RU2803944C1 - Method of formation of ileorectal suprampullar anastomosis in children - Google Patents

Abstract

FIELD: medicine; pediatric surgery.

SUBSTANCE: ends of the rectum and ileum are brought to the same diameter and connected according to the “end to end” type using a single-layer submucosal-muscular-serous separate interrupted suture, which is formed as follows: the needle is injected into the submucosal layer of the rectum, piercing the submucosal, muscular and serous layer. The puncture is made through the serous membrane to the surface of the intestine at a distance of 0.3–0.4 cm from the edge. The next injection of the needle is performed in the serous membrane of the ileum at a distance of 0.3–0.4 cm from the edge opposite the ileum, piercing the serous, muscular and submucosal membranes. The needle is punctured at the border of the intestinal mucosa and submucosa opposite the puncture in similar layers of the rectum, the surgical knot is formed on the instrument. When forming the next node, before comparing the walls of the intestines, the previous node is immersed inside with tweezers, leaving it between the walls of the intestines. The posterior and then the anterior lip of the anastomosis is formed, and to create an ileorectal connection, the anterior lip of the anastomosis is formed on a stent inserted before the formation of the anterior lip transanally into the rectum and into the adductor ileum to a depth of 5–10 cm from the distal edge of the ileum, and a silicone tube-stent with a diameter of 10–15 mm is used as a stent.

EFFECT: method makes it possible to provide the most physiological position of the intestine, tightness and patency of the anastomosis, maintain microcirculatory blood supply in the layers of the anastomosed intestinal walls, which contributes to better healing of the anastomosis in the postoperative period, prevents inflammation, leakage and stenosis of the anastomosis.

1 cl, 1 ex

Description

The invention relates to medicine, in particular to pediatric surgery, namely to coloproctology, and can be used in the surgical treatment of children with congenital malformations and acquired diseases of the colon, requiring total colectomy with resection of the ileocecal angle, but with preservation of the rectum above the pelvic level peritoneum.

As a result of a patent search in foreign and domestic literature, no analogue was found for the formation of an ileorectal supramullary anastomosis on a stent using a single-row precision suture in children.

There is a known method for forming a reservoir ileorectal anastomosis (RF patent No. 2138209, 1999). With this method, an end-to-end ileorectal anastomosis is performed, after which a reservoir is created by duplicating two anastomosed ileal loops. An invagination valve-spring is formed 3-4 cm proximal to the anastomosis. Seromyotomy of the afferent loop of the reservoir is performed. In this case, the serous-muscular layer of the antimesenteric edge of the intestine is obliquely dissected over a distance of 20-25 cm in a checkerboard pattern. The length of the notch is 12-15 mm. The interval between incisions is 4-5 cm. In a particular case, a small intestinal reservoir 10-12 cm long is performed. This anastomosis is formed in adults after a total colectomy due to tumor lesions and inflammatory bowel diseases.

The main disadvantage is the inappropriateness of using this type of anastomosis in children due to the characteristics of the growth and development of the child’s body. With the further growth of the child, this reservoir becomes an obstacle to the movement of feces, since the reservoir function of the rectum is preserved and increases with age due to the growth and adaptation of the rectum.

The literature also describes methods for forming intussusception small-colic anastomoses.

There is a known method of forming a small-colon anastomosis (RF patent No. 2373872, 2009), which includes the formation of a 3.5-4 cm long “proboscis” on the distal part of the anastomosed small intestine with a section of the mesentery and a terminal feeding vessel, transverse dissection of the colon wall, invagination into its lumen of the small intestinal “proboscis” with fixation of the latter to the walls of the large intestine with interrupted sutures.

There is a known method of forming an ileotransversoanastomosis (RF patent No. 2272585, 2006), in which anastomosis of the end of the ileum into the haustra of the transverse colon and intussusception of the anastomosis from a section of the small intestine into the colon are performed, while an artificial muscular valve is formed by connecting the free and omental muscle bands above the invaginated section of the small intestine with four 8-shaped sutures, and the small-intestinal anastomosis is performed with a single-row precision monofilament suture.

