RU2768485C1 - Method for applying a double-barreled ileostomy during laparoscopic right-sided hemicolectomy with media-lateral access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to colorectal surgery, oncology. At the first stage, a discharge double-barreled ileostomy is placed on the anterior abdominal wall in the projection of the caecum dome with a leading loop located from below and a diverting loop 5-7 cm long from above. At the second stage, the stoma is sutured. The right parts of the colon are mobilized by medial access, the part of the intestine carrying the stoma is isolated from the anterior abdominal wall and immersed into the abdominal cavity. Further mobilization is performed along the right lateral canal, a section of the intestine with a tumor is resected and removed through an ileostomal wound existing in the right iliac region. The stumps of the ileum and transverse colon are removed on the anterior abdominal wall and an inter-intestinal anastomosis is applied extracorporeal.

EFFECT: method provides for decompression in patients with colorectal cancer complicated by acute obstruction, preparing the patient for the radical stage, simplifying the video laparoscopic access, exposing the mesentery with vessels in the ileocecal corner and along the right parts of the colon, using an ileostomal wound to remove the resected part of the intestine with a tumor and to impose a small-colonic anastomosis.

1 cl, 1 dwg

Description

The invention relates to medicine, namely to colorectal surgery, can be used in the treatment of colon cancer complicated by colonic obstruction, by forming a double-barrel ileostomy at the first stage, followed by laparoscopic right-sided hemicolectomy at the second stage by media-lateral access. The technique of laparoscopic resections of the colon includes standard steps: intracorporeal mobilization and devascularization, followed by resection and anastomosis. With media-lateral access, before installing the ports, the double-barreled ileostomy is sutured. Then ports are installed in typical places, the right departments are mobilized. After that, the section of the intestine carrying the stoma is isolated from the anterior abdominal wall and immersed into the abdominal cavity. The wound of the anterior abdominal wall is sutured through all layers to seal the abdominal cavity. Again create a pneumoperitoneum and produce further mobilization. The mobilized section of the intestine is resected and removed, and the stumps of the ileum and transverse colon are brought to the anterior abdominal wall and an anastomosis is formed extracorporeally. The wound of the anterior abdominal wall is sutured tightly in layers.

A known method for the treatment of colon cancer by forming a loop ileostomy from the terminal ileum according to Thornball .).

The essence of the method is as follows: The formation of the ileostomy begins with the selection of the loop closest to the caecum. The smallest distance from the site of the proposed ileostomy to the cecum or fistula is 15-20 cm. A prerequisite for choosing a loop is the ability to pull it up 3-4 cm above the skin level. If this fails, it is necessary to mobilize the root of the mesentery of the small intestine at the site of the proposed ileostomy, which will increase the mobility of the loop by 5-7 cm. After selecting the loop, a braid is passed through its mesentery. Proximal to the braid, 3-4 cm, a mark is made by stitching with a silk ligature. An opening is formed in the right iliac region at the McBurney point. The skin is grasped with an Alice clamp and, together with the subcutaneous tissue, is excised to the aponeurosis with a circular incision 3-4 cm in diameter, depending on the thickness of the small intestine and its mesentery. The aponeurosis of the external oblique abdominal muscle is dissected crosswise, the muscles are bluntly pushed apart and the peritoneum is opened. The formed hole should freely pass three fingers: II, III, IV. Through the hole stretched with Farabef's hooks, a loop of the small intestine 8-10 cm long is taken out of the braid so that its proximal knee is on top, and the distal knee is on the bottom. The braid should remain at the level of the skin, and the leading knee should be free without tension. With the ascending colon preserved, before removing the loop, it is rotated 180 °, so that the adductor knee is on top. The next stage of the formation of a loop ileostomy is started only after suturing the wound of the anterior abdominal wall. Instead of a braid, a glass rod is inserted, placed in a rubber tube, which is fixed at both ends with a lavsan or silk ligature through a loop of the intestine. After that, with 13-15 catgut ligatures on an atraumatic needle, the intestine is sutured around the skin so that there are 4-5 ligatures on the distal end of the loop, 1-2 on the mesentery on both sides, and 5-7 on the proximal end of the loop. Ligatures are not cut. At the level of 5-6 mm from the skin, the abductor knee of the loop of the small intestine is crossed with an electrocautery at 1/2-3/4 of the circumference. Both ends of the intestine are treated twice with a 1% solution of iodonate, dried and sutured with the remaining catgut ligatures. Only ligatures are tied on the distal part of the intestine and on the mesentery. Ligatures on the proximal knee of the small intestine are stitched and tied only after the intestine is everted with the help of a “working” tupfer. All ligatures are cut off.

The disadvantages of this method are: conducting a laparotomy, the risk of fistula formation, retraction of the stoma with pronounced subcutaneous fat (obesity), stoma necrosis (insufficient mobilization, strangulation), development of adhesive process, volvulus of the small intestine around the intestinal segment that carries the stoma, prolapse, ventral hernia.

