model relates to medical equipment, devices for the formation of anastomoses of the urethra with a U-shaped urinary reservoir with orthotopic plastic of the bladder.

In order to reduce the number of complications caused by excessive trauma to stitched tissues and the failure of sutures in the device for forming an urethral anastomosis with a U-shaped reservoir containing a rod with a curved working end, three working angles were made at an angle of 120 degrees to each other and three 2 mm deep channel. 1 FIG.

Description

The utility model relates to medical equipment, devices for the formation of an anastomosis of the urethra with a U-shaped urinary reservoir with orthotopic plastic of the bladder.

Closest to the proposed is a device containing a rod with a curved working end (AS. USSR 212459, Bulletin No. 9 of 11.29.1968). However, its use in the formation of anastomoses is associated with a number of complications, such as the possibility of through flashing, wounding the urethra, the failure of the sutures between the urethra and the U-shaped urinary reservoir.

A new technical task is to reduce the number of complications caused by excessive trauma to stitched tissues and the failure of stitches.

To solve this problem, in a device containing a rod with a curved working end, three channels 2 mm deep are made at an angle of 120 degrees to each other at the working end, and are arranged longitudinally to his body.

The device shown in Fig. 1 contains a rod 1 with a curved working end 2, at the working end 2 are made at an angle of 120 degrees to each other evenly around its circumference and three channels 3, 2 mm deep, arranged longitudinally to his body. The device operates as follows:

Indications:

Cystectomy with distal resection of the urethra (large prostate gland, previous surgery in this area)

Multi-stage operations (difficulties in isolating the urethral stump, the risk of urinary incontinence)

Cystectomy in women with preservation of the urethra

After performing the main stages of the operation - bladder plasty, including the formation of the urinary reservoir from the ileum, they begin to form an enterocysto-urethral anastomosis, for which two rows of sutures are applied: the first connects the urethral edge of the urinary reservoir and the proximal edge of the urethra, the second connects the edges of the urethra the serous-muscular layer of the cuff of the urinary reservoir and the urethra.

The first row of sutures is performed as follows: to increase the convenience and reliability of the manipulation, the proposed device is introduced into the urethra (Fig 1), containing

a rod 1 with a curved working end 2 provided with channels 3 arranged on it at an angle of 120 degrees to each other and arranged longitudinally to its body, which serve as guides when suturing. Seams are placed at 2, 6 and 10 hours of the conditional dial. To perform each of the stitches, the needles are inserted into the urethra wall from the outside, through the corresponding channel 3 of the device proposed, through adjacent tissues 5-7 mm from its proximal edge, then the needle through the mucous membrane is passed into the guide channel of the device and removed from urethral lumen. After that, the needle is brought from the inside to the wall of the urethral part of the urinary reservoir and punctured outward 2 mm from its edge. Next, the needle is again immersed in the lumen of the urethra, passed through the wall of the urethra from the inside out, having a puncture point 2 mm from its proximal edge. After completing, in the same way, the other two sutures, the threads are pulled and the sutures are tied, while the urethral mucosa is moved into the urethral lumen and fixed to the urethral wall from the inside.

Then perform the second row of three seams located at 12; 4 and 8 hours around the circumference according to the conditional dial (Fig 4). by injecting at a distance of 1-2 mm from the edge of the serous-muscular layer of the cuff and the proximal edge of the urethra. For this, the device is removed from the urethra and a 14Fr catheter is inserted into the lumen of the urinary reservoir (Fig. 5).

Example:

Betenekov A.P., 58 years old, has been observed at the Scientific Research Institute of the TSC since 2004 with a diagnosis of Bladder Cancer T2N0M0, condition after combined treatment. Histology No. 9095-9119 of 05.25.06. Transitional Cr, moderately differentiated.

An anamnesis of the disease since 2003, when the first episode of macrohematuria occurred; first sought medical attention with complaints of urinary bleeding in 2004. During the examination: in the general blood test - a moderate decrease in hemoglobin to 105 g / l; in the biochemical analysis of blood, an increase in creatinine level to 115 mmol / l was noted, in the general analysis of urine - completely erythrocyte masses. Cystoscopically determined the presence of copiously bleeding villous tumor formation, located circularly in the neck of the bladder, more on the left, because of which the mouth of the left ureter was not visualized. Ultrasound examination of the abdominal organs revealed no data for distant and regional metastasis. An X-ray examination of the chest organs of the pulmonary pathology was not established. With iv excretory urography, data for impaired passage of urine from the upper urinary tract have not been established.

At the initial examination, the diagnosis was established: transitional cell carcinoma of the bladder T2-3? NxM0, about which the patient was given 2 courses of systemic x \ t according to the M-VAC scheme in preoperative mode. Against the background of chemotherapeutic treatment, local progression of the process was noted, with no signs of systemic progression. During the control cystoscopic examination, further spread of the tumor to the left side wall of the bladder was established. In this regard, on May 18, 2005, the patient underwent surgical treatment in the amount of radical cystectomy, bilateral ureterocutaneostomy, and bilateral pelvic lymphatic dissection. Macro drug: bladder with prostate gland and this. bubbles. In the removed cellulose, there is clearly no metastatic l \, cellulose tissue on the left with symptoms of edema and inflammation. On a section - the neck and the left side wall of the bladder are occupied by a tumor, possibly sprouting the left mouth of the ureter. Conclusion: bladder cancer, T2-4? No-xM0. After a planned histological examination, the final stage of the tumor process, T2N0M0, was established. Within 6 months after surgical treatment during the follow-up examination, data for local recurrence and systemic progression of the tumor process were not obtained.

