Rectocele treatment method

Abstract

FIELD: proctology.SUBSTANCE: used in the treatment of rectocele. To do this, the perianal skin is perforated along the anterior semicircle using the end light guide of a laser device with a wavelength of 1500 nm, in a pulsed mode of 0.5 s pulse – 0.5 s pause at a radiation power of 10 W. The end light guide is passed submucosally along the entire length of the anal canal from the perianal skin of the perineum to the anorectal junction with visual control of the pilot light mark and visual control of the staining of the mucous membrane at the site of exposure to a white-yellow color. The end light guide is brought in the energy supply mode to the anorectal junction, after which it is removed from the submucosal layer through the previously formed perforation of the skin. Similar perforations are performed sequentially in the perianal skin along the conditional line of the circumference of the perianal region in the projection of the rectocele, while the distance between the points of insertion of the light guide is 2–3 mm. Parallel submucosal passages of the end light guide are performed along the entire length of the rectocele circumference parallel to each other up to the lateral borders of the protrusion. Above the dentate line by 1–2 cm in the area of the anorectal junction, the mucous membrane is stitched with two interrupted sutures at 1–2 and 10–11 o'clock positions on the conventional clock face, capturing the muscle layer with a 25 mm long needle with a 5 / 8 curvature and a 2–0 thread thickness made of absorbable braided polymer material polyglycolide. If there is excess hemorrhoidal tissue at the site of mucosal suturing, additional mucopexy is performed from the interrupted suture using the same thread, with 1 to 4 stitches applied.EFFECT: method provides effective treatment of rectocele while maintaining an active lifestyle, a high rate of healing and rehabilitation, which eliminates the need for long-term hospitalization, due to strengthening the rectovaginal septum, its thickening, reducing diastasis of the bulbocavernous muscles, reducing or eliminating prolapse of the rectovaginal septum towards the vagina, and reducing the folding of the mucous membrane of the rectovaginal septum on the side of the rectum.2 cl, 1 dwg, 1 ex

Description

[0001] Field of invention

[0002] The invention relates to medicine, more precisely to proctology.

[0003] Technology Level

[0004] A method for surgical treatment of rectocele is known from the prior art, including colpoperineorrhaphy, isolation of the levators and their reinforcement with a graft. In this case, a flap is first cut from the skin of the anterior abdominal wall, corresponding to the length of the divergence of the levators, and sufficient in width to reinforce the suture and the edges of the competent tissue. In this case, the flap is perforated. Restoration of the anatomical structures of the perineum is carried out by fixing an autodermal flap to the levator ani suture using removable sutures. The ends of the threads are brought out through the mucosa of the posterior vaginal wall, the skin of the perineum and after the wound heals, the ligatures are removed from the tissues (Savchenko Yu. P. et al., A Method for Treating Rectocele with Removable Sutures, Bulletin of the Smolensk State Medical Academy, no. 2, 2003, pp. 59-62).

[0005] This method is characterized by high technical complexity, graft cost, severe pain syndrome and significant physical limitations for patients in the immediate postoperative period, a certain risk of complications such as bleeding (4-8%), suppuration (4-9%), suture rupture and graft detachment (up to 12%), disease recurrence (up to 18%), dysparenunia (up to 16%). Long healing and rehabilitation periods (more than 2 months) are also required.

[0006] The article by Zhumanov E. N., Kolgaev D. I., Muravlev A. I. et al., Pathogenetic prerequisites for the use of fractional microablative CO2 laser as a method of restorative treatment in patients after surgical correction of rectocele, Physiotherapist, 2018, No. 2, pp. 50-54 presents an overview of studies on the relevance and methods of treating rectocele, as well as an analysis of studies on the effect of fractional microablative CO2 laser on the arectonics of vaginal tissues after surgical correction of rectocele. The data available to date indicate the fundamental possibility of including fractional microablative CO2 laser as a method of restorative therapy for pathology of the pelvic organs and open up prospects for the development of a new direction in the rehabilitation treatment of patients after surgical treatment of rectocele as a method of regenerative physiotherapy.The relevance of interdisciplinary fundamental and clinical scientific research in this area is determined by the latest achievements and pace of development of modern regenerative medicine.

[0007] This method affects only the superficial structures of the posterior vaginal wall (mucosa and submucosa) and, when used alone, is not highly effective. Therefore, it is not used as a sole method for treating rectocele. It is recommended in combination with other techniques. The complication rate after the procedure is at least 7.6%.