Of the known technical solutions, the closest in purpose and technical essence to the claimed invention is the standard technique of laparoscopic right-sided hemicolectomy (Source: https://yandex.ru/turbo?text=https%3A%2F%2Fwww.puchkovk.ru%2Fkoloproktologiya%2Frak -tolstoy-obodochnoy-kishki%2Fmetodika-laparoskopicheskoy-pravostoronney-gemikolektomii%2F, accessed 10/30/2020), the essence of which is as follows: the operation begins with a high ligation of the great vessels. First, the ileocolic artery and vein are isolated and clipped, then the right colic vessels. Then, the parietal peritoneum is dissected in a single block from bottom to top directly behind the dome of the caecum. Para-aortic lymph node dissection is performed with isolation, skeletonization of the right ureter, aorta and inferior vena cava. The peritoneum is dissected along the right lateral canal, and the mesentery of the colon is exposed along the prerenal fascia retroperitonealis, completely removing the prefascial tissue. The hepatocolic and gastrocolic ligaments are transected, and the greater omentum is removed. The drug is removed in a special plastic container. Next, an interintestinal anastomosis is formed.

The disadvantages of the prototype are: possible bleeding when performing tissue dissection, damage to nearby organs during lymph node dissection (right ureter, kidney, etc.), evagination of the intestine into the stoma, strangulation, development of parastomal hernias. The impossibility of its implementation in patients with colorectal cancer complicated by acute colonic obstruction.

The purpose of the invention is to develop a new method for the formation of a double-barreled decompression ileostomy at the first stage of treatment of colon cancer complicated by obstruction, which will facilitate the subsequent laparoscopic right-sided hemicolectomy with media-lateral access.

The claimed invention is aimed at solving the problem, which consists in creating a method for applying a double-barrel ileostomy for the purpose of decompression in colon cancer complicated by obstruction, followed by laparoscopic right-sided hemicolectomy by media-lateral access. The inventive method is carried out as follows and is illustrated in Fig. one.

Under general anesthesia at the first stage (stage of decompression), an unloading double-barreled ileostomy (4) is placed on the anterior abdominal wall (5) in the projection of the dome of the caecum (1) with an afferent loop (3) located below and an outlet loop (2) of length 5-7 cm from above. Before the main final stage, the stoma (4) is sutured. Ports are installed in typical places, the right sections of the large intestine are mobilized by medial access using standard techniques. Then the section of the intestine, bearing the stoma, is isolated from the anterior abdominal wall (5) and immersed in the abdominal cavity. The wound of the anterior abdominal wall (5) is sutured through all layers to seal the abdominal cavity. Again create a pneumoperitoneum and produce further mobilization through the right lateral canal. A section of the intestine with a tumor is resected and removed through the ileostomal wound in the right iliac region. The stumps of the ileum and transverse colon are brought to the anterior abdominal wall and anastomosis is applied extracorporeally.

Compared with the prototype, the claimed invention has the following distinctive features:

- the stoma is formed in the projection of the dome of the caecum;

- two semilunar incisions up to 3-4 cm long in the longitudinal direction, the skin and subcutaneous tissue are excised to the aponeurosis;

- the leading loop is located below the dome of the caecum;

- the efferent stump is short, 5-7 cm long, at the level of the ileocecal angle;

- mesentery along a. ileocolika is pulled outwards and anteriorly;

- the ileum is fixed below the dome of the caecum.

Thus, the proposed method allows patients with colorectal cancer complicated by acute obstruction to perform decompression at the first stage, prepare the patient for the radical stage, simplify the video laparoscopic access, expose the mesentery with vessels in the ileocecal angle and along the right sections of the colon to perform a radical stage using videolaparoscopic technology with mediolateral access, use an ileostomy wound to remove the resected section of the intestine with a tumor and apply a small-colonic anastomosis extracorporeally.

Claims (1)

A method for applying a double-barrel ileostomy when performing laparoscopic right-sided hemicolectomy with a media-lateral access, including, at the first stage, the formation of a double-barrel ileostomy, at the second stage, laparoscopy, resection of the intestine, removal of the resected section of the intestine, formation of an interintestinal anastomosis, characterized in that at the first stage of decompression, an unloading double-barreled ileostomy is placed on the anterior abdominal wall in the projection of the dome of the caecum with an afferent loop located below and an outlet loop 5-7 cm long from above, at the second stage, the stoma is sutured, laparoscopic ports are installed, the right sections of the large intestine are mobilized by medial access, the from the anterior abdominal wall and immerse in the abdominal cavity the section of the intestine that carries the stoma, suture the wound of the anterior abdominal wall through all layers, creating a pneumoperitoneum, and further mobilize along the right lateral canal, resect the section of the intestine and with a tumor and is removed through the ileostomal wound in the right iliac region, the stumps of the ileum and transverse colon are removed to the anterior abdominal wall and an extracorporeal interintestinal anastomosis is applied.

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