controlled cecal bladder

Controlled cecal bladder surgery, also known as ileocecal bladder surgery, was first successfully used in clinical practice by Gilchrist et al. (1950). The basic surgical procedure is: freeing the ileocecal segment with mesenteric; closing the cecal broken margin, bilateral ureteral anastomosis in the cecum, that is, establishing a cecum storage bag; end ileum abdominal wall stoma. This procedure only uses the action of the ileocecal valve and the reverse peristalsis of the distal ileum to control the overflow of urine, so the effect of controlled urination after surgery is not ideal. Some authors in the country have nested the ileocecal suture or nested the end ileum into a nipple flap, which significantly enhanced the ability of the ileocecal valve to prevent overflow of urine. The main advantage of this operation is that the cecal storage bag has a good urine storage function, not only the capacity of 400 ~ 500ml, but also the pressure inside the bag is lower than the pressure of the base of the ileum abdominal wall, combined with the ileocecal valve and the ileocecal part ( Or the terminal ileal intussusception nipple flap prevents the function of overflowing urine and the reverse squirming of the distal ileum. The postoperative controllability is good. The patient does not need to wear the urine collector. When the cecum storage bag is filled with urine, the lower right will appear. Abdominal sensation, you can self-intubation urination; postoperative water and electrolyte and acid-base balance is basically normal, only a few cases of mild hyperchloremia acidosis; postoperative ureteral reflux may occur, but due to timing of intubation The urination is smooth and the renal function is good. Compared with the controllable ileal bladder surgery, the operation of establishing a urine storage bag (cecal storage bag) is relatively simple and time-consuming. Therefore, this procedure is often used in controlled urinary diversion. The main disadvantage is that complications similar to controllable ileal bladder surgery may occur after surgery. Curing disease: Indication 1. Patients with bladder, urethra or female genital malignant tumor have undergone total cystectomy or pelvic organ resection, or those with unremovable lesions but urinary tract obstruction. 2. Great vaginal fistula and bladder valgus, failed after multiple operations or can not be repaired. 3. Bladder ureteral reflux caused by neurogenic bladder, repeated urinary tract infections and severely impaired renal function. 4. Tuberculous bladder spasm condensation and tuberculous urethral stricture or tuberculous vaginal fistula. 5. Interstitial cystitis, necrotizing cystitis, etc. caused by severe contracture of the bladder, showing urinary incontinence. 6. Congenital malformations or severe trauma to the lower urinary tract that cannot be repaired. Contraindications 1. Patients with urinary tract infection fail to control; those with upper urinary tract tumors, stones or other serious diseases of the kidney. 2. Intestinal adhesions caused by abdominal trauma, surgery or inflammation, abdominal tuberculosis, tumor, inflammation or ileum have been extensively removed. 3. Serious illnesses in other systems may cause surgery. 4. There are skin diseases or infections in the surgical site, and women should suspend surgery during menstruation. Preoperative preparation 1. In order to avoid postoperative urine spillage around the collector, it is advisable to wear the urine collector on the right lower abdomen and select the best position of the ileal bladder stoma and mark it. 2. Intestinal preparation for intestinal mites, should be treated with mites. 2 to 3 days before surgery, half fluid, oral neomycin 1g, 4 times a day, or streptomycin 0.5g, 3 times a day, plus metronidazole 0.2g, 3 times a day and vitamin K 8mg, daily 3 times. Clean the enema before surgery. Because the sterilization of the colon is more difficult than the ileum, and the emptying of the cecum and ascending colon is not as easy as the sigmoid colon, the bowel preparation of this operation should be taken seriously, and the emptying and sterilization of the colon before surgery must be ensured. . 3. Prepare 1% neomycin solution 500ml for intraoperative irrigation of the ileal bladder. 4. Prepare blood 600ml. 5. Those who have not had the bladder removed, preoperative indwelling catheter to drain the bladder urine to facilitate the operation. Surgical procedure Incision Take the midline incision under the umbilicus. After entering the abdominal cavity, appendectomy was performed, and women of childbearing age underwent bilateral tubal ligation. The pelvic peritoneum was cut at the iliac vessels below the pelvic margin, and the lower end of the bilateral ureter was removed. The blood supply to the ureter was preserved. The ureter was cut near the bladder, the distal end was ligated, and the 8F catheter was inserted into the proximal end to temporarily drain the urine in the renal pelvis. With the fingers through the above pelvic peritoneal incision, in front of the sacral, behind the sigmoid mesenteric, blunt separation, forming a channel. The lower end of the left ureter is passed through the passage and pulled into the abdominal cavity. 2. Free ileocecal segment After entering the abdominal cavity, the right hemi-colon and transverse colonic hepatic curvature are revealed. Conventional appendectomy is performed. The peritoneum was cut open in the right colon, and the cecum and ascending colon were fully dissociated, and the omentum of the transverse colon was separated. The mesentery of this segment of the intestine was fan-shaped, separated, and the bleeding point was ligated. Be careful to keep 3 to 4 arcuate vessels. The colon was cut at the junction of the ascending colon and the transverse colon, and the terminal ileum was cut at a distance of 20 to 25 cm from the junction of the ileocecal area. The intestine cavity was repeatedly irrigated with isotonic saline and 1% neomycin solution to flush the contents. 