yǐ zhuàng jié. Chá ng dā n qi ā ng zà o k ǒ u sh? 2 English reference
single lumen sigmoidostomy 3 operation name
sigmoidostomy 4 alias of sigmoidostomy
sigmoidostomy 5 classification
general surgery/ Colon surgery/colostomy
6 ICD code
46.14 7 Overview
Single-cavity sigmoid colostomy is mostly used for Miles operation or Hartmann operation. 8 Colon-related anatomy < P > The colon is about 1.5m long, which is about 1/4 of the small intestine. There are four characteristics in the appearance of colon, which are easy to distinguish from small intestine: ① Colonic band: three longitudinal bands formed by the longitudinal muscle layer of colon wall, from the cecum end to the junction of sigmoid colon and rectum; (2) Colonic pouch: because the colon band is short and the colon is long, the intestinal wall is shrunk into a sac; (3) Fat pendant (intestinal fat pendant): It is formed by the accumulation of the visceral subperitoneal adipose tissue of the colon, which is most distributed along the colon band, flat in the proximal colon and pedicled in the sigmoid colon; ④ The intestinal cavity is larger and the intestinal wall is thinner (Figure 1.7.3.41). Colon is divided into cecum, ascending colon, transverse colon and sigmoid colon. The function of the colon is mainly to absorb water and store feces (Figure 1.7.3.42). The absorption is mainly in the right colon. Because its contents are liquid, semi-liquid and soft, it mainly absorbs water, inorganic salts, gas, a small amount of sugar and other water-soluble substances, but it cannot absorb protein and fat. If the peristalsis of the right colon decreases, the absorption capacity will be strengthened; If there is a hard fecal mass in the transverse colon, it often leads to constipation. The contents of the left colon are soft, semi-soft or solid, so it can only absorb a small amount of water, salt and sugar. If the peristalsis of the left colon is enhanced, the absorption capacity will be reduced, and diarrhea or loose stools will often occur. The colonic mucosa can only secrete mucus, so that the mucosa is lubricated to facilitate the passage of feces. After colon resection, the function of absorbing water is gradually replaced by ileum, so it will not cause permanent metabolic disorder mainly for any part or even all of colon resection.
The cecum is located in the right iliac fossa, which is the beginning of ascending colon, connected with the end of ileum, and has a blind tubular appendix at its lower end. The mucosa where the ileum protrudes into the cecum is folded into a lip-shaped ileocecal flap, which has the function of sphincter and can prevent the reflux of intestinal contents. The cecum is completely covered by peritoneum, so it has certain activity. If the range of motion is too large, it can form a mobile cecum, which can be twisted or enter the hernia sac. The ascending colon is the continuation of cecum, which goes up to the lower part of the right lobe of the liver, bends to the left to form a colonic hepatic curve, and it migrates to the transverse colon. The ascending colon is covered with peritoneum in front and on both sides, and its position is relatively fixed. But the posterior part is separated from the right kidney and ureter by honeycomb tissue and the posterior abdominal wall. There is a descending part of the duodenum slightly above the inner side of the hepatic curvature of the colon. When the right colon is removed, do not damage the duodenum, especially when there is adhesion. The transverse colon starts from the hepatic curvature of the colon, turns to an acute angle at the lower splenic pole to the left, forms the splenic curvature of the colon, and connects the descending colon downwards. The transverse colon is completely surrounded by peritoneum, and forms a transverse mesocolon, which is connected to the posterior abdominal wall. The position of splenic flexure of colon is high, and the upper part is close to the tail of pancreas and spleen. Attention should be paid to the protection of pancreas and spleen when colon resection is carried out. Similarly, in the case of splenic rupture and massive hemorrhage and splenectomy, the injury of colonic splenic flexure should be prevented at any time. The descending colon starts from the splenic flexure of the colon and goes down to the left iliac crest to meet the sigmoid colon. The descending colon is roughly the same as the ascending colon, and is only surrounded by peritoneum on the front and sides. Because the back of ascending and descending colon is outside the peritoneum, when there is hematoma behind the peritoneum, it is necessary to explore the extraperitoneal part of the colon freely to avoid serious consequences. The sigmoid colon starts from the left iliac crest and connects to the rectum at the upper edge of the third sacral vertebra. The mesentery of sigmoid colon is relatively long, so it is more active, which may be one of the causes of volvulus.
