RU2797219C1 - Method of surgical treatment of postoperative anal stricture - Google Patents

Abstract

FIELD: surgery; coloproctology.

SUBSTANCE: invention can be used for the treatment of postoperative stricture of the anal canal. Stepping back 3 mm on both sides of the stricture, two arcuate incisions are made converging 2 mm proximal and distal to the edges of the stricture. Then the scar tissue is dissected, after which the stricture is excised from the underlying healthy tissues. Two muco-submucosal flaps are formed, for which purpose one laxative incision of at least 1.5 cm each is performed on both sides of the wound edges along the anocutaneous line. An anal canal plasty is performed in the following way: the formed muco-submucosal flaps are pulled up to the anocutaneous line and sutured with separate interrupted sutures. The operation is completed by applying an ointment bandage.

EFFECT: method is highly effective, can significantly improve the results of treatment of the disease and reduce the time of wound healing to 10–12 days.

1 cl, 2 ex

Description

The invention relates to surgery, in particular to coloproctology and can be used for the treatment of postoperative stricture of the anal canal.

Postoperative stricture of the anal canal is an acquired pathology, which is characterized by a local or extended decrease in the lumen of the rectum (Pomazkin V.I., Mansurov Yu.V. Surgical treatment of cicatricial strictures of the anal canal // Surgery. Journal named after N.I. Pirogov. - 2011. - No. 1. S. 48-51). This pathology develops due to the formation of postoperative deforming extensive scars in the anal canal. Most often, postoperative stricture of the anal canal is a complication of hemorrhoidectomy (from 1.5 to 15%) and excision of the anal fissure (1-5%) (An V.K. Strictures of the anal canal and the choice of the method of their surgical treatment: abstract of diss. … Candidate of Medical Sciences, Moscow, 1996. 23 p.). Often, during such operations, a significant, sometimes excessive, amount of epithelial tissue is excised. Taking into account the severity of the individual ability of the organism to regenerate, after 1.5-6 months, the formation of cicatricial strictures occurs. Despite the fact that the pathology occurs infrequently, it has an extremely negative effect on the function of the rectum and its obturator apparatus, on the quality of life of the patient, making it difficult to defecate. Despite a significant number of methods of surgical treatment of anal stricture, all of them have a number of disadvantages, such as prolonged healing of the postoperative wound and relapse of the disease (Casadesus D., Villasana L. E., Diaz H. et al. Treatment of anal stenosis: a 5 -year review // ANZ J. Surg. 2007, Jul. Vol. 77(7), pp. 557-559).

Thus, dissatisfaction with the results of existing methods of surgical treatment of postoperative anal canal strictures requires the development of new highly effective methods of surgical treatment of postoperative anal canal strictures.

A search in the scientific medical and patent literature found various methods of surgical treatment of postoperative anal canal stricture.

A known method of surgical treatment of postoperative strictures of the anal canal, which consists in the sequential forced stretching of the anal canal, by bougienage (Andrianov AV Surgery. - 1988. - No. 12. - S. 129-131). The disadvantages of this method of surgical treatment of postoperative stricture of the anal canal is a significant incidence of recurrence (17-36%), which in the long term may even worsen the course of the disease, since at the time of the manipulation, the tissues of the anal canal are traumatized, which may lead to additional education. scars after excessive stretching (Habr-Gama A., Sobrado C.W., de Araujo S. E. et al. Surgical treatment of anal stenosis: assessment of 77 anoplasties // Clinics. - 2005. - Vol 60. - No. 1 . - P. 17-20).

Patent of the Russian Federation No. 2312619 (published on December 20, 2007) protects "Method of surgical treatment of cicatricial stricture of the anal canal". The method consists in dissection of strictures in the radial direction, partial excision of scar tissue. The disadvantage of this method is the long-term healing of the postoperative wound and the recurrence of the disease.

