RU2328992C1 - Method of surgical formation of invaginated one-row large intestinal anastomosis - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: intestinal resection is followed with adducting intestine invagination to abducting followed with interrupted suturing. Anastomosed adducting and abducting segments lumens are closed with stapling suture. Seromuscular layer is dissected circularly under staples until submucous layer of anastomosed adducting and abducting segments are uncovered. Intestinal anastomosis is formed with closed stapling suture in anastomosed intestine lumens. At first posterior lip is formed with interrupted one-row suturing punctures by submucous, muscular and serous membranes of one intestine and puncture out by serous, muscular and submucous membranes of the other intestine. Thus puncture in and out are carried out on distance 0.3-0.5 cm from edge of a seromuscular line of each anastomosed intestine in number of 3 sutures per 1 cm of suture line. Sutures are tightened after whole posterior semicircle is formed. Then anastomosed intestine segments closed with stapling sutures are cut off. Distal segment of mucosubmucous membrane by seromuscular of abducting anastomosed intestine. Surplus of mucosubmucous membrane of proximal adducting anastomosed intestine is formed by crossing its mucosubmucous membrane within 1-1.5 cm from seromuscular layer. Then anterior semicircle of intestinal anastomosis is formed by one-row sutures with knots outside. Puncture in and out is carried out by distance in 0.3-0.5 cm from edge of seromuscular line of each anastomosed intestine in number of 3 sutures per 1 cm of suturing line. Seams are tighten after whole anterior semicircle is formed. During formation of anterior anastomosis semicircle surplus of mucosubmucous membrane of adducting anastomosed intestine is invaginated free within lumen of abducting anastomosed intestine, covering suturing line of formed anastomosis with surplus.

EFFECT: method provides increased reliability of one-row anastomosis of large intestine; to lower operational traumatism and creates conditions for healing anastomosis by primary tension.

2 cl, 7 dwg, 2 ex

Description

The invention relates to medicine, to surgery, and in particular to methods of surgical formation of invagination single-row colonic anastomosis and can be used to create an anastomosis on the colon in the process of performing surgical interventions.

A known method for the surgical formation of invagination single-row intestinal anastomosis, including invagination of the adducting intestine into the outlet, followed by their stitching with interrupted sutures (see RF patent No. 2162661, IPC АВВ 17/11, 2001)

However, the known method in its use has the following disadvantages:

- insufficient reliability of the anastomosis in the colon,

- has excessive operational trauma,

- the technical complexity of creating a single-row anastomosis with the creation of conditions for the healing of the anastomosis by primary intention,

- all layers of the intestinal wall are used for intussusception, which increases the risk of scarring of the anastomosis.

The objective of the invention is to provide a method for the surgical formation of an invagination single-row colonic anastomosis.

The technical result is to increase the reliability of a single-row anastomosis in the colon, to reduce operational injuries, to achieve the technical simplicity of creating a single-row anastomosis with the creation of conditions for healing the anastomosis by first intention, to cover the seam line of the anastomosis with an excess of the mucous-submucous layer of the intestine.

The technical result is achieved by the fact that the proposed method for the surgical formation of invagination single-row colonic anastomosis, including conducting resection of the intestine after removal of the intestine into the outlet, followed by stitching with interrupted sutures, and after resection of the intestine, the lumens of the anastomosed segments of the leading and outlet intestines are closed with stitch sutures, dissected the circumference under the braces of the serous-muscular layer to the exposure of the submucosal layer of the anastomosed segments of the lead and discharge intestines, then create an intestinal anastomosis with gaps of anastomosed intestines closed with stitch seams, first by forming its posterior lip along the posterior semicircle with single-row nodular sutures injected sequentially along the submucosa, muscle and serous membranes of one intestine and punctured sequentially along the serous, muscular and submucous membranes of the other intestine, injection and puncture is performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures are tightened after e the formation of the entire posterior semicircle, then cut the segments of the anastomosed intestines closed by stitching seams, opening the lumen of the intestines, and immediately cut the distal segment of the mucous-submucosal layer along the serous-muscular discharge of the anastomosed intestine, create an excess of the mucous-submucous layer of the proximal end of the mucous membrane leading to anastomosis submucosal layer 1-1.5 cm from the serous-muscular layer, then form the anterior semicircle of the intestinal anastomosis with single-row nodular sutures nodules arms, and the injection and puncture is performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures are tightened after the formation of the entire front semicircle, during the formation of the anastomosis anterior semicircle, an excess of the mucous-submucous layer of the adducting anastomosed intestine invaginates freely into the lumen of the anastomotic outlet, covering the suture line of the created anastomosis with excess from the inside. In this case, the posterior and anterior semicircles of the intestinal anastomosis are sutured with No. 3/0 or No. 4/0 sutures with a monofilament suture from a long absorbable material.