[0008] The closest analogue is the method for treating rectocele, disclosed in RU 2704216 C1 dated 10 / 24 / 2019. This source discloses a method for the comprehensive non-surgical treatment and prevention of vaginal prolapse, including an examination and preparation for procedures, laser treatment of the vaginal mucosa using a pulsed fractional CO2 laser, and a course of pelvic floor muscle training procedures, including with training devices, characterized in that the said course of treatment consists of 4 stages and contains the following specified sequence of procedures and training:

[0009] Stage 1: a) laser treatment of the vaginal mucosa is performed in a clinical setting using a scanning vaginal attachment that transmits a fractional CO2 laser beam to the surface of the mucosa. The mucosa is scanned by making longitudinal and circular passes along its surface, with a laser wavelength of 10.6 μm, pulse energy per point per peak pulse of 3.9 mJ, five pulses are applied to each point, the scanning step is 1 mm, the duration of the entire procedure is 10-15 minutes;

[0010] conduct a course of b) hardware electrical impulse myostimulation of the pelvic floor muscles, using a vaginal sensor, with an impulse current strength of no more than 90 mA, procedure duration of 20 to 30 minutes, one procedure per day, daily - 28 days per course;

[0011] Stage 2: repeat the procedure a) laser treatment of the vaginal mucosa, see Stage 1 of the treatment course;

[0012] conduct a course of c) training the pelvic floor muscles using a mechanical vaginal trainer - a vaginal cone, each training session is carried out for 12-15 minutes a day, daily - 28 days per course;

[0013] Stage 3: repeat the procedure a) laser treatment of the vaginal mucosa, see Stage 1 of the treatment course;

[0014] repeat course c) training the pelvic floor muscles using a mechanical vaginal trainer, see stage 2 of the treatment course, daily for 28 days per course;

[0015] Stage 4: repeat procedure a) laser treatment of the vaginal mucosa, see Stage 1 of the treatment course.

[0016] The combined method is effective (approximately 70% of patients are satisfied), but 30% do not achieve a positive treatment outcome. It is characterized by a minimal complication rate. However, it is technically challenging, requiring numerous procedures and significant patient time. It does not result in a reduction in bulbocavernosus diastasis. There are no results available for follow-up periods exceeding one year.

[0017] The problems that this invention is aimed at solving are:

[0018] 1. One-stage surgical intervention to achieve a complete result.

[0019] 2. Surgical intervention should meet the requirements of minimally invasiveness in order to improve the quality of life of patients in the postoperative period (reducing pain, reducing restrictions on the life activity of patients after surgery, reducing the healing and rehabilitation time) and safety (reducing the risk of postoperative complications - bleeding, suppuration, suture divergence).

[0020] 3. Improving long-term treatment results - patient satisfaction, reducing relapses.

[0021] Disclosure of invention

[0022] The technical result of the claimed method is the simplicity of its implementation, the absence of the need for long-term hospitalization, usually no more than 4 hours, high efficiency - patient satisfaction after 1 year is above 85%, a low level of complications, only episodes of bleeding in 2% of cases, a low level of relapse of the disease 4% after 1 year of observation, a high quality of life of patients after surgery: maintaining an active lifestyle with limitation of significant loads, a high rate of healing and rehabilitation: healing is about 1 month, rehabilitation is about 1.5 months from the time of surgery.

[0023] The specified technical result is achieved through the following techniques.

[0024] The perianal skin near the anus is perforated with the end-face of the 1500 nm laser device using a 0.5 s pulse, 0.5 s pause, and a radiation power of 10 W. The end-face is then inserted submucosally along the entire length of the anal canal, from the perianal skin of the perineum to the anorectal junction, with visual inspection of the pilot light mark and visual inspection of the mucosal staining at the site of exposure to a white-yellow color. Tissue staining is visually determined to be a white-yellow color. Darker staining indicates tissue carbonization, which leads to tissue destruction and prolonged healing.The end light guide is brought in the energy supply mode to the anorectal junction, after which it is removed from the submucosal layer through the previously formed skin perforation, similar perforations are performed sequentially in the perianal skin along the imaginary line of the circumference of the perianal region in the projection of the rectocele, while the distance between the points of entry of the light guide is 2-3 mm, parallel submucosal wiring of the end light guide is performed along the entire length of the circumference of the rectocele parallel to each other to the lateral borders of the protrusion.

[0025] 1-2 cm above the dentate line in the anorectal junction area, the mucosa is sutured with two interrupted sutures at the 1-2 and 10-11 o'clock positions, including the muscular layer. This is similar to the vascular pedicle of a hemorrhoid, using a 25 mm needle with a 5 / 8 curvature and a 2-0 thread made of absorbable braided polyglycolide. This eliminates excess mucosal folding and creates a localized scar between the mucosa and muscular layer sutured together. The sutures should not be tightly adjacent to each other. If excess hemorrhoidal tissue is present at the mucosal suture site, additional mucopexy is performed from the interrupted suture using the same thread. The number of stitches ranges from 1 to 4, depending on the size of the hemorrhoid.

[0026] These manipulations help to strengthen the rectovaginal septum, thicken it, reduce the diastasis of the bulbocavernous muscles, reduce or eliminate the prolapse of the rectovaginal septum on the side of the vagina, and reduce the folding of the mucous membrane of the rectovaginal septum on the side of the rectum.

[0027] Brief description of drawings.