RF patent No. 2391917 (published on 06/20/2010) protects the "Method of surgical treatment of postoperative anal strictures", which we adopted as a prototype. The scar tissue is dissected, a flap is formed, anal canal plastic surgery is performed, a laxative incision is made, and an ointment bandage is applied. The scar tissue is dissected along the stricture of the anal canal. At the same time, the mucosa is separated in the form of a trapezium with a base in the depth of the rectum, equal to 3-4 cm, and an apex at the edge of the stricture wound. The side walls of the trapezoid flap are formed by dissecting the tissues in the direction of the base of the trapezium to a depth of 4-5 cm. Then, the mucosal folds are straightened, the flap is lowered 0.5-1.0 cm below the edge of the anus, fixed to the perianal skin with two or three interrupted sutures. A laxative linear skin incision is made at 6 o'clock, 3 cm from the edge of the anus, perpendicular to the Langer lines, 2 times longer than the top of the trapezoid flap, averaging 3-5 cm.

The disadvantage of the prototype is the duration of wound healing, which according to the authors of the prototype is 16 days.

The objective of the invention is to develop a highly effective method for the surgical treatment of postoperative strictures of the anal canal.

The technical result, manifested in the implementation of the proposed method, is to reduce the time of wound healing.

The technical result is achieved by the fact that, stepping back 3 mm on both sides of the stricture, two arcuate incisions are made, converging 2 mm proximal and distal to the edges of the stricture. Then the scar tissue is dissected, after which the stricture is excised from the underlying healthy tissues. Two muco-submucosal flaps are formed, for which purpose one laxative incision of at least 1.5 cm each is performed on both sides of the wound edges along the anocutaneous line. An anal canal plasty is performed; for this, the formed muco-submucosal flaps are pulled up to the anocutaneous line and sutured with separate interrupted sutures. The operation is completed by applying an ointment bandage.

Detailed description of the method.

Under spinal anesthesia, in the position of the patient lying on his back with legs apart, the surgical field is treated three times with antiseptic solutions. The anal sphincter is divulged with a rectal speculum. After divulsion visualize the extent and localization of postoperative stricture of the anal canal. Stepping back 3 mm on both sides of the stricture, two arcuate incisions are made with a scalpel, converging 2 mm proximal and distal to the edges of the stricture. Then, the scar tissue is dissected, after which the stricture is excised with a scalpel from the underlying healthy tissues. Anatomical tweezers mobilize and form two muco-submucosal flaps, for which one laxative incision is made with a scalpel on both sides of the wound edges along the anocutaneous line. Each incision is at least 1.5 cm long each. An anal canal plastic surgery is performed, for this, the formed muco-submucosal flaps are pulled with anatomical tweezers to the anocutaneous line and sutured with separate interrupted sutures with a monofilament polyglycolide thread No. 3/0 (for example, Biosyn No. 3/0). The operation is completed by applying an ointment bandage.

The practical feasibility of the proposed method is illustrated by examples from clinical practice.

Example 1: Patient K., 46 years old, was admitted to the surgical department of the clinic of the Rostov State Medical University of the Ministry of Health of Russia (RostSMU) with complaints of red blood discharge during defecation, intense unbearable pain in the anal canal, difficult emptying of the rectum, incomplete evacuation from the rectum intestines during defecation.

In the anamnesis, patient K. underwent surgery for chronic hemorrhoids of the 4th stage; in the postoperative period, against the background of a long-term non-healing postoperative wound, a postoperative stricture of the anal canal was formed for 7 months at 7 o'clock of the conditional dial.

Objectively, when viewed in mirrors at 7 o'clock of the conditional dial, a cicatricial deformity of the mucous membrane of the anal canal is visualized in the form of a dense, inactive whitish cord, 34 mm long, with a transition to the skin of the perianal region, narrowing the lumen of the anal canal.

Patient K. was diagnosed with postoperative stricture of the anal canal and underwent surgical treatment according to the claimed method.