There is a known method of end-to-side invagination small-colic anastomosis (RF patent No. 2215482, 2003), including right-sided hemicolectomy, suturing of the colon stump, characterized in that on the anterior wall of the colon, 5 cm from the stump, a transverse incision is made of all layers with a length of 2, 5-3 cm, departing 5-6 cm from this incision, and parallel to it, the seromuscular layer is dissected, preserving the mucous membrane 0.2 cm larger than the diameter of the small intestine, by traction for the two thread-holders produce a cone-shaped protrusion of the wall of the colon with a dissection of the mucous membrane at its apex, the stump of the small intestine is pulled through the formed serous canal and a single-row continuous serous-muscular-submucosal precision microsurgical suture is applied, the intestinal wound is sutured with a similar suture, the intussusception is fixed to the wall of the colon separate gray-serous sutures.

The disadvantages of these anastomoses are the risk of anastomotic failure, scarring, and ischemia in the anastomotic zone due to separation of the seromuscular layer from the submucosa at different levels.

The closest prototype of the proposed ileorectal anastomosis is the Method for forming a small-colic anastomosis described in the literature in conditions of acute intestinal obstruction and peritonitis (RF patent No. 2709253, 2019).

The method consists in the formation of a small intestinal anastomosis, when the afferent segment of the small intestine is crossed in an oblique transverse direction at an angle of 50°-60° to its mesenteric edge, the stump of the colon is also formed by crossing it in an oblique transverse direction at an angle of 50°- 60° to its mesenteric edge; a “window” is cut out in the antimesenteric part of the colon wall - an oval-shaped area with an area corresponding to the cross-sectional area of the small intestine; the end of the small intestine is connected to the oval opening in the colon in an “end-to-side” manner using a single-row continuous intestinal suture. In this case, the angle between the longitudinal axes of the stitched segments of the small and large intestine is 50-60°.

The disadvantage of this method is the non-physiological arrangement of the intestines in relation to each other - “end to side”, which can create an obstacle to the transit of intestinal contents through the intestines, and reflux and uncontrolled accumulation of feces into the stump of the colon is possible.

The anastomosis in this method is formed with a single-row continuous suture. At the present stage of development of surgery, a single-row intestinal suture is becoming the method of choice when forming interintestinal anastomoses, since double-row intestinal sutures lead to disruption of the blood supply to intestinal tissue along the anastomosis line, which subsequently provokes suture failure with the development of complications such as peritonitis. However, the use of continuous sutures also contributes to disruption of the blood supply to intestinal tissue due to compression of blood vessels by a through thread along the entire perimeter of the wound. Considering the peculiarity of the suture (capturing the serous-muscular-submucosal layer), it may be difficult to adequately assess the insertion and puncture of the needle due to the continuity of the suture.

The significant difference of the proposed method is the formation of the ileorectal connection “end to end”, thus creating the physiological and functionally most advantageous position of the intestinal loops relative to each other to maintain the timely transit of feces. When forming an anastomosis, a single-row submucosal-muscular-serous separate interrupted suture is used, when the needle is inserted into the submucosal layer of the rectum, piercing the submucosal, muscular and serous layers. The puncture is made through the serous membrane on the surface of the intestine at a distance of 0.3-0.4 cm from the edge. Next, the needle is inserted into the serous membrane of the ileum at a distance of 0.3-0.4 cm from the edge opposite the ileum, piercing the serous, muscular and submucous membrane. The needle is injected at the border of the mucous and submucous membranes of the intestine opposite the injection in similar layers of the rectum. A surgical knot is formed on the instrument. When forming the next node, before matching the intestinal walls, the previous node is immersed inside with tweezers and remains between the intestinal walls. To create an ileorectal connection, before forming the anterior lip of the anastomosis, a silicone stent tube with a diameter of 10-15 mm is inserted transanally into the rectum and into the adductor ileum to a depth of 5-10 cm from the distal edge of the ileum, depending on the age of the patient. After the latter, the anterior lip of the anastomosis is formed on it similarly to the posterior lip of the anastomosis.

