RU2454191C1 - Method of formation of interintestinal submersible invaginated anastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for formation of interintestinal submersible invaginated anastomosis. First suture is applied on posterior wall. First through puncture is made on outlet loop is made at the distance 4 cm from lumen from the side of serous membrane, the same thread is used to make second puncture into the edge of the same intestine without gripping mucous membrane, third puncture is performed on input loop on posterior wall near intestine edge, puncture out is made submucously. Altogether four sutures are applied: on posterior lip, anterior lip, lateral walls, submergence of inlet loop into outlet loop is performed, closing anastomosis line by its submergence into cushion. After it single sero-serous sutures are applied.

EFFECT: method makes it possible to improve adaptation of connected segments of intestine, accelerate regeneration, reduce risk of scar and stenosis development.

2 ex

Description

The invention relates to medicine and can be used in surgery.

One of the main problems of colorectal surgery remains a rather high frequency of inconsistency of sutures of colonic anastomoses. Severe fecal peritonitis, developing against the background of anastomotic insufficiency, causes high mortality rates. One of the ways of prevention is the choice of the optimal method for the formation of anastomosis in a specific clinical situation. To date, numerous experimental and clinical studies have proved that all inter-intestinal anastomoses to a greater or lesser extent heal by secondary intention, passing through all stages of purulent wound reparation. At the same time, the duration of the reparative process largely depends on the type of anastomosis formed (1).

One of the main requirements for intestinal sutures is their sufficient tightness and mechanical strength.

A morphological study of the colon established the existence of superficial and deep borderline submucosal plexuses (2), whose function is associated with the regulation of blood flow in the mucous membrane. Consequently, when seizure in the suture of the mucosa occurs common and irreversible changes in microcirculation along the line of the anastomosis. The experiment confirmed that the application of a double-row anastomosis leads to significant disturbances in microcirculation and transcapillary tissue exchange in the area of the joints of the anastomosis, which, in turn, causes tissue hypoxia, edema and hemorrhage, thereby closing the vicious circle of hemodynamics (3). With a two-row suture of the anastomosis, inflammatory tissue changes, intestinal wall necrosis in the areas of compression by the ligature persist for a long time, leading to the penetration of intestinal microflora into the abdominal cavity. The microflora of the colon, acting on tissue fibroblasts, leads to hypoxia, collagen metabolism is disrupted, as a result of which inflammation is maintained and the mechanisms of intestinal suture regeneration are upset (4). Healing in the area of the anastomosis formed by a single-row suture, in most cases, proceeds according to the type of primary tension. This contributes to the formation of a narrow linear scar of the anastomosis by 7-10 days (5).

In the literature, the seam of Lambert (1826) is known (6). Its essence lies in the fact that the injection and puncture of a surgical needle with a thread stitch length of 3-5 mm on each side of the connected intestinal segments is carried out only through the serous or additional muscle membrane, and when tying the ligature, a wide comparison of the surfaces of the serous membranes of the intestinal segments is achieved.

Also known is a single-row serous-muscular-submucosal suture with double stitching, described by A.V. Tokareva (7). Its essence lies in the fact that the injection and puncture of the needle with thread from each side of the anastomosis is sequentially performed, capturing all layers of the wall into the seam, with the exception of the mucous membrane and tying from the outside. In this case, the serous membranes of the anastomosed intestinal segments are widely compared.

A single-row through seam of L. Gambee (1956) (8) is described, the essence of which is that when the posterior lip of the anastomosis is formed, the knots of the threads are located inside the lumen of the organ (Alberta-Joli), and the anterior on the serous membrane. In this case, the suture of the front lip is carried out with a double puncture on each side, penetrating into the lumen of the organ. In this case, first of all, a wide comparison of the surfaces of the serous membranes of the intestine is achieved.

The double-row suture of I.D. Kirpatovsky is known with a separate comparison of the internal (for the submucosal basis) and the external, serous-muscular anatomical cases of the intestine (9). Its essence lies in the fact that with the canals of the intestinal segments closed by crushing pulp, the submucous membrane is stitched and matched with continuous mattresses or separate sutures that are tied after removal of the pulp, sealing the anastomosis. Then serous-muscular sutures are superimposed with a comparison of the serous membranes of the intestinal segments. Thus, a comparison of homogeneous intestinal membranes - submucosa, muscle and serous - is achieved.

Single-stitch seam G. Krafcsei (1981) (8). The posterior lip of the anastomosis is formed by through nodal sutures tangentially carried out at the base of the mucous membrane, and the anterior seam of the Lambert type, but with the submucous membrane being picked up in the suture. Thus, a wide comparison of the planes of the serous membranes of the anastomosed segments of the intestine is achieved, and on the posterior lip - the submucosa.