[0028] Fig. 1 shows the treatment scheme, where:

[0029] 1 - vagina,

[0030] 2 - anus,

[0031] 3 - internal sphincter,

[0032] 4 - mucous membrane of the anal canal,

[0033] 5 - light guide,

[0034] 6 - knot stitch,

[0035] 7 - pinpoint punctures of the perianal skin,

[0036] 8 - submucous conduction of the light guide from the anal canal.

[0037] Implementation of the invention

[0038] The perianal skin near the anus is perforated with the end-face of a 1500 nm laser device using a pulsed mode of 0.5 seconds on and 0.5 seconds off at a radiation power of 10 W. The end-face is inserted submucosally along the entire length of the anal canal, from the perianal skin of the perineum to the anorectal junction, with visual inspection of the pilot light mark and visual inspection of the mucosal staining at the site of application, reaching a white-yellow color. Tissue staining is determined visually; darker staining indicates tissue carbonization, which leads to tissue destruction and prolonged healing.The end light guide is brought in the energy supply mode to the anorectal junction, after which it is removed from the submucosal layer through the previously formed skin perforation, similar perforations are performed sequentially in the perianal skin along the imaginary line of the circumference of the perianal region in the projection of the rectocele, while the distance between the points of entry of the light guide is 2-3 mm, parallel submucosal wiring of the end light guide is performed along the entire length of the circumference of the rectocele parallel to each other to the lateral borders of the protrusion.

[0039] 1-2 cm above the dentate line in the anorectal junction area, the mucosa is sutured with two interrupted sutures at the 1-2 and 10-11 o'clock positions, including the muscular layer (similar to suturing the vascular pedicle of a hemorrhoid). The sutures are placed using a 25 mm needle with a 5 / 8 curvature and a 2-0 thread made of absorbable braided polyglycolide. This suture eliminates excess mucosal folding and creates a localized scar between the sutured mucosa and muscular layer. The sutures should not be tightly adjacent to each other. If there is excess hemorrhoidal tissue at the site of mucosal suturing, additional mucopexy is performed from the interrupted suture using the same thread, while the number of stitches depends on the size of the hemorrhoidal node (from 1 to 4).

[0040] Clinical example. Patient V., 42, complains of difficulty passing stool, requiring manual pressure on the perineum when passing hard stools, intermittent distending pain in the rectum and perineum, pain during intercourse, and hemorrhoids that swell with stool. She considers herself ill for several years. Conservative treatment has been ineffective. Her medical history includes three births with perineal ruptures.

[0041] On examination and testing, lower anterior rectocele grade 2, chronic combined hemorrhoids stage 2.

[0042] Treatment - submucous laser treatment of the anterior wall of the anal canal up to the anorectal junction was performed under TVVA with an end-on light guide in pulsed mode and a power of 10 W. Two absorbable interrupted sutures were applied in the projections of 10-11 and 1-2 o'clock at the level of the anorectal junction on the mucosa with suturing of the internal sphincter, submucous laser destruction of internal hemorrhoids at 5, 7 and 11 o'clock with suturing of the vascular pedicles at 5 and 7 o'clock and mucopexy of excess mucosa at 1, 7 and 11 o'clock. Excision of the external skin component at 5, 7 and 11-1 o'clock with contactless laser treatment of skin wounds. Surgery time is 24 minutes.

[0043] Hospitalization time: 3.5 hours. Pain score at discharge: 3 on the VAS scale. NSAIDs were taken once daily before bowel movements for 11 days. Returned to work after 8 days. Returned to full activity and normal exercise after 29 days. No complications. No relapse after 1 year of follow-up. High satisfaction with the treatment after 1 year (over 95% according to the survey results).

Claims

1. A method for treating a rectocele, characterized in that the perianal skin is perforated along the anterior semicircle with the end light guide of a laser apparatus with a wavelength of 1500 nm, in a pulsed mode of 0.5 s pulse - 0.5 s pause at a radiation power of 10 W, the end light guide is passed submucosally along the entire length of the anal canal from the perianal skin of the perineum to the anorectal junction with visual control of the pilot light mark and visual control of the staining of the mucous membrane at the site of action to a white-yellow color, the end light guide is brought in the energy supply mode to the anorectal junction, after which it is withdrawn from the submucosal layer through a previously formed perforation of the skin, similar perforations are performed sequentially in the perianal skin along an imaginary line of the circumference of the perianal region in the projection of the rectocele, while the distance between the points of entry of the light guide is 2-3 mm,Parallel submucosal passages of the end light guide are performed along the entire circumference of the rectocele parallel to each other up to the lateral borders of the protrusion; 1-2 cm above the dentate line in the area of ​​the anorectal junction, the mucous membrane is sutured with two interrupted sutures at 1-2 and 10-11 o'clock positions of the conventional clock face, capturing the muscle layer with a 25 mm long needle with a 5 / 8 curvature and a 2-0 thread thickness made of absorbable braided polymer material polyglycolide.

2. The method according to paragraph 1, characterized in that, in the presence of excess hemorrhoidal tissue at the site of mucosal suturing, additional mucopexy is performed from the interrupted suture with the same thread, while 1 to 4 stitches are applied.

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