The objective of the proposed method is to create the most physiological complete connection of the ileum and rectum after colectomy.

The technical result is to ensure the strength and tightness of the anastomosis, preserve the microcirculatory blood supply in the layers of the anastomosed intestinal walls, in addition, the method helps to minimize the risk of complications such as leakage, anastomositis, anastomotic stenosis.

The method is carried out as follows.

After a total colectomy, the end of the ileum and the end of the rectum are mobilized above the level of the pelvic peritoneum. To compare intestines of different diameters, a longitudinal incision of the ileum is made along the antimesenteric edge in the proximal direction until the diameter of the ileum is equal to the diameter of the rectum. After matching the ends of the ileum and rectum in diameter, two stay sutures are placed on opposite sides of the rectum. The next stage is the formation of the posterior lip of the anastomosis with single-row submucosal-muscular-serous interrupted sutures with 4/0 or 3/0 monofilament on an atraumatic stabbing needle at a distance of 0.4-0.5 cm between the sutures. When forming a suture, the needle is inserted into the submucosal layer of the rectum, piercing the submucosal, muscular and serous layers. The puncture is made through the serous membrane on the surface of the intestine at a distance of 0.3-0.4 cm from the edge. Next, the needle is inserted into the serous membrane of the ileum at a distance of 0.3-0.4 cm from the edge opposite the ileum, piercing the serous, muscular and submucous membrane. The needle is injected at the border of the mucous and submucous membranes of the intestine opposite the injection in similar layers of the rectum. A surgical knot is formed on the instrument. When forming the next node, before matching the intestinal walls, the previous node is immersed inside with tweezers and remains between the intestinal walls. The number of sutures on the posterior lip of the anastomosis depends on the diameter of the intestine. Before forming the anterior lip of the anastomosis, a silicone stent tube with a diameter of 10-15 mm is inserted transanally into the rectum and into the adductor ileum to a depth of 5-10 cm from the distal edge of the ileum, depending on the age of the child. After the latter, the anterior lip of the anastomosis is formed on it similarly to the posterior lip of the anastomosis. After the anastomosis is formed, it is peritonized by the pelvic peritoneum. The previously introduced stent tube is sutured to the skin of the perianal area on both sides with a 2/0 braided thread on a cutting atraumatic needle with two single interrupted sutures, one on the side of each gluteal region.

This method was used to operate on 7 patients at the pediatric surgery clinic in Yekaterinburg. Complications from the anastomosis were not noted in any case.

The proposed method of anastomosis formation has a number of advantages:

1) The anastomosis is formed “end to end”, which allows maintaining the most physiological and functionally advantageous position of the intestine and the most physiological movement of feces along the intestinal tube.

2) Formation of an anastomosis with a single-row submucosal-muscular-serous interrupted suture has all the advantages of a double-row intestinal suture - good hemostasis, tightness, satisfactory mechanical strength; The suture allows maximum preservation of the blood supply to the intestinal wall, promotes good adaptation of the edges while maintaining the case structure and complete contact of the mucosa. Immersion of the ends of the threads of interrupted sutures allows you to maintain the asepticity of the seam.

3) Formation of an anastomosis on a stent allows for better control of the diameter of the formed connection, promotes better healing of the anastomosis in the postoperative period, and prevents inflammation and anastomotic failure.

Example 1. Patient K., a 5-year-old boy, was admitted as planned with complaints of stool retention for up to 7 days, bloating and enlargement of the abdomen, lack of effect from laxatives and cleansing enemas. The child underwent laboratory, ultrasonographic, endoscopic and x-ray studies and was diagnosed with a congenital malformation of the large intestine. Neuromuscular dysplasia.

The patient underwent surgical intervention: Laparotomy, total colectomy, resection of the ileocecal angle, end-to-end ileorectoanastomosis.

