ureterosigmoid anastomosis

There are many methods for ureteral sigmoid anastomosis, each with its own advantages and disadvantages. This kind of surgery has the following advantages: 1 the surgery has less damage to the patient; 2 the patient can automatically control the bowel movement after surgery, without using the urine bag; 3 there is no mouthwash on the abdominal wall. However, there are more complications due to the merger of urine and feces. When patients tend to age, a small number of patients can also be incontinent. This procedure is only performed when the patient refuses to undergo ileal bladder surgery and requires urinary shunt. Treatment of diseases: bladder cancer Indication 1. Bladder cancer after total cystectomy. 2. Complete bladder valgus. 3. Refractory bladder vaginal fistula. 4. Some permanent urinary incontinence is not effective after angioplasty. Preoperative preparation 1. On the 3rd day before surgery, enter a high-calorie, high-protein, low-slag diet to strengthen nutrition; 24 hours before surgery to give a fluid diet (double). 2. Sulfonamide 1g, 4 times a day, for 3 consecutive days. Or oral streptomycin was started 36 hours before surgery, 0.5g every 6 hours. 3. A few days before surgery, 200ml saline can be enema once, so that it stays and walks down to test whether there is no incontinence. 4. For 48 and 24 hours before surgery, each serving was 15 ml of castor oil. On the 2nd day before surgery, 2000ml of warm saline was used every night. Two hours before surgery, 500 ml of 1% neomycin was used for rectal enema to remove intestinal dirt. 5. Blood potassium, sodium, chloride and co2 binding. Surgical procedure Take the submucosal tunnel anastomosis as an example. 1. Position: The patient takes the supine head and lowers the position, so that the intestines in the pelvis are moved upwards for easy operation. 2. Incision: The midline of the suprapubic pubis is leftward. 3. Separate and cut the ureter: After entering the abdominal cavity, cover the small intestine with gauze pad, block and push open, cut the posterior peritoneum before the ureter, expose the ureter, and cut off at the lowest position of the pelvic ureter or from the appropriate lesion. ligation. The proximal ureter has a built-in ureteral catheter to temporarily drain urine to reduce abdominal cavity contamination. 4. Formation of colonic tunnel: Select the appropriate sigmoid colon segment, select the appropriate colonic band for a longitudinal incision of 3 to 4 cm, cut the serosa and muscle layer, and sneak into the mucosa to separate the sides. 1 ~ 1.5cm, make a tunnel. Pay attention to stop bleeding, do not break the mucous membrane. 5. Trim the proximal end of the ureter: separate the proximal ureter, but do not completely detach the tissue around the ureter, so as not to affect the blood supply. The tissue around the proximal end of the ureter needs to be divided, and cut longitudinally 1.5cm, and then the mouth of the tube is cut into an elliptical bevel, so that the anastomosis can be expanded by 3 times to ensure smooth drainage. 6. Anastomotic ureteroscopic sigmoid colon: Cut a small opening in the lowermost end of the sclerosing plexus muscle layer, and the elliptical section of the ureteral end is equal, and align the two incisions for end-to-side anastomosis, first use 4-0 chrome gut line The upper and lower corners of the ureter and the mucosal layer of the intestinal wall are sewed with a needle, and then the suture is sutured for about 8 to 10 stitches. 7. Suture tunnel: After the ureter is placed in the tunnel, the ureteral wall and the muscular wall of the intestinal wall of the tunnel are fixed with 2 to 3 needles to reduce the anastomotic tension. Then, the sarcoplasmic layer of the intestinal wall was sutured 4 to 5 needles with a thin wire to embed the ureter in the tunnel. 8. Peritoneal suture after suturing: Finally, the medial edge of the posterior peritoneal incision was sutured to the outside of the anastomotic line, and the lateral posterior peritoneum was sutured to the inside of the anastomotic line, so that the anastomosis was relocated outside the peritoneum Generally, the right anastomosis is performed first, and then the left ureteral anastomosis is performed at the appropriate part of the sigmoid colon near the anastomosis. complication 1. Anastomosis of the ureteral intestine can cause the following complications: ureteral reflux, ureteral obstruction, anastomotic leakage, and infection. The anastomotic leakage is caused by ureteral blood flow disorder and improper suture. It is necessary to take decisive measures (such as abdominal drainage, ureterostomy and application of a large number of antibiotics) according to the severity of leakage, in order to save the patient's life. 2. Hyperchloremia acidosis: The incidence rate is about 30% to 48.5%, which varies with various primary diseases. Hyperchloremia acidosis is a condition associated with tubular insufficiency. After ureteral sigmoid anastomosis, the sigmoid colon will reabsorb the chloride, hydrogen and ammonium ions in the urine, and will be discharged again by the kidneys, which will increase the acid burden of the kidney by more than two times, resulting in imperfect renal tubular acid function. Causes the consumption of bases and the imbalance of water and electrolytes. For such patients, it is important to regularly check the binding of blood chloride and plasma co2. If there is any abnormality, measures such as indwelling of the rectal anal canal, anti-infection and taking basic drugs should be adopted. However, after the anal canal is pulled out, the symptoms of the disorder may still recur. 3. Renal dysfunction: After ureteral anastomosis, the burden of the kidney is increased compared with preoperative, and the ascending infection of the kidney and the narrowing of the anastomosis can lead to renal dysfunction. 4. Loss of potassium: After the combination of ureter and sigmoid colon, blood potassium may be reduced. There are two ways to lose potassium: One is kidney excretion: the potassium excreted in the urine comes from the distal curved tube. Some people have used microdissection to find kidney damage in cases of potassium loss, mainly in the proximal curved tube and collecting small tubes. Although these damages do not affect the excretion of potassium, they reduce the reabsorption of water and potassium, resulting in polyuria and hypokalemia. The second is the secretion of the colon: after ureteral colon anastomosis, the potassium in the urine is not absorbed in the intestine, and the number of postoperative bowel movements increases, so the potassium contained in the intestinal secretions is also excreted in the urine. Most patients with hypokalemia and hypokalemia can be alleviated after appropriate supplementation with drugs.

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