After an operation for resection of the intestine

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Operations on the intestines

The main types of operations on the intestine: suturing the wound of the intestine - enteroraphy; intestinal opening subsequent stitching - enterotomy (for example, to remove the foreign body of the intestine); imposition stoma, i.e., an artificial external fistula of the intestine, an ejinostomy, an ileostomy, a colostomy (see Fig. Enterostomy) and anus praeternaturalis (see); the imposition of an anastomosis, i.e., an artificial internal intestinal fistula. bypassing the unremovable obstruction in the intestine (for example, inaccessible to removal of the tumor); resection of intestines, i.e., removal of the affected part of the intestine, with the restoration of its continuity through an anastomosis or with the application of anus praeternaturalis.


Fig. 3. Insulation of the intestine:
1 - with one bent clamp;
2 - two straight clamps.

Operation on the intestine always threatens contamination of the operating field with intestinal contents. For protection, the part of the intesti

nal tract that is to be operated is first emptied of compression, isolated by applying soft intestinal clamps (Fig. 3), and fence with napkins and tampons. Without clamps (finger compression), one can do without sewing a small single wound of the intestine. Having finished work on the intestines and removing the clamps, replace the napkins, tampons, gloves and tools. To open and intersect the intestine, use a small (often pointed) scalpel and straight blunt scissors (see Fig. Surgical instruments). The remnants of the contents flowing from the intestinal opening are immediately removed with an aspirator and gauze balls. Sewing and stitching of the intestines - Intestinal suture. A bypass anastomosis is imposed by connecting the intestines side by side (Fig. 4); layer-by-layer stitching is started before the intestinal opening on the back of the future anastomosis (Fig. 5).


Fig. 5. Anastomosis application side to side: 1 - a gray-serous suture is applied, the intestine is opened; 2 - the suture is mucous shells on the back wall of the anastomosis; 3 - a seam of the mucous membrane is applied along the front wall anastomosis.

Resection of the intestine is carried out with extensive damage to it, with tumors, tuberculosis, actinomycosis, etc. The most extensive resection (up to several meters) may be required for intestinal gangrene (due to curvature, infringement. thrombosis of blood vessels), with ulcerative colitis. The loop to be resected is insulated by applying two clamps on each side. Together with the site of the intestine, the corresponding part of her mesentery is also removed, excising a wedge directed from the apex to the root of the mesentery (Fig. 6). Crossed in this case the vessels are grasped by terminals or pre-ligated with ligatures. Anastomoses after resection are superimposed differently (Fig. 7).


Fig. 7. Types of anastomoses: 1 - end to end; 2 - side to end; 3 - isoperistaltic anastomosis application; 4 - end in the side.


Fig. 8. Ileotransversostomy. An anastomosis was applied side to side, the defect of the mesentery and parietal peritoneum was sewn.

After restoring the aseptic nature of the operating field, changing instruments, sew a defect in the mesentery to avoid infringement of intestinal loops (Fig. 8). Resection of small areas of the intestine does not affect digestion. After extensive resection of the small intestine, digestion and assimilation of food are disrupted; patients who are deprived of most of the large intestine suffer from diarrhea. Patients after operations on the intestine need a special regimen as directed by a doctor.
Measures after operations on the intestine - Postoperative period.
Cm. also Bowel obstruction.

Medical and social expertise

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Medico-social examination and disability with the consequences of extensive intestinal resections

CONSEQUENCES OF VASIC RESOURCES OF THE INTESTINE

Many pathological processes in the abdominal cavity (intestinal obstruction, trauma, Crohn's disease, etc.) result in a different resection of the small or large intestine.

The most pronounced disorders occur after extensive resection of the small intestine. By extensive resection is understood as the removal of not less than -2 m of the small intestine, under the subtotal - 4/5 of its length.

Removal of the small intestine before 1 m completely compensated for 3 months, 2 m or more - within 12-18 months, with subtotal resection - compensation is not achieved.

Extensive resection of the small intestine can lead to the development of a pathological syndrome, which is called the syndrome of the small intestine (SCC) of varying severity.