Protocol: median laparotomy, bypassing the umbilicus on the left. Upon opening the peritoneum, the sharply dilated loops of the colon immediately prolapse. The large intestine has a normal location, expanded throughout, its diameter is 12-15 cm, the walls are thinned, there are no haustra, the contents are mainly gas. The rectum is formed correctly, has a diameter of up to 3 cm, its walls are elastic, and the patency for stent No. 12 is complete. The resection zone was determined - from the ileocecal angle, the entire colon to the rectum 4 cm above the pelvic peritoneum. After performing a total colectomy and resection of the ileocecal angle, an end-to-end ileorectal anastomosis was created on a stent. The ileum descends freely into the pelvis. To compare the diameters of the intestines, the lumen of the ileum was expanded by dissecting the anterior wall along the antimesenteric edge by 2 cm. The formation of the posterior lip of the anastomosis was performed with single-row submucosal-muscular-serous interrupted sutures with monosyn 4/0 on an atraumatic stabbing needle at a distance of 0.4 cm between the sutures. When forming a suture, the needle was inserted into the submucosal layer of the rectum, piercing the submucosal, muscular and serous layers. The puncture was made through the serous membrane on the surface of the intestine at a distance of 0.3 cm from the edge. Next, the needle was inserted into the serous membrane of the ileum at a distance of 0.3 cm from the edge opposite the ileum, piercing the serous, muscular and submucous membrane. The needle was injected at the border of the mucous and submucous membranes of the intestine opposite the injection in similar layers of the rectum. A surgical knot was formed on the instrument. When forming the next node, before matching the intestinal walls, the previous node was immersed inside using tweezers and remained between the intestinal walls. Before forming the anterior lip of the anastomosis, a silicone stent tube No. 12 was inserted transanally into the adductor ileum to a depth of 6-8 cm from the distal edge of the ileum. After the latter, the anterior lip of the anastomosis is formed on it similarly to the posterior lip. The anastomosis is formed hermetically. Peritonization was performed using the pelvic peritoneum. The “window” in the mesentery of the small intestine is sutured. Layer-by-layer sutures were made on the laparotomy wound. The previously inserted transanal tube-stent is sutured to the skin of the gluteal regions on both sides with 2/0 nylon using two single interrupted sutures, one on the side of each gluteal region.

The postoperative period was uneventful and without surgical complications. The stent tube was removed on the 6th day after excretion of feces. The sutures were removed on the 11th day after surgery. The child was discharged in satisfactory condition under the supervision of a surgeon at his place of residence. In the long-term postoperative period (follow-up 1 year), no surgical complications were noted, defecation was spontaneous every day, stool was mushy.

Thus, the most physiological complete connection of the ileum and rectum is achieved after colectomy. The tightness and patency of the anastomosis is ensured, the microcirculatory blood supply is preserved in the layers of the anastomosed intestinal walls, which promotes better healing of the anastomosis in the postoperative period, prevents inflammation, failure and stenosis of the anastomosis.

Claims (1)

A method for forming an ileorectal supramullary anastomosis in children, including matching the ends of the intestines using a single-row intestinal suture, characterized in that the ends of the rectum and ileum are brought to the same diameter and are compared “end to end” using a single-row submucosal-muscular-serous separate nodal a suture, which is formed as follows: the needle is inserted into the submucosal layer of the rectum, piercing the submucosal, muscular and serous layers; the puncture is made through the serous membrane onto the surface of the intestine at a distance of 0.3-0.4 cm from the edge; the next injection of the needle is made in the serous membrane of the ileum at a distance of 0.3-0.4 cm from the edge opposite the ileum, piercing the serous, muscular and submucous membrane; the needle is punctured at the border of the mucous and submucous membranes of the intestine opposite the injection in similar layers of the rectum, a surgical node is formed on the instrument, when forming the next node, before comparing the intestinal walls, the previous node is immersed inside using tweezers, leaving it between the intestinal walls; the posterior and then the anterior lip of the anastomosis are formed, and to create an ileorectal connection, the anterior lip of the anastomosis is formed on a stent, which is inserted before the formation of the anterior lip transanally into the rectum and into the adductor ileum to a depth of 5-10 cm from the distal edge of the ileum, and A silicone stent tube with a diameter of 10-15 mm is used as a stent.