2 English references Uretersigmoidostomy
ureteral sigmoid colon anastomosis
Operation name: ureter sigmoid colon anastomosis
Uretersigmoidostomy is another name for uretersigmoidostomy.
Classification 5 Pediatric Surgery/Ureteral and Bladder Diseases Surgery/Bladder Eversion Surgery
6 ICD code 56.7 1
To summarize the surgical methods of uretersigmoid colon anastomosis in the treatment of bladder eversion. There are many methods for uretersigmoid colon anastomosis, and each method has its own advantages and disadvantages. This operation has the following advantages: ① the operation has less damage to the patient; ② Postoperative patients can automatically control urination and defecation without using urine bag; ③ There is no fistula in abdominal wall. However, due to the confluence of urine and feces, there are many complications. When patients tend to get old, a few patients will also be incontinent. This operation can only be performed when the patient refuses to undergo ileal bladder surgery and needs urinary diversion.
Bladder eversion is prone to serious urinary tract infection due to the defect of the anterior wall of the bladder, urine overflow and the exposure of the mucosa of the posterior wall, which is often complicated with other congenital malformations. So most of them died in infancy (figure 12.22.3.20 1, 12.22.3.202).
According to the degree of bladder eversion, it can be divided into four types: ① mild: bladder sphincter eversion with mild hypospadias; ② Medium-sized: bladder neck and bladder triangle everted, exposing ureter orifice; ③ More serious: the posterior wall of bladder is exposed with pubic symphysis separation, except urethral malformation and rectus abdominis and muscle sheath defect; ④ Severe type: all the bladder walls are everted, accompanied by complete hypospadias, extensive defects of abdominal wall and pubic symphysis, which may be combined with dislocation of hip joint, inguinal hernia, omphalocele, spina bifida, atresia or intestinal malformation (Figure 12.22.3.203).
The main treatment methods of bladder eversion are as follows: ① The newborn can be closed without osteotomy within 48 hours after birth; After 48 hours, bilateral osteotomy is needed. After osteotomy, simple sling can be used to traction to 3 years old, and external fixation or closure can be done after 3 years old; ② Testosterone should be used with caution in patients over the age of L; ③ hypospadias repair 12 ~ 18 months (phase I); ④ Upper urinary tract (ultrasound) and bladder volume (cystography) were detected every year; ⑤ Reconstruction of bladder neck with or without enterocystoplasty; ⑥ Empty bladder by pressing or intermittent catheterization.
8 indicates 1. After total cystectomy for bladder cancer.
2. Complete bladder eversion.
3. Irreparable bladder fistula.
4. Some permanent urinary incontinence is invalid after plastic surgery.
5. Bladder eversion cannot be formed or failed to form.
6. The ureter has no obvious dilatation, hydronephrosis and normal renal function.
7.*** sphincter function is normal.
9 preparation before operation 1. Eat a high-calorie high-protein low-residue diet 3 days before operation to strengthen nutrition; Liquid diet (double) was given 24 hours before operation.
2. sulfaguanidine 1g, 4 times a day for 3 days. Or oral streptomycin 36 hours before operation, 0.5g every 6 hours.
3. A few days before the operation, 200ml of normal saline *** 1 time is feasible. Let it stay on the ground and try to see if there is incontinence.
4. castor oil was given 48 and 24 hours before operation, 65438±05ml each. Two days before operation, 2000ml of warm normal saline was used every night. Two hours before operation, 500 ml 1% neomycin was used as rectal * * * to remove the dirt in the intestinal cavity.
5. Measure the binding force of potassium, sodium, chloride ion and co2 in blood.
10 anesthesia continuous epidural anesthesia or continuous spinal anesthesia.
1 1 operation steps 1 1. 1. Incision was made around the everted bladder (figure 12.22.3.2 1).
1 1.2 2. Excision of bladder mucosa and partial muscularis. Bladder mucosa and part of muscularis can be removed, but the deeper muscularis can be preserved to strengthen the abdominal wall and prevent hernia (Figure 12.22.3.22).
1 1.3 3. After bilateral ureters are released into the abdominal cavity, the peritoneum is cut at the pelvic margin to find ureters. Generally, a funicular ureter is faintly visible in the peritoneum on the right side of the rectum, which is easy to identify. The left ureter can be cut through peritoneum at the outer edge of sigmoid colon and searched from outside to inside in turn. After finding the ureter, lift it and separate it towards the bladder until it is cut off at the low position. The distal end was ligated with silk thread. Select a suitable ureteral segment for transplantation in sigmoid colon area.