09/27/2006, the patient underwent a stage of reconstructive-plastic surgical treatment in the volume of orthotopic intestinal plastic surgery of the bladder with a fragment of the ileum of the ileum with a U-shaped reservoir of low pressure with a cuff from the serous-muscular layer, urethral tube and enterocysto-urethral anastomosis, according to the proposed method.

The position of the patient on the operating table with the extension in the sacral region. The surgical field was processed according to Grossikh-Filonchikov. Under THES, a median laparotomy, revision of the abdominal cavity was performed. In the projection of the bladder, a tumor-like formation of stony consistency on the right wall in the prostate gland. Manipulation in the abdominal cavity is significantly difficult due to the large amount of fatty tissue. The peritoneum from the navel is cut out by a triangle with the capture of urachus, vas deferens and the wall of the bladder. Both ureters are secreted below the iliac vessels and are crossed, intubated, with silicone catheters. The ureters are thin, 10 Fr. catheters are difficult to hold. With some technical difficulties, due to the large size of the bladder and the severity of paravesical tissue, mobilization of the lateral walls of the bladder with ligation of the upper and lower vesical vascular complexes was performed. The internal pelvic fascia was dissected on both sides, the pubic-prostatic ligaments were ligated and crossed, and the dorsal venous complex was treated. A bougie of 28 Fr was inserted into the urethra;

The bordering sections highlight the urethral wall to a depth of 5 mm (to prevent ischemia of the urethral tissue), then the tissue of the proximal end of the urethra is excised and its lumen is opened. The complex - the bladder with paravesical tissue, prostate, seminal vesicles and the adjacent peritoneum is removed. A lymphadenectomy was performed, on both sides, no clearly enlarged lymph nodes were detected, the proximal border at the level of bifurcation of the iliac arteries.

Retreating 20 cm from the ileocecal angle, a graft 60 cm long was cut out from the ileum, it was detubularized and reconfigured with a U-shaped graft to form a urethral tube up to 5 cm long with a funnel shape. The urethral part of the urinary reservoir is formed in such a way that a 12-14 Fr. catheter should pass freely into the lumen. The mucous membrane of the urethral end is captured by a soft non-crushing clamp, stretched and peeled in an acute way at the level of the submucosal layer. The muscular-serous layer is wrapped up for about 8 mm, so that a cuff is formed, which is fixed by three serous-serous sutures to the proximal wall of the urethral tube.

Anastomosis was performed according to the proposed method: the sutures were laid in two rows to reduce the likelihood of developing ischemia in the area of the anastomosis. The first row of seams - three seams were placed at 2, 6 and 10 hours of the conditional dial. The needle was injected outside the urethra, through adjacent tissues at a distance of 5-7 mm from the urethral wall, and the needle was injected through its lumen outward at a depth of about 5 mm. To facilitate the removal of the needle outside, we used the proposed device

The needle was passed through the mucosa, so that it fell into the corresponding guide channel 3 of the proposed device and removed from the urethral lumen to the mucosa at a distance of 2 mm from the urethral edge of the urinary reservoir. Further, the needle was again immersed in the urethral lumen, drawn through the inside of the urethra from the outside to the point of injection at a distance of 2 mm from the proximal edge of the urethra, when this suture was tightened, the mucous membrane of the urethral tube was moved into the urethral lumen and fixed to the urethral wall from the internal side. Two other seams from this row were similarly made. Next, a second row of 3 seams was performed. To do this, the device was removed from the urethra, a catheter of HFr size was inserted into the lumen of the urinary reservoir. The injections were carried out at 12, 4, 8 hours of the conditional dial. The needle was drawn between the serous-muscular edge of the cuff of the urinary reservoir and the proximal edge of the urethra at a distance of 1-2 mm from the edge, on the one and, accordingly, on the other hand. For

prevention of torsion, kink of the urethral tube with anastomosis, the anterior wall of the reservoir with two sutures is fixed to the periosteum of the pubic bones.

Anastomosis of ureters with a transplant according to Nesbit on modeling catheters. The ureteral drainage tubes and the Petzer catheter are removed through the front wall of the graft. Control of tightness and hemostasis. Two tubular drainage through the iliac region into the pelvis. Suturing an operating wound Aseptic dressing.

The urethral catheter was removed 16 days after surgery (2 days after removal of the cystostomy catheter).

In total, according to the proposed method, 15 patients were operated on.

Complications associated with the failure of the anastomosis, the formation of external and internal urinary fistulas, the development of strictures were noted.

Claims (1)

A device for forming an enterocystourethral anastomosis, comprising a rod with a curved working end, characterized in that at the working end there are three channels 2 mm deep located at an angle of 120 degrees to each other and arranged longitudinally to his body.