Single-row sero-muscular-submucosal suture of Pirogov-Bir-Mateshuk (9). The needle is injected from the side, capturing the serous and muscle membranes and entering the submucosal section, then again injecting through the submucosa into the muscle and serous membranes, with a puncture 3-5 mm from the edge of the intestinal segment, with a knot tied to the serous membrane (Pirogov suture -Bira). The same seam, but performed, starting with the injection of a needle into a section of the submucosal membrane and with tying a knot on the side of the organ canal, was proposed by V.P. Mateshuk (1945, 1952). Thus, this seam with the correct technique for its implementation provides a comparison of the submucous, muscle and serous membranes of anastomosed organs, as well as a high rate of eruption of ligatures due to nodes facing the inside of the organ channel.

The disadvantages of this method of anastomosis are the small area of comparison of the surfaces of the serous membranes of the connected intestinal segments, the possibility of impaired adaptation of the submucosal membrane when tying threads, prolonged (up to 3 months or more) migration of suture ligatures into the organ channel, causing delayed regeneration of the anastomoses due to ulceration of the mucous membrane , the development of cicatricial-stenotic process in the anastomosis zone.

The objective of the invention: to restore the integrity, continuity of the colon, by forming a submersible invagination anastomosis.

The aim of the invention is to increase the reliability of the intestinal anastomosis in difficult conditions by increasing the area of contacting serous membranes, mucous membranes (in the discharge loop), forming a cuff-roller in the anastomosis zone, forming a "sphincter apparatus", by increasing the number of layers of muscle cells, eliminating violations adaptation of the edges of the connected segments of the intestine, acceleration of the terms of regeneration of the mucous membranes, reduction of the cicatricial-stenotic process in the anastomosis, decrease in the number of a suture.

This goal is achieved by performing a laparotomy, mobilization of the colon, resection of the colon, the first suture is applied to the posterior wall, injecting through the discharge loop through from the side of the serous membrane at a distance of 4 cm from the intestinal lumen. There has been a plot on the discharge loop, which will form contact areas from the mucous membranes and serous membranes. An increase in the contact of these areas will lead to the fact that the number of layers of muscle cells will increase, thereby forming an additional "sphincter apparatus." With the same thread, a second injection is performed into the edge of the same intestine from the same side, without trapping the mucosa. The second injection in the discharge loop will lead to the fact that contiguous mucous membranes 1 = 2 cm are visible, and a portion of the serous membrane 1 = 2 cm appears. The third injection is performed on the adduction loop along the posterior wall at the edge of the intestine, while the submucosa is punctured. Similarly, the remaining stitches are applied. And when tying occurs, the contact of serous surfaces of intestinal segments occurs. It is important to note that the leading loop is retracted or immersed in the outlet, forming a cuff, cushion. Due to such a seam, the adaptation of the tissues of the same name is improved, and the regeneration time is accelerated. A total of 4 sutures are applied (front, rear lip, sides). On top of a single gray-serous sutures. Thus, the minimum amount of suture material is used.

The proposed method for the formation of anastomosis in the colon is used at the Department of Hospital Surgery of Ryazan State Medical University. Acad. I.P. Pavlova, on the basis of the MUZ GK BSMP Ryazan.

Example 1

Patient Z. 70 years. Received July 5, 2010.

The diagnosis is final clinical.

Main: Cancer of the rectosigmoid division of 4 tbsp. Condition after anterior resection of the rectum.

Received with a complaint of abdominal pain, mainly in the lower parts, stool retention, bloating.

Sick 3 months, when they began to bother abdominal pain, bloating, constipation.

Upon receipt, the stomach is evenly involved in the act of breathing, it is not swollen, soft, moderately painful along the colon, more along the left flank.

With fibrocolonoscopy: 17 cm tumor formation 5 × 4 cm in size with ulceration and bleeding upon contact, narrowing the intestinal lumen by 2/3. They managed to endoscopically with difficulty. Biopsy. Cytology.

The result of a cytological study: in the preparation, a cytogram of a malignant epithelial tumor.

Pathological examination: a picture of a moderately differentiated adenocarcinoma.

Ultrasound of the abdominal organs: the structure of the liver is homogeneous, the edge along the costal arch. The spleen is not enlarged, homogeneous. The gall bladder is absent. Choledoch 4 mm. The ducts are not expanded. The pancreas is a 23 mm head, homogeneous. There is no free fluid in the abdominal cavity. Paraaortic lymph nodes are not detected.

The patient was consulted by a therapist.

OAK dated 6.07.

