double-stapled anterior resection

The double stapler anastomosis technique uses a rotary head linear closure to close the rectal end, and then uses a modified end-to-end stapler (PCEEA) to extend from the anus into the end-end anastomosis of the proximal intestine. The previous single EEA stapler was used to solve the problem of anastomosis caused by the incision of the rectal stump and the inconsistency of the two ports of the knot and the rectum. The double stapler not only can successfully complete the low position, even the ultra low position anastomosis, and significantly reduces the occurrence of anastomotic leakage. Since 1980, Knight and Griffen have proposed this law, which has been widely carried out at home and abroad. Curing disease: Indication Double anterior resection is suitable for early rectal cancer more than 5cm from the anus, and the residual rectal length is feasible and low. Contraindications 1. When the rectal cancer is removed 3cm distal to the cancer, the anorectal ring needs to be removed together, or the end-to-end anastomosis can not be performed. 2, with partial colon obstruction, may be considered to do the transverse colostomy or Hartmann surgery first, and then anastomosis after 2 weeks. 3. The cancerous lesions in the middle and lower rectum have penetrated the intestinal wall and infiltrated the surrounding structures. 4, senior, infirm, with other serious diseases of the heart, lung, liver, kidney dysfunction, can not tolerate transabdominal surgery. Surgical procedure 1. The surgical procedure is basically the same as that of pre-operative anterior resection. After completing the rectal dissection and clearing the fat vascular tissue around the rectum 3~5cm below the tumor plane, it is better to block the rectal cavity below the tumor plane with the non-injured right angle clamp. . 2, distal rectal cavity lavage anal to 4 fingers, inserted into the catheter through the anoscope, lavage with 1:4000 chlorhexidine solution or dilute iodophor solution, completely remove the feces and shed tumor cells. 3. Closing the rectal stump Close the rectal stump 3 to 5 cm below the plane of the rectal tumor with a rotary head linear occluder (roticulator 55). At the upper edge of the closure, the rectum is removed and the closure is removed, at which point the rectal stump is completely closed. 4, remove the specimen, continue to remove the lymph nodes of the inferior mesenteric vascular roots, and ligation, disconnect the inferior mesenteric vessels and left mesenteric vessels until the plane of the sigmoid colon to be resected, disconnect the sigmoid colon, remove the specimen. 5, anastomosed proximal colonic end with a 2-0vicryl absorbable suture to do a purse suture, placed into the nail anvil, tighten the purse suture, and ligation. After completing the rectal cavity lavage, the perineal group can be placed into the shaft of the curved port stapler (PCEEA) to tighten the end screw, so that the conical guide head pokes out from the center of the rectum closed end until all Poke out, then put the sleeve of the proximal rod in the proximal colon into the conical head, and screw the end of the screw to the colored mark to complete the alignment. Open the safety spring, hold the handle, fire the cut, and staple the nail once. Finally, relax the tail screw, turn and exit the stapler. 6. Check whether the upper and lower resection circles are complete. If necessary, use an inflation test to check whether the anastomosis is tight and there is no leakage. complication 1, anastomotic leakage Prevention is more important than treatment for the treatment of anastomotic leakage. After completing the anastomosis, pay attention to the following three points: 1 check whether the upper and lower resection circles are complete; 2 fill the pelvic cavity with normal saline and check the anastomosis with or without leakage through the anal insufflation; Prevent pelvic fluid from immersing in the effusion in the effusion, and observe the presence or absence of faecal juice in the aspirate. The above three points are effective for preventing and reducing the occurrence of anastomotic leakage. After anastomotic leakage, if there is no signs of peritoneal irritation, it can strengthen the pelvic irrigation and systemic application of antibiotics and supportive treatment, and can self-heal. For those with signs of peritoneal irritation, abdominal drainage and transverse colon failure functional ostomy should be performed immediately. During the operation, the distal intestine cavity of the stoma should be cleaned and irrigated, and the feces should be removed. The stoma should be cut and formed in one stage. 2, anastomotic stricture The literature reports that the incidence is between 0% and 22%. The causes of stenosis are: 1 the anastomosis itself is fine, 34mm is suitable for adult stapler; 2 postoperative recovery of normal diet delay, resulting in thin feces, not formed, resulting in the lack of natural expansion of the formation of stool after surgery; 3 anastomotic It is easy to cause stenosis after leakage; 4 the fat and vascular tissue clearance around the anastomosis is not enough in the anastomosis, and the scar hyperplasia leads to stenosis; 5 cases of ultra-low anastomosis due to anastomotic sphincter contraction, especially the effect of internal sphincter tension It is more prone to stenosis. It is worth noting that: 2 weeks after surgery, the rectal examination should be routinely performed to understand the anastomotic condition. If the stenosis tendency is found, the daily examination should be dilated. If there is no stenosis, it should be reviewed once a month after surgery. Generally, if the stool is normally formed, no stenosis will occur in the future. 3, recurrence Total mesorectal excision (TME) can effectively reduce the local recurrence rate after low anterior resection of the double stapler and ensure the safety of low and ultra low anterior resection. The principle of TME is to use sharp separation technique under direct vision to remove the distal mesorectum of the tumor by not less than 5 cm. In addition, the local recurrence rate of patients is also related to the early pathology. Shanghai Ruijin Hospital reported that TME had 306 resections in the low position of the double stapler and 20 cases after recurrence. The recurrence rate was 6 and 7%. Among them, Dukes B recurred in 4 cases, accounting for B stage 2, 3%; C stage recurred 9 For example, accounted for 12, 5%; 7 cases of recurrence in stage D, accounting for 53, 9%. Therefore, the stage of the disease has a role that can not be ignored for local recurrence.