RU2432129C1 - Handmade enteroplexy technique in creation of intestinal anastomoses involved in abdominal surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery, and can be applied in handmade enteroplexy in creation of intestinal anastomoses involved in abdominal surgery. A suturing procedure includes dissection of a seromuscular-submucosal layer only on a posterior anastomotic lip under constrictors stopping an intestinal lumen along a posterior semicircle of the anastomosed intestines without dissection of a mucous layer, i.e. without opening of the intestinal lumen. The seromuscular-submucosal suturing procedure covering the whole posterior lip is followed by dissection of the mucosa of the anastomosed intestines along an upper edge of the suture. The anterior semicircle of the intestines is transected completely. Further, the procedure continues with a single-layer uninterrupted suture covering the seromuscular-submucosal layer on the anterior lip with the same filament.

EFFECT: technique allows reducing suture line contamination.

1 ex, 3 dwg

Description

The invention relates to medicine, namely to methods for applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery.

There is a method of applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery (see Korepanov V.I., Mumladze RB, Markov I.N., Vasiliev I.T. Intestinal suture. - M .: RMAPO. -1995 - 74 s .; Single-row continuous suture of anastomoses in abdominal surgery / Edited by V.N. Egiev. M .: Medpraktika - M. - 2002. - 100 p.), This is the closest to the claimed continuous single-row serous-muscular submucosal suture applied to the anastomosed ends of the intestines with atraumatic thread of conditional size 3 / 0-5 / 0.

The disadvantage of this method is the high degree of contamination of the intraluminal intestinal microflora of the surgeon's hands, suture material and surgical instruments, occurring from the moment the first sutures are applied to the posterior lip of the anastomosis, because it is necessary to open the lumen of the anastomosed intestines. Anastomosis is applied on average in 12-15 minutes, while the seam on the back lip takes 2/3 of the total time, i.e. 8-11 minutes. Prolonged direct contact by the surgeon's hands, suture material and surgical instruments from the intestinal mucosa from the side of its lumen leads to a high degree of infection of the suture line (especially with colonic anastomosis) with the formation of microabscesses in the intestinal wall and the development of peritonitis, which subsequently leads to failure of the small intestine anastomoses in 1 , 5-3% of cases, and colonic in - 3.5-5%.

The present invention more simply, reliably and effectively solves the problem of applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery.

The resulting technical result consists in increasing the effectiveness of treatment. Performing an intestinal suture according to the proposed method significantly reduces the time of direct contact with the surgeon's hands, suture material and surgical instruments of the intestinal mucosa from the side of its lumen, because continuous single-row serous-muscular-submucosal suture on the posterior lip of the anastomosis is applied without crossing the mucous layer (without opening the intestinal lumen), i.e. under sterile conditions. The proposed method for applying intestinal suture was used in the formation of 8 small intestine and 6 large intestinal anastomoses, complications (including insolvencies) were not observed.

Pulling the wall of the intestine for the undissected mucosa contributes to a good visualization of the layers of the intestinal wall, so suturing the posterior lip of the anastomosis is technically simpler.

The proposed method of applying an intestinal suture significantly accelerates the process of anastomosis, because the time for which a seam is placed on the back lip is reduced to 4-6 minutes, takes only 1/2 of the total time and accordingly reduces it to 8-11 minutes.

The proposed method for applying intestinal suture is simple and available for use by a surgeon of any skill.

The specified technical result is achieved by the fact that in the method of applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery, the suture is applied to the posterior lip of the anastomosis faster, easier and in sterile conditions.

The invention is illustrated by drawings, where in Fig.1 schematically shows a seam of the posterior lip of the interintestinal anastomosis without cutting the mucous layer;

figure 2 - a view of figure 1;

figure 3 - suture of the front lip of the interintestinal anastomosis.

The method of applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery is as follows.

After resection of the intestine, the anastomosed ends 1 are held by squeezing intestinal pulp 2 closing their lumen. On the anastomosed ends of the intestine 1, under the pulp 2, 1-1.5 cm departing from them, serous-muscular is dissected in the transverse direction along the entire length of the posterior semicircle of the intestines. -mucosal layer 3, while the mucosa 4 is not dissected, i.e. the lumen of the intestines does not open. Hemostasis is achieved by point coagulation. From the incision line, the mesentery 5 was separated from the serous membrane of the intestine by 6-8 mm. Then, atraumatic thread 6 of the conditional size 3 / 0-5 / 0 began the formation of the anastomosis with one serous-muscular-submucosal nodal suture from the mesenteric edge, located on the opposite side from the surgeon. The continuous single-row suture was applied “on oneself”. At the distal anastomosed end of the intestine, 7 injections were carried out in the submucosal layer, puncture on serosa. At the proximal anastomosed end of the intestine, 8 injections were performed on serose, an injection from the submucosal layer. An injection from the side of the serosa was performed, departing 5-7 mm from the edge of the section, the stitches were located at a distance of 6-7 mm from each other. The assistant carried out a constant traction for the free end of the thread, preventing the weakening of the already imposed seams. After suturing the entire posterior lip, the mucosa of the anastomosed intestines is dissected along the upper edge of the suture, then the entire anterior semicircle of the intestines 9 is intersected, then a single-row continuous suture continues to be applied to the anterior lip with the same thread 6 with the capture of the serous-muscular-submucous layer 3. The ends of the used thread 6 communicate with each other (figures 1, 2, 3).