Under spinal anesthesia, in the position of the patient K. lying on his back with legs apart, the surgical field was treated three times with antiseptic solutions. Performed a divulsion of the anal sphincter with a rectal mirror. After divulsion, the extent and localization of the postoperative stricture of the anal canal were visualized. Stepping back 3 mm on both sides of the stricture, two arcuate incisions were made with a scalpel, converging by 2 mm, proximal and distal to the edges of the stricture. Then, the scar tissue was dissected, after which the stricture was excised with a scalpel from the underlying healthy tissues. Anatomical tweezers were used to mobilize and form two muco-submucosal flaps, for which one laxative incision was made with a scalpel on both sides of the wound edges along the anocutaneous line. Each cut is 1.7 cm long each. An anal canal plasty was performed, for this, the formed muco-submucosal flaps were pulled up with anatomical tweezers to the anocutaneous line and sutured with separate interrupted sutures with a monofilament polyglycolide thread No. 3/0 (for example, Biosin No. 3/0). The operation was completed by applying an ointment bandage.

The postoperative period was uneventful, without complications. The wound in the anal canal healed by primary intention on the 11th day.

Example 2: Patient M., 39 years old, was admitted to the surgical department of the clinic of Rostov State Medical University with complaints of red blood discharge during defecation, intense unbearable pain in the anal canal, difficult emptying of the rectum, incomplete evacuation from the rectum during defecation.

In the anamnesis, patient M. c underwent surgery for a chronic anal fissure; in the postoperative period, against the background of a long-term non-healing postoperative wound, a postoperative stricture of the anal canal was formed for 5 months at 6 o'clock of the conventional dial.

Objectively, when viewed in mirrors at 6 o'clock of the conditional dial, a cicatricial deformity of the mucous membrane of the anal canal is visualized in the form of a dense, inactive strand, 28 mm long, with a transition to the skin of the perianal region, narrowing the lumen of the anal canal.

Based on the foregoing, patient M. was diagnosed with postoperative stricture of the anal canal.

Under spinal anesthesia, in the position of the patient lying on his back with legs apart, the surgical field was treated three times with antiseptic solutions. Performed a divulsion of the anal sphincter with a rectal mirror. After divulsion, the extent and localization of the postoperative stricture of the anal canal were visualized. Stepping back 3 mm on both sides of the stricture, two arcuate incisions were made with a scalpel, converging by 2 mm, proximal and distal to the edges of the stricture. Then, the scar tissue was dissected, after which the stricture was excised with a scalpel from the underlying healthy tissues. Anatomical tweezers were used to mobilize and form two muco-submucosal flaps, for which one laxative incision was made with a scalpel on both sides of the wound edges along the anocutaneous line. Each cut is 1.5 cm long each. An anal canal plasty was performed, for this, the formed muco-submucosal flaps were pulled up with anatomical tweezers to the anocutaneous line and sutured with separate interrupted sutures with a monofilament polyglycolide thread No. 3/0 (for example, Biosin No. 3/0). The operation was completed by applying an ointment bandage.

The postoperative period was uneventful, without complications. The wound in the anal canal healed by primary intention on the 12th day.

In the surgical department of the clinic of Rostov State Medical University, according to the proposed method, 15 patients with postoperative strictures of the anal canal were operated on, according to the proposed method. In all cases, postoperative wounds healed by primary intention, the terms of wound healing ranged from 10 to 12 days. In the long-term follow-up period, no cases of relapse were detected in any patient.

Thus, the proposed method of surgical treatment of cicatricial stricture of the anal canal is highly effective and can significantly improve the results of treatment of the disease, in comparison with the prototype to reduce the time of wound healing to 10-12 days.

Claims (1)

Method for surgical treatment of postoperative stricture of the anal canal, including dissection of scar tissue, formation of a flap, plasty of the anal canal, making a laxative incision and applying an ointment bandage, characterized in that, having previously retreated 3 mm on both sides of the stricture, two arcuate incisions are made, converging between themselves 2 mm proximal and distal to the edges of the stricture, the scar tissue is dissected, after which the stricture is excised from the underlying healthy tissues; two muco-submucosal flaps are formed, for which one laxative incision of at least 1.5 cm long is performed on both sides of the wound edges along the anocutaneous line, then the anal canal plastic surgery is performed, for this, the formed muco-submucosal flaps are pulled to the anocutaneous line and sewn with separate nodal sutures.