RU2296513C1 - Method for surgical treatment of patients with extrasphincter pararectal fistulas - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with treating complicated chronic pararectal fistulas. One should mobilize rectal mucous-submucous layer at suturing in the internal fistulous foramen, dissect fistulous pathway and apply an allotransplant for strengthening rectal muscular wall. Moreover, after detachment of mucous-submucous fragment at crossing the fistulous pathway it is necessary to suture in the internal fistulous foramen from the side of submucous layer with a single-row precision suture. External part of fistulous pathway should be dissected from the side of perineal wound up to rectal wall. The part of fistulous pathway perforating rectal muscular wall should be partially sutured in from the side of submucous layer. From the same side one should suture in the stump of fistulous pathway and put into muscular thickness of anal sphincter due to longitudinal exfoliation of anal sphincter's fibers. As an allotransplant one should apply a polypropylene netting to put onto the fistulous stump by covering the defect in anal sphincter. The netting should be fixed in rectal muscular wall. The innovation enables to decrease the number of relapses, provide prophylaxis of post-surgical failure of anal sphincter.

EFFECT: higher efficiency of therapy.

5 dwg, 1 ex

Description

The invention relates to medicine and relates to methods for surgical treatment of diseases of the rectum and pararectal space, in particular, patients with extrasphincteric pararectal fistulas.

The following methods of surgical treatment of extrasphincteric pararectal fistula are known:

Excision of a pararectal fistula with suturing the stump of the fistula from the perineal wound and posterior dosed sphincterotomy according to the method of A.N. Red (1). (V.D. Fedorov, Yu.V. Dultsev, Proctology, Moscow, 1984, pp. 99-102).

The disadvantage of this method: during the operation, a back dosed sphincterotomy is performed, passing through the inner opening of the pararectal fistula to the sutures on the stump of the fistulous course. The sphincter dissection recommended by the author is 1.5-2.4 cm, which often leads to the development of anal sphincter insufficiency.

Excision of the pararectal fistula with complete dissection and suturing of the anal sphincter (2). (A.M. Aminev, Guide to proctology, vol. 3, Kuibyshev, 1973, p. 273-288).

The disadvantage of this method: excision of the fistula with suturing of the anal sphincter in case of suppuration leads to a divergence of the edges of the wound and the development of insufficiency of the anal sphincter.

Excision of the fistula with plastic movement of the mucous membrane, exfoliated for a considerable extent along the front or rear semicircle of the rectum (3). (N.M. Blinnichev, Acute and chronic paraproctitis, dissertation abstract for the degree of Doctor of Medical Sciences, Kuibyshev, 1972).

The disadvantage of this method: the inability to use with a high location of the inner opening of the pararectal fistula. Exfoliation of the mucous membrane over a large extent and its displacement along the circumference of the rectum can lead to disruption of microcirculation in the moved flap.

Excision of a pararectal fistula with plastic closure by polymer absorbable films of the internal opening of the fistula from the lumen of the rectum and stump of the fistula from the perineal wound (4). (T.V. Abuladze, Autografts and explants in surgery of chronic paraproctitis, abstract of the dissertation for the degree of Doctor of Medical Sciences, Tbilisi, 1992). This method is taken as a prototype.

The disadvantage of the prototype: fixing the patch of the polymer absorbable material to the area of the inner opening of the pararectal fistula is performed from the side of the rectal lumen with subsequent suturing of the mucous membrane above the patch. This method of installing the graft to the inner opening of the pararectal fistula leads to frequent suppuration of the wound and rejection of the graft with the development of relapse of the pararectal fistula. Absorbable polymeric biocompatible materials have insufficient strength and pronounced tissue reaction.

The aim of the invention is to improve the results of surgical treatment of patients with complex extrasphincter pararectal fistulas, reduce the number of relapses of the disease, and prevent postoperative anal sphincter insufficiency.

This goal is achieved by the fact that the internal fistula opening is sutured from the submucosal layer with a single-row precision suture, and a polypropylene mesh is used as an allograft, laid in the thickness of the muscular wall of the rectum on the stump of the fistulous passage.

The invention is illustrated by graphic material. Figure 1 shows the superposition of a single-row suture on the inner opening of the fistula from the side of the submucosal layer of the rectum. Figure 2 shows the bundle of muscle fibers of the anal sphincter and immersion of the sutured stump of the pararectal fistula. Figure 3 shows the laying of a polypropylene graft on the stump of a pararectal fistula. Figure 4 shows the restoration of the integrity of the anal sphincter. Figure 5 shows the fixation of the mobilized mucous-submucosal flap to the perianal skin, drainage of the submucosal space and pararectal tissue.

The method is as follows. Anesthesia - epidural anesthesia or intravenous anesthesia. The patient's position is standard on the back with legs raised and divorced on the supports. The fistulous passage is stained with a methylene blue solution with the addition of a 3% hydrogen peroxide solution. After determining the localization of the internal opening of the pararectal fistula, the submucosal space of the rectum is hydrotreated with a 0.25% novocaine solution on the side of the internal opening of the fistula. A half-moon skin incision is performed, departing 0.5 cm from the transition line. Acute route using a special double-edged scalpel is performed detachment of the mucous-submucosal flap with the intersection of the fistulous passage and 2-3 cm above the last. The prepared mucous-submucosal flap (1) is grasped with two Alice clamps. The inner hole of the fistula, located on the prepared mucous-submucosal flap, is sutured from the submucosal layer with a single-row continuous precision suture (2) using synthetic absorbable material (Biosyn, Maxon). The outer part of the fistulous course is excised from the perineal wound to the wall of the rectum. Purulent cavities and bay-like extensions of the fistulous course are opened and scraped with a Volkman spoon. The fistulous course at the muscular wall of the rectum intersects, is treated with 5% tincture of iodine and is scraped out with a Volkman spoon. The perineal wound is drained with the help of stable through PVC drainages (3) and sutured in layers. On the part of the submucosal space, the part of the fistulous passage located in the muscular wall of the rectum is sutured with a chrome catgut (4). A longitudinal stratification of the fibers of the anal sphincter and immersion of the sutured stump of the fistulous passage (5) into the thickness of the muscle layer are performed. An allograft made of polypropylene mesh (6) 1.5 × 1.0 cm in size is installed on top of the sutured stump of the fistulous passage and fixed intramuscularly with a non-absorbable synthetic suture material (Surgilen, Nonafil). The anatomical integrity of the anal sphincter is restored by stitching the muscle fibers in the transverse direction with a chrome catgut (7). The mucous-submucosal flap of the rectum fits in its place and is sutured to the perianal skin with kapron sutures (8). The submucosal space is drained by polyvinyl chloride tubes (9) for 3-4 days to prevent the formation of a hematoma and suppuration of the wound.

