RU2448655C2 - Method of plastic surgery on posterior wall of rectus sheath in surgical management of open gastrointestinal fistulas with vascularised muscle flap - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and may be applicable for plastic surgery on a rectus sheath in surgical management of gastrointestinal fistulas. A vascularised muscle flap is formed from a rectus muscle. The flap is delivered from a muscle compartment. A donor zone is reinforced with a polypropylene mesh explant placed in the sheath between its anterior and posterior walls and fixed to the posterior wall of the sheath by single sutures. A muscle grafting follows draining and closing the sheath.

EFFECT: method enables higher resistance of the donor zone to mechanical effect.

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Description

The invention relates to medicine, namely to surgery. The aim of the invention is to improve the results of surgical treatment of unformed incomplete gastric and intestinal fistulas by plasty with a flap on a vascular pedicle formed from the rectus abdominis muscle and simultaneous plasty of the posterior wall of its vagina - vagina m. recti abdominis - polypropylene mesh explant.

Unformed incomplete fistulas of the gastrointestinal tract are a complex and unresolved problem of abdominal surgery. They arise due to the failure of the gastric and intestinal suture and perforation of the wall of the hollow organ. Unformed fistulas are complicated by severe disturbances in homeostasis, local and widespread peritonitis, arrosion bleeding, new intestinal fistulas and sepsis (Kanshin N.N., 1998; Grigoryev E.G., Kogan A.S., 2000). An effective method of surgical treatment of these fistulas is muscle plasty with a flap on the vascular pedicle (Vazin N.A., 1946; Petrov V.P. et al., 2003). A number of authors (Grinev M.V., 1992, Bykov V.P. et al., 2008) use the rectus abdominis muscle for this purpose, which, after mobilization and intersection, is transferred from its vagina to the abdominal cavity or wound of the anterior abdominal wall. The fascial vagina after removal of the muscle flap beyond it is drained with a silicone tube and sutured. This operation reduces the strength of the abdominal wall and may cause the formation of a postoperative hernia in the long term.

The back wall of the vagina of the rectus abdominis muscle throughout has a different structure. The muscular-aponeurotic section of the posterior wall is located from the edge of the costal arch to the arcuate line located about 5-6 cm below the navel. The posterior wall of the vagina is formed by the aponeurosis of the transverse muscle and the posterior leaf of the bifurcated aponeurosis of the internal oblique muscle. Partially into the back wall the bundles of the transverse muscle penetrate (T. Zolotareva, 1972). The lower, fascial section of the posterior wall of the rectus vagina from the arcuate line to the upper edge of the pubis is presented in the form of a thin fascial plate, which is the transverse fascia of the abdomen (Zolotareva T.V., 1972).

Unlike analogues (Grinev M.V., 1992, Bykov V.P. et al., 2008), after the formation and removal of the rectus flap from the fascial vagina, we perform plastic surgery of the posterior wall of the vagina with a polypropylene mesh explant, followed by drainage of the vagina and suturing wounds of the anterior wall. With a muscle flap, close the intestinal fistula.

Description of the technique of the developed method of plastics

At the first stage, according to well-known rules, a flap is formed from the rectus abdominis muscle. After a longitudinal dissection of the anterior wall of the fascial vagina of the rectus abdominis muscle, the muscle is secreted in a sharp and blunt way for a length sufficient to cover the unformed fistula. The rectus muscle after mobilization crosses laterally, and the formed muscle flap is removed outside the fascial vagina (Fig. 1). A polypropylene mesh explant, the dimensions of which correspond to the exposed part of the posterior wall of the vagina, is placed in the vaginal cavity and is fixed to the posterior wall with single sutures (Fig. 2). The fascial vagina is drained with a silicone tube and sutured. A graft placed between the anterior and posterior walls of the vagina of the rectus abdominis muscle increases the resistance of the donor zone to mechanical stress. Muscular flap cover the intestinal fistula (Fig.3).

Figure 1 schematically shows the first stage of treatment of an unformed intestinal fistula with a flap from the right rectus abdominis muscle on the feeding upper epigastric artery. The number 1 denotes a muscle flap moved to the abdominal cavity to the intestinal fistula, the number 2 - the exposed part of the posterior wall of the vagina of the rectus muscle, the number 3 - the intestinal loop with a functioning unformed fistula.

Figure 2 schematically presents the second stage of surgical treatment - plastic of the posterior wall of the vagina of the rectus abdominis muscle. Numeral 1 denotes a muscle flap moved to the abdominal cavity to the intestinal fistula, numeral 2 - part of the posterior wall of the rectus sheath, covered with a polypropylene mesh explant, which is fixed with sutures to the posterior wall; number 3 - a bowel loop with a functioning unformed fistula.

Figure 3 schematically shows the third stage of surgical treatment of an unformed intestinal fistula - drainage and suturing of the vagina of the right rectus abdominis muscle, muscle plastic of the intestinal fistula. Numeral 1 denotes a muscle flap moved to the abdominal cavity to the intestinal fistula, 3 indicates an unformed fistula of the intestinal loop covered by a muscle flap, 4 indicates a sutured wound of the anterior vaginal wall of the right rectus muscle, and 5 indicates a tubular drainage in the rectus vagina.

Information sources

1. Vazin N.A. Debate // Tr. XXV All-Union Congress of Surgeons, Moscow, October 1-8, 1946 - M., 1948. - P.275-278.

2. Grigoriev E.G. Surgery of severe purulent processes / E.G. Grigoriev, A.S. Kogan. - Novosibirsk: Nauka, 2000 .-- 314 p.

3. Grinev M.V. The technique of closing the full formed duodenal fistula opening into the purulent cavity / M.V. Grinev // Vestn. surgery. - 1992. - No. 1/2/3. - S.236-237.

4. Kanshin N.N. Treatment of unformed fistulas of the small intestine in conditions of purulent peritonitis / NN Kanshin // Surgery. - 1998. - No. 10. - S. 37-40.

5. Ermolov A.S. On concepts and terms in modern herniology: what should be clarified? / A.S. Ermolov, A.V. Upyrev // Herniology (hernias). - Moscow, 2006. - No. 3 (11). - S.18-19.

6. Zolotareva T.V. Surgical anatomy of the anterolateral abdominal wall / T.V. Zolotareva // Surgical anatomy of the abdomen. Ed. A.N. Maksimenkova. - L .: Medicine, 1972. - Ch. II. - S.23-53.

7. Pat. 2338468, Russian Federation, IPC А61В 17/00. A method of surgical treatment of unformed mixed incomplete fistulas of the gastrointestinal tract with a split muscle flap on the vascular pedicle / Bykov V.P., Berezin A.V., Baranov S.N., Lebedev N.P .; declared 02.22.2007; publ. 11/20/2008, bull. Number 32.

Claims (1)

A method for plastic surgery of the rectus vagina during surgical treatment of fistulas of the gastrointestinal tract, including the formation of a muscle flap on the vascular pedicle from the specified muscle, after removing which from the fascial sheath the donor area is strengthened with a polypropylene mesh explant placed in the vagina between its front and back walls and fixed to the back of the vagina with single seams; after drainage and suturing of the vagina, muscle plasty of the intestinal fistula is performed.

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