Er. 3.8 · 10 ¹² / l, HB 127 g / l, Lake. 4.2 · 10%, P-6%, S-48%, L-36%, M-10%, ESR 34 mm / h.

Biochemical blood test from 6.07.

Bilirubin commonly. 13.2 μm, direct 4.4, indirect 8.8.

Total protein 89 g / l, blood amylase 28.3 mg / starch, blood glucose 4.3 mmol / l.

07/20/2010. Laparotomy Resection of the sigmoid colon.

Lower middle laparotomy. The tumor originates from the upper ampullar part of the rectum (rectosigmoid part). No distant metastases were detected. Mobilization of the sigmoid and rectum. The inferior mesenteric artery is crossed at the mouth. Lymphatic dissection along the abdominal aorta and in the pelvis. The rectum was resected. Formed invagination sigmorectoanastomosis capron 3.0 control of hemostasis. Drainage of the pelvis. Stitches on the wound.

In the postoperative period, the patient was in the intensive care unit, where she was given conservative, symptomatic therapy. 07/21. transferred to the department. Therapy is continued. 07/23. there was a chair, gases began to escape. 07/26. drains removed. Healing by first intention. Sutures removed 4.08. The patient was discharged in satisfactory condition under the supervision of an oncologist at the place of residence.

Example 2

Patient K., 71 years old. Received in the surgical department with a complaint of an increase in body temperature to 37.2 ° C in the evenings, weight loss of 7 kg, severe weakness. Inspected, surveyed.

Ultrasound: conclusion: signs of moderate diffuse changes in the pancreas. Volumetric formation in the right iliac region.

Protocol of CT scan of abdominal organs: in the right ileal region, it is detected from the dome of the cecum and throughout the ascending section a volumetric formation of 105 × 60 × 83 mm is determined circularly, unevenly narrowing the lumen of the colon.

Colonoscopy: conclusion of C-r of the cecum.

Pathological examination: low-grade adenocarcinoma with ulceration.

Cytological examination: in smears of a cell of low-grade adenocarcinoma.

General clinical, biochemical parameters within normal limits.

08/19. Laparotomy Right-sided hemicolonectomy with the application of ileotransversoanastomosis (intussusception) end to end.

In the postoperative period, the patient was in the intensive care unit, conservative, symptomatic therapy was carried out; 08.20. the patient was transferred to the department, conservative therapy continued. 08/23. drains removed. 08/24. gases began to flow, there was a chair. Wound healing by primary intention, sutures removed 2.09. In satisfactory condition, the patient was discharged under the supervision of an oncologist.

Bibliography

1. Godlevsky A.I. Suture of the colon and ways to increase its integrity: Abstract. dis ... cand. honey. sciences. M 1978; 5-7.

2. Vasina E.N. Morphology of vascular-tissue relations in the submucosa of the gastrointestinal tract is normal and in acute impaired blood flow: Author. dis ... cand. honey. sciences. M. 1980; fifteen.

3. Vlasov A.P. Intestinal suture in conditions of impaired blood supply: Author. dis ... Dr. med. sciences. Samara 1991; 31.

4. Korepanov V.I., Mumladze RB, Markov I.N., Vasiliev I.T. Intestinal suture. M: RMAPO 1997; 71.

5. Klintsevich V.Yu. An experimental study of the reliability factors of the intestinal suture. Wedge. chir. 1992; 1: 25-27.

6. G.E. Ostroverkhov, D.N. Lubotsky, Yu.M. Bomash. Operative surgery and topographic anatomy. - M .: Med-na. - 1972. S. 574-575.

7. A.V. Tokareva. Comparative evaluation of various types of intestinal sutures in newborns and young children. // Chir. - 1990. - No. 8, p. 17-20.

8. V.I. Korepanov, S.Kh. Stepanyan, S.M. Poghosyan. New types of intestinal suture (review of foreign literature) // Khir. - 1991. - No. 9, p. 167-172.

9. I.D. Kirpagovsky. Intestinal suture and its theoretical basis. - M .: Med-na - 1964 .-- 174 p.

Claims (1)

A method of forming an intestinal submersible invagination anastomosis, including laparotomy, mobilization of the colon, resection of the colon, characterized in that the first suture is applied to the posterior wall; perform the first injection on the discharge loop at a distance of 4 cm from the lumen from the side of the serous membrane through, the second thread is made with the same thread into the edge of the same intestine without trapping the mucous membrane; the third injection is performed on the lead loop along the posterior wall at the edge of the intestine, submucosa is punctured; In total, four sutures are applied: on the posterior lip, the anterior lip, the lateral sides, while the leading loop is immersed in the outlet, closing the anastomosis line by immersing it in the roller, single gray-serous sutures are applied on top.