Criteria of examination of work capacity.
The CCM in the process of formation passes through three stages. Stage I occurs after surgery, lasts 2-4 weeks and is characterized by diarrhea up to 10 times a day and significant water-electrolyte disorders. During this period intensive parenteral therapy is carried out.

II stage - re-adaptation in terms of up to 6 months after surgery, characterized by stabilization of bowel dysfunction, loss
body weight, vitamin B12-deficiency anemia due to cyanocobalamin hypovitaminosis and steatorrhea. Possible nerve and mental disorders, tetany.

III stage - the equilibrium, or the stage of the formed CCM, occurs in the period of 6-12 months after the operation, characterized by the disappearance or loss of diarrhea, stabilization of body weight, disappearance or alignment disturbed metabolism.

Degree of severity of the CCM.
The main clinical manifestations of this syndrome can be divided into local and general. Local manifestations include abdominal pains of various, predominantly noisy character, flatulence, diarrhea (up to 4-10 times a day), accompanied by polyphecal, steatorrhea, creators. Of the general manifestations, significant loss of body weight deserves special attention, in some ballrooms to exhaustion, weakness, hypotension, hypoproteinemia, vitamin deficiency, hypocalcemia, hypochromic iron and vitamin B12-deficiency anemia, endocrinopathies and edema.
By severity of clinical manifestations, a light, medium and severe degree of SCC is isolated.

With mild severity of the syndrome patients sometimes worry about abdominal pain of uncertain localization, more often in the navel, meteorism, diarrhea periodically (up to 1-2 times a day. 1-2 times a week) if the diet is violated or after carrying out work of considerable severity. The general condition is not violated. There are no abnormalities in blood tests. Minor changes in the coprogram (steato and createrorrhea). Deficiency of body weight up to 5 kg without a tendency to reduce it.

With an average degree of severity of the CCM, there are persistent dysfunctions of the intestine: flatulence, abdominal pain, diarrhea up to 3-5 times a day with varying degrees of changes in feces (polyphecal, steatorrhea + +, creatorrhea + +). The general condition almost does not suffer, and the body weight is reduced by 5-10 kg.

A feature of severe SCC is the presence, in addition to diarrhea, of a significant metabolic disorder that is expressed in the loss of body weight of more than 10 kg, hypoproteinemia, vitamin deficiency, hemopoiesis, hypocalcemia. the presence of osteoporosis, endocrine insufficiency and protein-free edema.

Criteria and approximate terms of VUT. The duration of the VUT depends on:
- a disease, in respect of which resection has been performed;
- volume of intestinal resection;
- rate of readaptation;
- the course of the underlying disease after surgery;
- complications after surgery:
- concomitant diseases;
- social factors.

The estimated timeframe for VUT is from 2 to 10-12 months, depending on the above criteria. Part of the patients after the completion of treatment on the sick list are sent to the ITU.

Graduation criteria for VUT:
- normalization of the general condition, regression of pathological syndromes;
- normalization or stabilization of changes caused by resection;
- absence or elimination of complications;
- a stronger scar;
- normalization of hematological and biochemical parameters.

Contraindicated types and working conditions (regardless of the severity of the clinical course):
- labor with marked physical or neuro-mental stress;
- the prescribed pace;
- forced position of the body;
- vibration;
- labor with the tension of the muscles of the anterior abdominal wall;
- work in which it is impossible to comply with the diet (frequent travel, business trips).

Indications for referral to ITU:
- formed a CCM of light or medium severity, if necessary, correction of labor activity;
- heavy CCM;
- Subtotal resection of the small intestine within 3-4 months after the operation due to unfavorable prognosis.

Survey standards for referral to the ITU (depending on the severity of the CCM):
- general tests of urine and blood;
- special studies for the evaluation of impaired metabolic species with CCS - water-electrolyte (K, Na, Ca), protein (total protein, protein fractions, albumin-globulin coefficient), carbohydrate (if necessary - sugar curve);
- Coprogram.

Criteria for disability groups.
III group of disability (moderate limitation of vital activity) is established with mild and moderate degree of CCM, when in communication with contra-indications at employment there is a decrease in qualification or reduction of volume of work or re-training is necessary.