The fundamental difference between the proposed method and the known one is that the inner hole of the fistula is sutured from the submucosal layer with a precision single-row suture with synthetic absorbable material, and is not reinforced with a patch from a polymer absorbable film installed from the rectal lumen. Part of the fistulous passage perforating the muscular wall of the rectum is partially excised from the submucosal layer. The hole in the fistula in the muscular wall of the rectum is sutured with catgut and immersed in the muscles of the anal sphincter by longitudinally dissecting the fibers of the internal anal sphincter. The stump of the fistulous passage is covered by a patch from a polypropylene mesh, which is fixed in the muscular wall of the rectum with woven threads. The defect in the anal sphincter is sutured with catgut sutures. A mobilized mucous-submucosal flap of the rectum with a sutured internal fistula opening fits into its place without reduction or lateral displacement and is fixed to the perianal skin by nylon sutures.

The advantage of the proposed method is as follows: the use of a polypropylene mesh transplant with high strength and minimal tissue reaction, fixed in the muscle wall of the rectum, significantly reduces the permeability for infection in the sutured stump of the fistulous passage and strengthens the muscle wall of the rectum at the perforation site with its fistulous underway. Suturing of the internal opening of the fistulous passage from the submucosal layer allows you to completely isolate the rectal lumen from the fistulous passage and the perineal wound. Using the proposed method eliminates traumatic damage to the muscles of the anal sphincter, which is the prevention of anal incontinence in the postoperative period.

The proposed method was applied in the coloproctology department of Samara State Medical University in two patients with pararectal fistulas.

1. Patient K., 41 years old. Medical history No. 15204/910. He entered the coloproggology department of the hospital surgery clinic on September 15, 04 with a clinical diagnosis: complete extrasphincter pararectal fistula of 3 degrees of difficulty, relapse. Upon admission to the clinic, the patient had a functioning pararectal fistula. The external opening of the pararectal fistula was determined at 7 o'clock on the dial 5 cm from the edge of the anus, the internal opening of the fistula was localized in the posterior crypt at a height of 3 cm. There were pronounced cicatricial changes along the pararectal fistula and in the submucosal space in the region of the internal opening. In 2002, he underwent surgery for ischiorectal paraproctitis. The abscess was opened, however, a pararectal fistula with a constant discharge of pus was formed. In 2003, the patient underwent surgery to excise a pararectal fistula without a clinical effect. 1 month after surgery, the fistula recurred. 09/20/04 in the clinic the patient underwent an operation to excise a pararectal fistula by the proposed method. The patient recovered. The patient was examined by the operating surgeon 2 months after discharge. The function of the anal sphincter is saved. There is no relapse of the fistulous course.

2. A similar operation was performed on a patient F. 56 years old with a complete extrasphincteric pararectal fistula of 4 degrees of difficulty with a positive effect.

The use of a polypropylene mesh to strengthen and seal soft tissues in the stump of the fistula of the rectum improves the results of treatment, strengthens the muscle structures of the anal sphincter and reduces the likelihood of postoperative failure of the anal sphincter. The proposed method is possible and appropriate to use in patients with extrasphincteric complex pararectal fistulas, especially with a high location of the internal opening of the fistulous course. The method can be recommended for use in practical medicine.

Information sources

1. Fedorov V.D., Dultsev Yu.V. Proctology, Moscow, 1984, pp. 99-102.

2. Aminev A.M. Proctology Guide. T.3. Kuibyshev, 1973, p. 273-288.

3. Blinnichev N.M. Acute and chronic paraproctitis. Abstract for the degree of Doctor of Medical Sciences. Kuibyshev, 1972.

4. Abuladze T.V. Autografts and explants in the surgery of chronic paraproctitis. Abstract for the degree of Doctor of Medical Sciences. Tbilisi, 1992.

Claims (1)

A method for the surgical treatment of patients with extrasphincteric pararectal fistulas, including mobilization of the mucous-submucosal layer of the rectum with suturing of the fistula’s internal opening, excision of the fistulous passage, the use of an allograft to strengthen the muscular wall of the rectum, characterized in that after detachment of the mucous-submucosal flap with intersection of the fistulous the fistula internal opening from the submucosal side with a single-row precision suture, the external part of the fistulous course is excised from the side of the perineal wound to the wall of the rectum, the part of the fistulous passage perforating the muscle wall of the rectum is partially sutured from the submucosal layer, then the stump of the fistulous passage is sutured from the side of the submucosal layer and immersed in the thickness of the anal sphincter muscle by longitudinal delamination of the fibers of the anal sphincter, after which they are used as an allograft, a polypropylene mesh, lay it on the stump of the fistula, closing the defect in the anal sphincter, and fix it in the muscle wall of the rectum.

Images