1 1.4 4. There are three methods for ureter sigmoid colon anastomosis:
11.4.1(1) direct anastomosis method: ① make a small incision in the colon band to reach the intestinal cavity, with a length of about 0.5 ~ 1 cm. Incise the muscle layer and mucosa of sigmoid colon (figure 12.22.3.23A, b).
② The lower end of the ureter is slightly split or cut into an inclined plane to enlarge the orifice (Figure 12.22.3.24).
③ The oval inclined plane of ureter is aligned with the incision of intestinal wall, and 40 intestinal lines are intermittently sutured between everted ureter and the edge of colonic mucosa (Figure 12.22.3.25a ~ c).
Attention should be paid to the direction of ureter during anastomosis, and the inclined plane of ureteral orifice should be anastomosed with colon incision in natural state, so as to avoid rotating and twisting ureter and causing poor urine flow. Before anastomosis, it is necessary to estimate the appropriate length and sew a needle on the front wall near the broken end for marking. Colon mucosa tends to contract inward after incision, so the mucosa must be sutured at the anastomosis to ensure the mucosa-to-mucosa anastomosis and avoid the scar stenosis at the anastomosis after operation. In addition, because there is no tunnel protection in direct anastomosis, the suture should be properly tightened, and generally about 10 ~ 12 stitches are needed to avoid urine leakage at the anastomosis.
The advantage of this method is that anastomotic stenosis is not easy to occur and urination is smooth. However, because the ureter is directly opened on the colon wall, the gas and feces in the intestine are easy to reflux, causing upward infection and upper urinary tract dilatation, which affects the curative effect.
1 1.4.2 (2) Tunnel anastomosis: ① After the ureter is led out from both sides of the colon, the serosa and muscularis are cut to the submucosa in the colon band, with a length of about 3 ~ 4 cm (Figure 12.22.3.26).
② The submucosal stealth separation of both sides is about 1 ~ 1.5 cm. The incision of the intestinal wall should be stopped carefully to avoid the formation of hematoma in the tunnel (Figure 12.22.3.27).
③ Cut the end of ureter by 0.5 ~ 0.7 cm, and evert it with 50 catgut for 3 stitches (Figure 12.22.3.28).
④ The ureter leads out from the submucosa on both sides of the sigmoid colon (Figure 12.22.3.29). Cut a small hole in the mucosal layer at the far end of the tunnel with scissors (Figure 12.22.3.26438+00).
⑤ The ureter was embedded into the incision of colonic mucosa by 0.5 ~ 1.0 cm, and 40 intestinal lines were sutured intermittently, and fixed with 3 ~ 4 stitches. Carefully check whether the ureteral orifice has completely entered the intestinal cavity to prevent some orifices in the tunnel from opening, so as to avoid urine leakage from the anastomotic orifice after operation. Then the seromuscular layer of the cut intestinal wall was sutured intermittently with thin thread (Figure12.22.3.211).
⑥ When the intestinal wall is sutured, a tunnel passing through the ureter will be formed between the seromuscular layer and the mucosal layer, and the ureter should not be too tight or twisted. The total length of the tunnel is about 4 ~ 5cm (Figure 12.22.3.3438+02).
The advantage of this method is that the ureter passes through the tunnel of intestinal wall, and the tunnel structure can play the role of flap such as ureter bladder wall to prevent urine and feces from flowing back, causing hydronephrosis and infection. The disadvantage is that there is no mucosa-to-mucosa anastomosis when ureter is implanted into intestinal cavity, and it is easy to form stenosis after operation.
1 1.4.3 (3) Combination method: ① Same tunnel anastomosis method, the length of the seromuscular layer in the colon band is about 3 ~ 4 cm. Free the edges of both sides and ligate the bleeding point. Cut the end of the ureter by 0.8 ~ 1.0 cm or cut it into an inclined plane, aim the nozzle at the mucosal incision at the far end of the tunnel, and cut the mucosal incision of the intestinal wall smaller with 40 intestinal lines intermittently sewing 8 ~ 10 needles, so as to avoid the greater tear during suture and the incompatibility between the ureteral orifice and the mucosal incision (Figure12.22.3.