the blood supply of the right colon (fig. 1.7.3.43) comes from the right branch of the middle colon artery, the right colon artery and the ileocolic artery, which branch from the superior mesenteric artery. About 25% patients have no middle colonic artery, but are replaced by a branch of the right colonic artery. Some patients have two middle colonic arteries. The blood supply of transverse colon comes from the middle colon artery of superior mesenteric artery. The blood of the left colon comes from the left colon artery and sigmoid colon artery which branch from the inferior mesenteric artery. Veins go hand in hand with arteries and eventually pour into portal vein. There is no anastomosis between the left colon artery and the middle colon artery, and there are few marginal arteries, which is called Roilan point here, so we should pay attention to it during operation. Lymphatic vessels also accompany blood vessels, pass through the lymphatic vessels at the roots of superior and inferior mesenteric arteries to lymph nodes near abdominal aorta, and finally inject into thoracic duct. Therefore, in radical treatment of colon cancer, it is necessary to remove the whole intestine and its mesentery supplied by the colon artery. 9 indications
Single-cavity sigmoidostomy is suitable for:
1. After radical resection of low rectal cancer, permanent artificial operation is performed, such as after combined resection of rectum and anal canal through abdomen and perineum. It's commonly called Miles operation.
2. Sometimes, after resection of the lesion, when the primary intestinal anastomosis cannot be performed due to edema of intestinal wall or poor general condition, or the distal end cannot be put forward for double-cavity stoma outside the abdominal cavity, the distal end can be closed and placed in the abdomen, which is generally called Hartmann operation (Figure 1.7.3.41). If the distal colon is difficult to suture, it can be sutured with skin for stoma, which is called modified Hartmann operation (Figure 1.7.3.42). 1 preoperative preparation
1. Explain to the patient the reasons why colostomy (artificial colostomy) is necessary. If it is handled properly, it can still adapt to normal life. It is best to introduce a colostomy patient who has been able to live a normal life first, and it is more convincing to talk to him.
2. Try to improve the patient's general condition, such as correcting anemia, the hemoglobin should be above 12g; If the serum protein is too low or the weight loss is significant, intravenous nutrition should be done first.
3. Female patients should be examined for cancer infiltration. If the posterior wall of * * * needs to be removed, rinse * * * every day 2 days before operation.
4. For tumors with fixed low position, or cancers located in the anterior wall of rectum with urinary symptoms, cystoscopy, retrograde ureterography or intravenous pyelography should be done to find out whether this part of urogenital system is invaded.
5. After anesthesia, place the catheter under strict aseptic technique, preferably Foley balloon catheter, then fix the scrotum and * * * (together with the catheter) on the inner side of the right thigh with rubber plaster, and connect the catheter to the bottle under the operating table.