3. Restore intestinal continuity The proximal end of the ileum is anastomosed (or end-to-end) with the distal end of the transverse colon to restore continuity of the intestine. 4. Establish a cecum storage bag First, the cecal end of the cecum was closed, and the broken end was firstly sutured with a 2-0 absorbable line, and the muscle layer was sutured with a thin wire. Then, intussusception is formed in two ways. The ileocecal nesting suture method: on the serosal membrane of the intestinal wall of 1.0 to 1.5 cm on both sides of the ileocecal junction, the wound is first formed with an electric cauterizer or a blade, and the musculature of the ileum and cecum is sutured intermittently with a thin thread. A total of 8 to 10 needles in a circle, the ligature suture forms a hood. Ileum ileal inlay method: separating the ileum mesenteric junction adjacent to the ileocecal junction 6-8 cm, making it a mesangial area ("window"), inserting the ileum into the ileum to form a nipple flap; The base portion is sutured with a thin wire to suture the sheath portion and the pulp muscle layer of the intestine tube. 5. Ureteral-cecal anastomosis A small incision is made in the appropriate part of the cecal colon band, and the right ureteral stump cut into a bevel is moved to the small incision. Insert the ureteral stent tube before the anastomosis. One end of the stent tube is inserted into the renal pelvis through the ureteral stump, and the other end is pulled out of the intestinal lumen from the ileal stump through the cecal storage bag. The right ureteral stump and the small incision margin of the cecum wall were sutured with a 5-0 absorbable line for 6-7 needles. The first needle was sutured and the ureteral stent tube was fixed. The outer layer was sutured with 6 to 7 needles by suture between the colonic band and its sarcolemma and the ureteral adventitia. The available length of the left ureter is often limited, and the cecum segment should be moved down and rotated 90° to the left so that it can be anastomosed to the left ureter. 6. Ileum abdominal wall stoma A circular incision with a diameter of about 2 cm is made at the appropriate part of the right lower abdomen, and the aponeurosis and muscles are cut open to the abdominal cavity. The corresponding wound edge of the aponeurosis and the transverse transverse fascia is sutured by a thin wire, so that the passage can accommodate two transverse fingers. The terminal ileum is pulled out of the abdominal wall through this channel. The ileal wall of the ileum of this operation is mostly a stoma that is flush with the abdominal wall. A 2.5 cm wide strip of polyester was placed on the outside of the ileum of the ileocecal portion of the base of the ileocecal region, and circled around the ileum wall. One side of the polyester ring was sutured and fixed to the ileal muscle layer of the base of the nest, and the other side was sutured with the anterior rectus sheath of the abdominal wall passage. Finally, the ileal stump is sutured to the skin of the abdominal wall incision. The ileal abdominal wall stoma of this operation can also be made into a nipple shape, so that the urine collector can be worn when there is a possibility of overflowing after surgery. After the ileal abdominal wall stoma is completed, a soft drainage tube is inserted into the cecum storage bag. The bilateral ureteral stent tube and the drainage tube in the cecum storage bag were sutured separately by silk thread. 7. Fixed Lift the outer edge of the right posterior peritoneal incision, cover the closed margin of the cecum storage bag and the ureter-cecal anastomosis, and suture it with the adjacent posterior peritoneum or the cecum, sigmoid colon and distal ileum. Fixation, the closed edge of the cecum storage bag and the ureter are fixed in the peritoneum. 8. Place drainage The indwelling rubber drainage strip or the double lumen drainage tube is placed outside the peritoneum. The mesenteric defect and the posterior peritoneal incision were closed with a thin wire suture. 9. Suture incision Conventional suture of the abdominal wall incision. complication As with controllable ileal bladder surgery, this procedure is also a variety of operations in the intestine and urinary tract performed in the abdominal cavity. Therefore, postoperative complications are basically the same. Early complications include urinary fistula, intestinal obstruction, infection, stagnation of the cecal storage bag, or necrosis. These complications can be avoided as long as the preoperative preparation is sufficient (especially for bowel preparation) and the intraoperative operation is correct. If the above complications occur after surgery, refer to the relevant content of controlled ileal bladder surgery for treatment. Late complications include ureteral-cecal anastomotic stenosis, urinary tract infection (mainly pyelonephritis), cecal urinary bag stones, ileal abdominal wall ostomy, urinary intubation difficulty, and mild hyperchloremia acidosis. . The causes and treatment of these late complications are also the same as for controlled ileal bladder surgery. It should also be noted that although ureteral reflux is found in most cases after cecal urinary tract angiography, as long as the patient can periodically intubate and urinate, this reflux has little damage to the renal parenchyma and does not have to be treated. In addition, for the ileum of the ileum, which is difficult to correct after surgery, it is necessary to wear urine collector and timed cannula for urination, or to change to ileal bladder surgery.