② The seromuscular layer of the intestinal wall is sutured intermittently above the ureter with thin lines, and the suture can slightly cover the adventitia of the ureter to prevent retraction (Figure 12.22.3.2 14).
In fact, the combined method is the synthesis of the first two methods, which has the advantages that mucosal anastomosis is not easy to cause stenosis and tunnel flap.
After ureter sigmoid colon transplantation, the cut retroperitoneum was sutured intermittently with 10 silk thread.
Matters needing attention in operation 12 1. Continuous suture of 40 or 50 flat catgut threads at the anastomotic site has less knots and less foreign body reaction, so as to avoid urine leakage after operation.
2. Pay attention to avoid damaging the mesenteric vessels at the retroperitoneal incision.
3. After the bilateral anastomosis is completed, adjust the anal canal to a proper position and fix it on the skin around * * * to prevent it from slipping out.
4. When separating ureter, attention should be paid to ensure blood supply to avoid postoperative wall necrosis.
5. During ureter sigmoid colon anastomosis, attention should be paid to suture the mucosal layer of both to prevent postoperative urine leakage.
6. The position of ureter should be straightened to prevent torsion.
13 after ureter sigmoid colon anastomosis, the following treatments were performed:
1. Go back to the ward, lie flat for 6 hours, then change to semi-lying position, fasting, intravenous rehydration, gastrointestinal decompression for 2 ~ 3 days to prevent flatulence. The porous anal canal was placed in rectum, and the urination was observed and the fluid volume was recorded. Generally, liquid diet is introduced 3 days after operation, and semi-liquid diet is improved 5 days after operation, and then the food intake is gradually increased.
2. Use antibiotics (such as penicillin and metronidazole).
3. After indwelling the anal canal 1 week, take it out, insert it at night if necessary, and practice defecation during the day. Pay attention to blood biochemistry (carbon dioxide binding capacity, urea nitrogen, creatinine) and electrolytes. Intravenous pyelography can be performed after 3 months.
14 complications 14. 1 1. Anastomotic obstruction can occur in the early stage after ureter sigmoid colon anastomosis. The main reason may be that anastomotic edema leads to temporary poor urine flow. Some people advocate inserting the anastomotic stoma into the ureteral catheter and leading it out of the body through * * * to avoid obstruction caused by edema. However, some people think that catheter is easy to cause retrograde infection.
14.2 2. Perchloric acid poisoning is the most common complication after operation. Urine stays in the intestine and widely contacts the colon mucosa, and hydrogen ions, chloride ions and ammonium ions are absorbed in large quantities. After ammonium chloride is absorbed, some ammonium chloride is converted into urea and hydrochloric acid in the liver and blood. After hydrochloric acid reacts with alkaline buffer, sodium chloride and carbonic acid are generated. Sodium chloride, urea and another part of ammonium chloride are discharged into the colon with urine through the kidney, while urea can be converted into ammonia by urea decomposing bacteria, and chloride ions and ammonium ions are absorbed by the intestine, forming intestinal-renal circulation. At the same time, sodium chloride and potassium ions are constantly excreted, which reduces alkali consumption and alkali reserve and aggravates hyperchlorinated acidosis. The most important prevention and treatment method is to reduce the long-term retention of urine in the intestine and the absorption of chloride. If necessary, short-term indwelling anal canal to drain urine, training sick children to defecate frequently during the day, and inserting anal canal to urinate at night. At the same time, oral sodium bicarbonate 0. 1 ~ 1g, three times a day.
14.3 3. Hypokalemia and hypokalemia cause hypokalemia syndrome and hypokalemia paralysis. There are two ways to lose potassium: ① Potassium is filtered from glomerulus and excreted from renal distal convoluted tubule. Potassium excretion from renal distal convoluted tubule is not affected by potassium deficiency in vivo. For example, if renal function declines, the function of renal proximal convoluted tubule to reabsorb potassium decreases, and ammonium chloride and urea with osmotic diuretic effect may cause dehydration of cells, resulting in a large amount of potassium excretion in cells, which will increase the loss of potassium. ② The content of potassium in normal people's intestines is high, and part of it is absorbed by colon. After anastomosis, the frequency of defecation increased, and urine and intestinal potassium were excreted with urine, which reduced potassium absorption and increased potassium loss.
14.4 4. Ascending pyelonephritis can be secondary to pyelonephritis caused by anastomotic stenosis or intestinal urine and feces retrograde into the upper urinary tract.
14.5 5. Renal insufficiency