Among the essential features characterizing the proposed method for the surgical formation of an invagination single-row colonic anastomosis, the following are distinctive:

- closing the gaps of the anastomosed segments of the adducting and diverting intestines with staples,

- dissection around the circumference under the braces of the serous-muscular layer to the exposure of the submucosal layer of the anastomosed segments of the adducting and discharge intestines,

- creating an intestinal anastomosis with gaps of anastomosed intestines closed with stitch seams by first forming its posterior lip along the posterior semicircle with single-row nodular sutures injected sequentially along the submucosa, muscle and serous membranes of one intestine and punctured successively along the serous, muscular and submucous membranes of the other intestine, the puncture is performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures are tightened after forming of the entire posterior semicircle,

- cutting sections of the intestines closed with stitch seams, opening the intestinal lumen, and immediately cutting the distal segment of the mucous-submucosal layer along the serous-muscular discharge of the anastomosed intestine,

- creating an excess of the mucous-submucosal layer of the proximal end of the adducting anastomosed intestine by crossing its mucous-submucous layer 1-1.5 cm from the serous-muscular layer,

- the formation of the anterior semicircle of the intestinal anastomosis with single-row nodal sutures with the nodules outward, the injection and puncture being performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures tighten after the formation of the entire front semicircle,

- invagination during the formation of the anastomosis anterior semicircle of the excess of the mucous-submucous layer of the adducting anastomosed intestine freely into the lumen of the outlet anastomosed intestine with the excess mucous-submucous layer covering the inside of the suture line of the created anastomosis,

- stitching of the posterior and anterior semicircles of the intestinal anastomosis with sutures No. 3/0 or No. 4/0 by monofilament thread from a long absorbable material.

The method is as follows.

After resection of the intestine, the gaps of the anastomosed segments of the leading and outlet intestines are closed with brace sutures. Then, a circular dissection is performed under the braces of the serous-muscular layer until the submucosal layer of the anastomosed segments of the adducting and abducting intestines is exposed. An intestinal anastomosis is created with the gaps of the anastomosed intestines closed by stitching seams, first by forming its posterior lip along the posterior semicircle with single-row knotted sutures No. 3/0 or No. 4/0 using monofilament suture from a long absorbable material, injected sequentially along the submucosa, muscle and serous membranes of one intestine and punctured sequentially on the serous, muscle and submucous membranes of the other intestine. In this case, the injection and puncture is performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. Sutures tighten after the formation of the entire posterior semicircle of the formed anastomosis. Then cut the segments of the intestines closed with stitching seams, opening the lumen of the intestines, and immediately cut the distal segment of the mucous-submucosal layer along the serous-muscular layer of the outlet anastomosed intestine. An excess of the mucous-submucous layer of the proximal end of the adducting anastomosed intestine is created by crossing its mucous-submucous layer 1-1.5 cm from the serous-muscular layer. Then, the anterior semicircle of the intestinal anastomosis is formed with single-row interrupted sutures No. 3/0 or No. 4/0 from a long-absorbable material from nodules with a long absorbable nodule sequentially along the serous, muscle and submucous membranes of one intestine and a puncture successively along the submucosa, muscle and serous membranes of the other intestine, moreover, an injection and an injection are performed at a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. The sutures are tightened after the formation of the entire anterior semicircle of the formed anastomosis, while during the formation of the anterior semicircle of the anastomosis, the excess of the mucous-submucous layer of the adducting intestine is invaginated freely into the lumen of the discharge anastomosed intestine, covering with an excess of the mucous-submucous layer from the inside of the suture line.