6. Before operation, all patients should evaluate the position of colostomy when lying on their back, sitting and standing, and make a mark, and it is best to inject a little sterilized ink to avoid improper positioning during operation. 11 anesthesia and ***
continuous epidural anesthesia or general anesthesia. Routine cystolithotomy with head down and feet high is adopted (Figure 1.7.3.43). Hip abduction, sacrum slightly elevated. The operation was divided into two groups (abdominal operation group and perineal operation group). The advantages are that after the abdominal surgery, the surgery can be performed without turning the patient over, and in case of difficulties, the two surgical groups can be operated jointly, which increases the safety of the surgery and shortens the operation time. 12 surgical procedures
1. perform a median incision on the left lower abdomen, from 2 ~ 4 cm above the umbilicus to the pubic symphysis. After entering the abdominal cavity, step by step explore whether there is cancer metastasis in the whole abdominal cavity. First, touch the liver for induration, and then check the lymph nodes near the anterior abdominal aorta, inferior mesenteric vessels and internal iliac vessels for metastasis. Finally, find out the scope of cancer and its surrounding conditions. If it is determined that it can be resected, the small intestine should be pushed to the upper abdomen with a wet saline gauze pad to fully expose the surgical field. Tie the intestine with gauze at the proximal end of the cancer. Lift the sigmoid colon, pull it to the right, cut it along the left root of sigmoid mesocolon and the peritoneal fold of the descending colon, and extend it to the pelvic cavity to the rectovesical recess (rectovesical recess in women). The pelvic peritoneum is separated to the left to expose the left ureter, spermatic vein or ovarian vein to avoid injury. Free sigmoid mesocolon to the right to the bifurcation of abdominal aorta, and pay attention to the separation and resection of lymph nodes near the left iliac blood vessel (Figure 1.7.3.44).
2. Turn the sigmoid colon to the left, cut the right root of sigmoid mesocolon in the same way, go up to the root of inferior mesenteric artery, go down to the rectum and bladder recess, meet the opposite incision, and recognize the direction of the right ureter at the same time (Figure 1.7.3.45).
3. Expose the inferior mesenteric vein on the right side of the root of inferior mesenteric artery, and after injecting anticancer drugs (generally 5Fu 25mg), ligate two veins with medium nonabsorbing thread. The inferior mesenteric artery (2 proximal and 1 distal) was clamped with 3 hemostatic forceps, and then two were ligated with non-absorbable thread after cutting. If lymph nodes in sigmoid mesocolon have been found to be swollen and stiff, and cancer metastasis is suspected, ligation should be performed at the root of the inferior mesenteric artery, and attention should be paid to avoid damaging the ureter during ligation (Figure 1.7.3.46).
4. Enter the presacral space before the sacrum, and sharply separate the dorsal part of rectum to the pelvic floor under direct vision, beyond the coccyx dust (Figure 1.7.3.47). At present, it is considered that radical resection of rectal cancer should include all the mesorectum or at least the mesorectum 5cm below the tumor, so it is called total mesorectal excision,TME), because the residual tumor cells in the mesorectum is one of the main reasons for local recurrence after operation. In the past, blunt separation by hand was easy to tear the mesorectum, which led to incomplete resection. Care should be taken not to damage the presacral venous plexus during separation. In case of injury and a large amount of bleeding, gauze pad can be used to fill the pressure first, then finger can be used to press the venous hole on the sacrum surface, and then special stainless steel nail can be used to nail it, which can obtain satisfactory hemostasis effect. If there is no stainless steel nail, it can be filled with hot saline gauze pad to stop bleeding.
5. Lift the rectum upward and backward, and use scissors, electrotome or stripper to separate the anterior wall of the rectum from the bladder, vas deferens, seminal vesicle and posterior wall of prostate (women should separate the rectum from the posterior wall of prostate) (Figure 1.7.3.48).
6. Separate the bilateral rectal ligaments. First, the rectum is lifted up to the left, exposing the right rectal ligament, and then it is clamped with two long curved hemostatic forceps, and then it is cut off and ligated (the inferior rectal artery is also ligated). Care should be taken to avoid damaging the ureter when clamping or ligating. Then the left rectal ligament was treated in the same way. Separate the rectum from the front, back, left and right to the levator ani plane (Figure 1.7.3.49).
