1. [Enterostomy based on abdominal wall tension and fascial locking: a theory of preventing stoma complications and parahernia]
- Author
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L, Wang, Y B, Zhao, J G, Ding, J J, Han, Y Y, Ma, X, Wu, T H, Wang, J, Ma, Z Y, Zhang, Z D, Li, X Q, Bu, A W, Su, and Aiwen, Wu
- Subjects
Abdominal Wall ,Enterostomy ,Humans ,Surgical Stomas ,Incisional Hernia ,Fascia - Abstract
No consensus on standardized technique of enterostomy creation has been made meanwhile high heterogeneity of surgical procedure exists in 'stoma creation' chapters of textbooks or atlases of colorectal surgery. The present article reviews the anatomy of tendinous aponeurotic fibers which is crucial for abdominal wall tension and integrity. Through empirical practice we hypothesize a procedure of enterostomy creation basied on abdominal wall tension plus anchor suture for fascia fixation which could theoretically decrease short-term stoma complication rates and long-term parastomal hernia rates. Surgical techniques are as followed: (1) preoperative stoma site mark for de-functioning ileostomy should be positioned at the lateral border of rectus abdominis muscle (RAM) to decrease the difficulty of stoma reversal and for permanent colostomy should be placed overlying the RAM to promote adhesion; (2)Optimal circular removal or lineal opening of skin, and avoid dissection of subcutaneous tissue; (3) Lineal dissection of natural strong fascia (rectus sheath) at stoma site and blunt separation of muscular fibers. The tunnel of the fascia should be made with appropriate size without undue tension. To prevent the formation of dead space, additional suturing at fascia layer is unnecessary. (4) Anchor suture for fascia fixation at two ends of fascia opening could be considered to avoid delayed fascia disruption and parastomal hernia. (5) After pull-through of ileum or colon loop, 4-8 interrupted seromuscular sutures could be placed to attach loop to skin. For ileostomy, self-eversion of mucosa can be successful in vast majority of cases and a Brooke ileostomy is not necessary. The efficacy and safety of this procedure should be tested in future trials.肠造口手术技术细节尚无统一标准,外科学教材中的手术原则存在较大异质性。在回顾腹壁结构和腱膜的精细解剖基础上,结合作者们的实践经验,尝试提出一种基于腹壁张力和筋膜锁定缝合的肠造口技术。技术操作细节为:(1)临时性造口选择右腹直肌外缘,永久性造口选择左侧腹直肌内促进粘连;(2)皮肤行适合尺寸的圆形开孔(临时性也可一字型),皮下组织和深筋膜行钝性分离;(3)沿腹外斜肌腱膜纤维方向切开筋膜层,钝性扩开肌肉组织,腹横筋膜层水平切开小口后,扩张腹壁隧道至适合尺寸,临时性造口肠袢能恰好无阻力地提出腹壁为适宜,永久性造口稍有阻力为适宜,但均不要预留运针空间以免致死腔形成;(4)永久性造口可考虑在筋膜切线两端单纯或8字锁定缝合,避免慢性筋膜撕裂;(5)肠壁提出后,与皮肤简单固定4~8针;通常临时性回肠造口黏膜可自行翻出,无需外翻缝合;永久性造口可视情况黏膜外翻缝合。理论上讲,该技术可降低术后短期并发症和远期造口疝的发生率。期待能够在未来的研究中,验证该技术的安全性和有效性。.
- Published
- 2022