Experimental studies of the proposed method for the surgical formation of invagination single-row colonic anastomosis in clinical conditions have shown its high efficiency. The method, when used, ensures the creation of a reliable single-row anastomosis in the colon, the reduction of operational injuries is achieved, the technical simplicity of the creation of a single-row anastomosis achieved allows the serous-muscular submucosal layers of the same segments to be well adapted to create conditions for healing of the anastomosis by primary intention, covering the suture line with an anastomosis mucosal submucosa of the intestine allowed to increase the physical strength of the created anastomosis . Moreover, the proposed method does not pose a threat of scarring of the anastomosis due to the use of the most flexible and mobile mucous-submucous layer of the intestine for invagination. In addition, the method provides the surgeon with the ability to visually control the passage of the needle through the same layers of the intestinal wall.

The essence of the proposed method for the surgical formation of invagination single-row colonic anastomosis is illustrated in Fig.1-7, which show the stages of formation of the anastomosis:

figure 1 - closed by stitching the ends of the resected intestine;

figure 2 - circular dissection of the serous-muscular layer to the submucosa;

figure 3 - the creation of the posterior lip of the anastomosis with closed gaps of the intestine;

figure 4 - the creation of excess mucosal submucosal layer of the proximal end of the leading anastomosed intestine;

figure 5 - the creation of the front lip of the invagination anastomosis;

figure 6 - invagination anastomosis with an excess of the mucous-submucosal layer (inside view);

Fig.7 is a General view of the anastomosis.

The implementation of the proposed method for the surgical formation of invagination single-row colonic anastomosis is illustrated by the following clinical examples.

Example 1. Patient K., 58 years old, was admitted to the State Health Institution of the Moscow Automobile and Aircraft Safety Bureau with a diagnosis of Stage III sigmoid colon cancer.

Surgery was performed with resection of the sigmoid colon and with the creation of an invagination single-row colonic anastomosis.

After resection of the intestine, the gaps of the anastomosed segments of the leading and outlet intestines were closed with stitching sutures. Then, a circular dissection was performed under the braces of the serous-muscular layer until the submucosal layer of the anastomosed segments of the adducting and abducting intestines was exposed. An intestinal anastomosis was created with the gaps of the anastomosed intestines closed with stitch seams, first by forming its posterior lip along the posterior semicircle with single-row knotted sutures No. 4/0 using monofilament suture from a long absorbable material, injected sequentially through the submucosa, muscle and serous membranes of one intestine and sequentially through serous, muscular muscle submucosa of the other intestine. In this case, an injection and puncture was performed at a distance of 0.3 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. The sutures tightened after the formation of the entire posterior semicircle of the anastomosis. Then, sections of the intestines closed with bracket seams were cut, the intestinal lumen was opened, and the distal segment of the mucous-submucosal layer was cut off along the serous-muscular outlet of the anastomosed intestine. An excess of the mucous-submucous layer of the proximal end of the adducting anastomosed intestine was created by crossing its mucous-submucous layer 1 cm from the serous-muscular layer. Then, the anterior semicircle of the intestinal anastomosis was formed with single-row nodal sutures No. 4/0 of a monofilament thread from a long absorbable material with nodules outwards, sequentially along the serous, muscular and submucous membranes of one intestine and a puncture sequentially along the submucosa, muscle and serous membranes of the other intestine, and they were punctured at a distance of 0.3 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. The sutures were tightened after the formation of the entire anterior semicircle, while during the formation of the anterior semicircle of the anastomosis, an excess of the mucous-submucous layer of the adducting anastomosed intestine invaginated freely into the lumen of the anastomosing intestine, covering the line of sutures of the created anastomosis with an excess of the mucous-submucous layer.

The postoperative period is smooth. After 3 months, during the control colonofibroscopy, the anastomosis is freely passable, a small mucosa in the anastomosis is noted. Inflammation of the anastomosed intestine and anastomosis zone is not visualized. There are no complaints. Disability restored.

Patient K., 62 years old, was admitted to the State Institution of Medical and Biochemistry with a diagnosis of diverticulosis of the sigmoid colon complicated by intestinal bleeding.

A hemicolectomy was performed with the creation of an invagination single-row colonic anastomosis.