7. On the left side of the original incision, it is equivalent to the junction of the middle and outer 1/3 of the connecting line between the anterior superior iliac spine and the umbilical foramen (that is, the ostomy mark before operation). Make a circular incision with a diameter of about 2.5 ~ 3 cm to remove the skin, subcutaneous tissue and aponeurosis of the external oblique abdomen. Separate the internal oblique muscle and transverse abdominal muscle along the direction of muscle fiber, and cut the peritoneum. A straight hemostatic forceps with teeth was inserted into the abdominal cavity from this stoma, and the proximal sigmoid colon was clamped, and a hemostatic forceps was clamped at its distal end, and the sigmoid colon was cut between the two forceps. Pull the proximal sigmoid colon stump out of the stoma about 4 ~ 6 cm outside the abdomen for artificial use (Figure 1.7.3.41). Or according to Goligher's method, the proximal sigmoid colon is led to the stoma position through the retroperitoneal tunnel. The biggest advantage of extraperitoneal colostomy is that the enterostomy segment is led out through the peritoneum, which eliminates the space of the paracolonic groove and eliminates the potential danger of hernia in the small intestine. Because the covered peritoneum has a certain protective effect, it can resist the occurrence of stoma retraction, prolapse and parahernia, and can reduce complications such as obstruction, stenosis and stoma edema.
8. The proximal colon stump is temporarily protected with gauze, and the distal colon stump is purse-string sutured with thick non-absorbable thread, so that the stump is buried in the intestinal cavity, and then wrapped with gauze or rubber gloves and sent into the presacral recess (Figure 1.7.3.411).
9. After resection of sigmoid colon and rectum, the abdominal cavity was flushed with warm saline. After thorough hemostasis, the peritoneum on both sides of the pelvic floor was continuously sutured with No.1 chrome catgut to reconstruct the pelvic floor (Figure 1.7.3.412).
1. The fat in the proximal colon wall is intermittently sutured with several stitches to peritoneum, fascia and subcutaneous tissue. The colon pulled out of the abdomen was still clamped with a toothed hemostatic forceps, and it was released 48 hours after operation (Figure 1.7.3.413).
11. At present, most colostomy sites adopt open suture method. That is, cut off the broken end of the colon clamped by the toothed hemostatic forceps, disinfect and stop bleeding with mercuric chloride, and intermittently sew the whole layer of the intestinal wall edge and the surrounding skin edge with a 1 # chrome catgut, with each needle being 1cm apart (Figure 1.7.3.414).
12. After the artificial operation, disinfect the one-piece or two-piece artificial bag immediately; It can prevent wound infection and reduce nursing burden.
13. The proximal sigmoid mesocolon was intermittently sutured to the peritoneum of the lateral wall layer with a thin nonabsorbable thread to prevent internal hernia after operation (Figure 1.7.3.415). Finally, the small intestine is restored to its normal position, and the omentum is pulled down to cover the small intestine, so that the small intestine does not contact with the abdominal incision to prevent postoperative intestinal adhesion. The incision was sutured layer by layer.
14. When the rectum has been completely separated in the abdominal operation group, the operation group will start the operation. First, put a piece of dry gauze into the rectum, then make a purse-string suture around the edge of * * * with a thick non-absorbable thread, and close the mouth of * * *. Then make a fusiform incision at a distance of * * * 2 ~ 3 cm, from the front to the middle of perineum and from the back to the tip of coccyx (Figure 1.7.3.416).
15. cut the skin and subcutaneous tissue and ligate the bleeding point. Use tissue forceps to clamp the two edges of the skin incision on the * * * side and wrap it. Hold the tissue forceps, pull the * * * to the other side, use the retractor to pull the lateral edge of the incision outward, continue to separate along the medial edge of the ischial tubercle and gluteus maximus, and try to remove the fat in the ischiorectal fossa to expose levator ani, and pay attention to ligating the * * * artery (Figure 1.7.3.417).
16. Push the rectum forward, and cut the coccyx ligament in front of the coccyx tip to expose levator ani (Figure 1.7.3.418).
17. Insert the left index finger into the posterior rectal space above levator ani, and put the left iliac tail.