The method has proven to be highly effective, easy to perform, virtually eliminating the complications that occur in the above prototype. The proposed method can be successfully applied in the formation of intestinal anastomoses "end to end", "side to side" and "end to side".

Clinical example

As an illustration, we give an example. Patient Sh., 64 years old, medical history No. 1341, was admitted to the Municipal Clinical Hospital No. 5 on 11.03.08 with a diagnosis of ZNO of the transverse colon T _Z N _O M _O. Condition after tumor resection at the height of intestinal obstruction from 01/15/08. Formed full lip-shaped colonic fistula. Received as planned for the operational closure of the fistula.

On March 12, 2008, an operation was performed under endotracheal anesthesia: laparotomy, resection of the adducting colon, 3 cm backward from the anterior abdominal wall, with the application of a crushing intestinal pulp covering the lumen. The distal end of the transverse colon is isolated from adhesions and also 3 cm below it is squeezed by crushing intestinal pulp. The proximal and distal ends of the intestine are brought together. Under the pulp, departing from them by 1-1.5 cm, a serous-muscular-submucous layer of the intestine was dissected throughout the length with a scalpel, while the mucosa was not dissected. Hemostasis was achieved by point coagulation. Then, a Polysorb multifilament thread of Auto Suture company of conditional diameter 4/0 with an atraumatic needle (biodegradation period of 70-90 days) was applied to one serous-muscular-submucosal nodal suture from the mesenteric edge. Next, the formation of the anastomosis was performed according to our proposed method. At the distal anastomotic end of the intestine, an injection was carried out in the submucosal layer, an injection was performed on serosa. At the proximal anastomosed end of the intestine, an injection was performed on serose, an injection from the submucosal layer. After suturing the entire posterior lip, the mucosa of the anastomosed intestines was dissected along the upper edge of the suture, then the entire anterior semicircle of the intestines was crossed. Intestinal pulp with cut off sections of the colon was removed. Further, a single-row continuous suture with the capture of the serous-muscular-submucosal layer was continued on the front lip with the same thread. The ends of the thread used are tied together. The application time of the anastomosis was 11 minutes. After suturing, a fistula was excised together with a skin flap, the defect of the anterior abdominal wall was restored by layer-by-layer suturing. Through the counterperturbation in the left mesogastrium, a polyvinyl chloride drainage tube was brought to the line of the anastomosis. The middle wound was sutured in layers.

Bacterial inoculation of swabs taken after suturing the posterior lip of the anastomosis from the hands of the surgeon, suture thread, needle holder and tweezers did not give microflora growth. After the operation, the patient did not have a temperature reaction; the leukoformula did not undergo inflammatory changes in the general blood test. On the 2nd day after the operation, distinct intestinal noises appeared, and the gases passed away on their own. The drainage tube has been removed. The chair appeared on the 3rd day after the operation, became daily, single, mushy, from the 7th day it took on a formal character. On 8-9 days after the operation, the sutures were removed, 03/21/08 the patient was discharged in satisfactory condition. The fate of the patient is traced for 1.5 years, the quality of life does not suffer.

Claims (1)

The method of applying a manual intestinal suture during the formation of intestinal anastomoses in abdominal surgery, which consists in applying to the anastomosed ends of the intestines a circular single-row continuous suture with the capture of the serous-muscular-submucous layer with atraumatic thread of conventional sizes 3 / 0-5 / 0, characterized in that when applying a seam on the posterior lip of the anastomosis under the intestinal pulp closing the intestinal lumen only a serous-muscular-submucous layer is dissected along the posterior semicircle of the anastomosed intestines without cutting the mucosa layer, i.e. without opening the lumen of the intestines, only after applying the serous-muscular-submucosal suture to the entire posterior lip, the mucosa of the anastomosed intestines is dissected along the upper edge of the suture, then the entire anterior semicircle of the intestines is completely intersected, then a continuous continuous suture with a serous grasp continues to be applied to the front lip with the same thread muscle submucosal layer.

Images