After resection of the intestine, the gaps of the anastomosed segments of the leading and outlet intestines were closed with stitching sutures. Then, a circular dissection was performed under the braces of the serous-muscular layer until the submucosal layer of the anastomosed segments of the adducting and abducting intestines was exposed. An intestinal anastomosis was created with the gaps of the anastomosed intestines closed with stitch seams, first by forming its posterior lip along the posterior semicircle with single-row knotted sutures No. 3/0 with monofilament suture from a long absorbable material, injected sequentially along the submucosa, muscle and serous membranes of one intestine and sequentially through serous, muscular muscle submucosa of the other intestine. In this case, an injection and puncture was performed at a distance of 0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. The sutures tightened after the formation of the entire posterior semicircle of the anastomosis. Then, sections of the intestines closed with bracket seams were cut, the intestinal lumen was opened, and the distal segment of the mucous-submucosal layer was cut off along the serous-muscular outlet of the anastomosed intestine. An excess of the mucous-submucous layer of the end of the adducting anastomosed intestine was created by crossing the proximal segment of the intestine of the mucous-submucous layer 1 cm from the serous-muscular layer. Then, the anterior semicircle of the intestinal anastomosis was formed with single-row knotted sutures No. 3/0 of a monofilament thread from a long absorbable material with nodules outwards injected sequentially along the serous, muscle and submucous membranes of one intestine and punctured sequentially along the submucosa, muscle and serous membranes of the other intestine, and injected and punctured at a distance of 0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line. The sutures were tightened after the formation of the entire anterior semicircle, while during the formation of the anterior semicircle of the anastomosis, an excess of the mucous-submucous layer of the adducting anastomosed intestine invaginated freely into the lumen of the anastomosing intestine, covering the line of sutures of the created anastomosis with an excess of the mucous-submucous layer.

The postoperative period is smooth. After 3 months, during the control colonofibroscopy, the anastomosis is freely passable, a small mucosa in the anastomosis is noted. Inflammation of the anastomosed intestine and anastomosis zone is not visualized. There are no complaints. Disability restored.

The proposed method was tested in the coloproctology department of the regional clinical hospital in Astrakhan for 33 patients (18 women and 15 men) during operations on the colon due to oncopathology and diverticular disease. In none of the 33 operations did the inconsistency of the sutures of the anastomosis occur at follow-up periods of up to one year. The anastomosis healed by primary intention with the formation of a small roller. No late complications from the anastomosis have been identified.

Claims (2)

1. The method of surgical formation of invagination single-row colonic anastomosis, including conducting after resection of the intestine invagination of the adducting intestine into the abduction followed by suturing with interrupted sutures, characterized in that after resection of the intestine, the lumens of the anastomosed segments of the adduction and abduction intestines are closed with staple sutures, dissecting the circumference under the circumference under the circumference the serous-muscular layer to the exposure of the submucosal layer of the anastomosed segments of the adducting and discharge intestines, then an intestinal anastomo is created h with gaps of anastomosed intestines closed with stitch seams, first with the formation of its posterior lip along the posterior semicircle with single-row nodular sutures injected sequentially along the submucosa, muscle and serous membranes of one intestine and punctured sequentially along the serous, muscle and submucous membranes of the other intestine, and the injection and puncture are performed on a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures are tightened after the formation of the entire posterior semicircle sti, then cut the segments of anastomosed intestines closed with stitch seams, opening the lumen of the intestines, and immediately cut the distal segment of the mucous-submucosal layer along the serous-muscular discharge of the anastomosed intestine, create an excess of the mucous-submucous layer of the proximal end of the anastomosed mucosa of the intestinal mucosa-re-intestinal mucosa 1-1.5 cm from the serous-muscular layer, then form the anterior semicircle of the intestinal anastomosis with single-row interrupted sutures with the nodules outward, and the injection and puncture are performed on a distance of 0.3-0.5 cm from the edge of the serous-muscular line of each of the anastomosed intestines in the amount of 3 sutures per 1 cm of the suture line, and the sutures are tightened after the formation of the entire front semicircle, while during the formation of the anterior semicircle of the anastomosis, an excess of mucous the submucosal layer of the adducting anastomosed intestine is invaginated freely into the lumen of the adducting anastomosed intestine, covering the suture line of the created anastomosis with excess from the inside. 2. The method according to claim 1, characterized in that the posterior and anterior semicircles of the intestinal anastomosis are sutured with No. 3/0 or No. 4/0 sutures with a monofilament thread from a long absorbable material.

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