II group of disability (expressed limitation of vital activity) is established at a severe degree of CCM.

I group of disability (pronounced limitation of vital activity) is established in severe SCC with complications in the form of intestinal fistula or after subtotal resection of the intestine.
A source

Resection of the sigmoid colon - causes, indications, prognosis and consequences

author: surgeon Korotkikh SN

The most common operation on the large intestine in abdominal surgery, after appendectomy and operations on the rectum. This operation is classified as planned or emergency. Emergency are conducted in approximately 80% of cases.

Patients enter the clinic with a clinic of intestinal obstruction, due to a swelling of the sigmoid colon, or a tumor obturation, or a clinic of intestinal bleeding ( ulceration of the tumor, or bleeding from polyps), abdominal injuries with extensive damage to the sigmoid colon (gunshot wounds, blast injury, blunt trauma stomach). In 20% of the diseases are detected in planned surveys. The surgeon takes the tactics and the choice of the surgical intervention volume directly during the operation and depends on the disease, the spread and localization of the process, the condition and age of the patient.

Causes of resection of the sigmoid colon

Tumor obturation, necrosis, perforation, massive bleeding from ulcers or polyps, extensive damage to the intestine.
Indications for resection of the sigmoid colon: Dolihosigma (megosigma) with recurrences of a turn, polyps with malignization, polypos with relapsing bleeding, Stage 1-2A cancer, complicated diverticulitis, Nonspecific ulcerative colitis with recurrent bleeding, extensive injury.

Tactics of choice of volume and method of operation

1. When turning sigma with gangrene, the operation of Hartmann or Mikulich is performed. In Hartmann's operation, a resection of the non-viable sigmoidal area is performed, with suturing of its distal end and removal of the unnatural anus. It is used in weakened and elderly patients.
Operation Mikulich provides a resection of sigma. The leading and leading ends of the intestine are stitched together for 4-5 cm. then sutured into the abdominal wall in the form of a double-barreled. At the second stage through 3, months the intestinal fistula is closed.

2. Sigmoid cancer: In the presence of a tumor in the middle third of the intestine, the entire sigmoid colon is removed in a single block with surrounding fiber and lymph nodes. Also read about bowel cancer of the 4th stage.

3. Two-stage resection of the colon according to Grekov's method. It is carried out in 2 stages. A-combination of external and internal lead of intestinal contents (removal of a loop with a tumor with the application of anastomosis side to side)

4. Left-sided hemicolectomy: indications - cancer of stage 2B-3, left-sided ulcerative colitis, diverticulitis with complications, malignant polyposis of thick and sigmoid colon. Many do not know how to treat polyps in the intestine correctly.
With these indications, the B-resection of the site of the damaged excretory intestine is performed, the stitching of the stump is tight.

Complications after surgical treatment

1- intra-abdominal bleeding, usually from poorly bandaged vessels. cutting of ligatures.

2- Development of peritonitis due to inadequate sanation of the abdominal cavity, failure of anastomosis sutures, incomplete sealing of seams during closure of stumps and anastomoses.

3- Not adequate drainage of the abdominal cavity.

4- Early adhesive intestinal obstruction.

5- Intercourse abscesses.

Adhesive disease, adhesive intestinal obstruction.

Forecast

As a rule, favorable, Violations of water-electrolyte balance in the literature are not observed, Recurrences of cancer are rare, the survival rate of patients after resection of the sigmoid colon is 98-100%. After routine surgical treatment, after preparation of the patient for surgical treatment, the percentage of postoperative complications is minimized, the postoperative period proceeds more smoothly.

Sources: http://www.medical-enc.ru/10/kishechnik_4.shtml, http://www.invalidnost.com/publ/mediko_socialnaja_ehkspertiza_pri_nekotorykh_zabolevanijakh/mseh_i_invalidnost_posle_rezekcij_kishechnika/2-1-0-151, http://hirurgs.ru/content/rezektsiya-sigmovidnoi-kishki-prichiny-pokazaniya-prognoz-i-posledstviya



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