ANUS PRAETERNATURALIS (unnatural anus) — it is created by crossing of a large intestine with a vshivaniye only bringing or both of its ends in a wound of an abdominal wall.
And. the river needs to distinguish from side colic fistula (colostomia), at Krom only one wall of a gut is hemmed and is opened; through such fistula the gut is emptied partially, fecal masses continues to come to underlying departments (see. Colostomy ).
Distinguish single-barreled and double-barreled And. river; besides, it can be constant and temporary.
At single-barreled And. the ruble is brought to an abdominal wall the bringing end of a gut which is taking away the end leaves entirely or is sewn up tightly and falls to an abdominal cavity.
At double-barreled And. rubles are brought to an abdominal wall both ends of completely crossed large intestine therefore an opportunity to wash out the lower piece of intestines is created and to enter into it medicinal substances.
Depending on indications, And. the river or colic fistula are imposed for a while or remain forever. In the first case after need, at the remained lower piece of a gut, its ends can be sewed, and then the normal way for passing of fecal masses is recovered.
Transabdominal colotomy as the simplest way of education And. the river was offered A. Littre in 1710. For the first time with success operation of imposing And. the river was made this way by Pillore in 1776. But surgeons avoided to impose And. river because of risk of development of peritonitis. Therefore Kallisen (H. Callisen) suggested to make an extra peritoneal lumbar colotomy, and Amyuss (J. Z. Amussat, 1839) simplified it, doing cross section. So there were two ways of a colotomy, long time colotomia iliaca Littre and extra peritoneal colotomia lumbalis Amussat which were called by name authors. With implementation of antiseptics surgeons became more courageous to resort to a colotomy, indications to a cut arose hl. obr. at neudalimy new growths of a rectum. The English surgeons preferred a back lumbar colotomy. In 1884 Brayent (T. Bryant) reported about similar operations at 62 patients, 26 of which died within a month.
The German and Scandinavian surgeons, on the contrary, gave preference of a lobby of colotomia iliaca, technically more easily to feasible. However, both a lumbar, and ileal colotomy, though gave the patient relief, had an identical shortcoming: fecal masses was only partially allocated through intestinal fistula. To eliminate this defect, various ways were offered: Maydl (K. Maydl, 1883) suggested to create an intestinal spur by sewing together among themselves of the bringing and taking away loops of a large intestine; More true (A. Verneuil, 1885), except creation of a spur, suggested to cut off a part of a front wall of a gut thanks to what the opening became wider. The collie (Colley, 1885) made a lumbar colotomy in two stages with an interval in 5 — 7 days. First stage: as well as Brayent, it extended a gut from a wound on width of 4 — 5 fingers and held it a special prop; second stage: cut off the site of a wall of a gut and even absolutely crossed it. A. D. Kni (1887) also extended a gut in a wound and created a spur, postponing opening of a gut for the second stage. Albert (E. Albert) after extraction of a gut carried out a strip of a yodoformny gauze to an opening of mesocolon and completely crossed a gut when it grew together with edges of a wound, i.e. created double-barreled And. river. In 1881 Schinzinger completely crossed to two patients a sigmoid gut and its central end brought to skin of a stomach as single-barreled And. the ruble, and lower sewed up tightly and shipped in an abdominal cavity.
In 1884 the same operation with success was made by Madelung (O. of W. Madelung). After it applied Polosson (Polosson, 1885), Zonnenburg (E. Sonnenburg, 1886), A. G. Undercut (1886), etc. Creation single-barreled And. river yielded the best results, than sigmoidostomy.
However at full impassability of a gut the loop closed from two parties above a tumor turned out that threatened with heavy complications. Therefore Ridel (G. Riedel, 1886) began to bring both ends of the crossed sigmoid gut to an abdominal wall. In 1887 H. N. Ivanov in Mariinsky hospital in St. Petersburg imposed the patient single-barreled And. the ruble who is taking away the end of a gut sewed up tightly and shipped in an abdominal cavity, and a tumor of a rectum (melanocarcinoma) at the same moment removed with perineal access. The patient died in 2,5 months of metastasises, but operation laid the foundation for the new method of operating afterwards developed Η. P. Trinkler (1906) and Lokkart-Mammeri (J. River of Lockart-Mummery, 1923).
Vittsel (F. The lake of Witzei, 1894), imposing a spur, carried out an intestinal loop through a direct muscle, hoping to create a sphincter. Gakker (V. Hacker, 1899), based on the principle Vit-aiming, aimed to create a lock or a szhimatel from the left direct muscle of a stomach. At these ways of imposing And. hit of contents of intestines in underlying department was eliminated with river, but the continence a calla and gases was not reached.
And. rubles impose: 1) as the final stage of bryushnopromezhnostny amputation of a rectum at cancer; 2) at a neudalimy tumor of a rectum (double-barreled And. river); 3) after a resection of a loop of the sigmoid gut which became lifeless owing to torsion; 4) at an atresia of a rectum on all its extent; 5) at the bullet and chipped wounds which are followed by big destructions of sigmoid, direct guts or crotches (single-barreled or double-barreled And. river).
Impose more often And. the river in the left ileal area on a sigmoid gut (anus sigmoideus), is more rare — on the centerline on a cross colon (anus transversatis) and as an exception — on the ascending gut (the cecostomy is usually made). Imposing single-barreled is most often made And. river after belly and perineal amputation of a rectum concerning cancer. For this purpose after the termination of a stage of operation in an abdominal cavity the crossed sigmoid gut is removed at the left in ileal area at the level of a navel through a separate slanting section with drawing apart muscles. The intestinal loop with the kept mesentery without tension is brought in a wound to 2 — 4 cm over the level of skin, pressed by the terminal or Payr's clip.
In order to avoid possible infringement of intestinal loops carefully take in a crack between both a side and front abdominal wall brought to an abdominal wall by a loop of a large intestine. The section of skin and an aponeurosis do no more, than width of the removed loop, in order to avoid hernial protrusion or evagination of an intestinal loop demands. Some surgeons excise the site of skin in the form of an oval; on corners of a wound put one-two skin stitches. The clip is removed in two days, previously having greased skin in a circle of a wound with zinc paste. Gradually the end of a gut is reduced and labelloid intestinal fistula through which there is emptying of a gut forms. For prevention of various complications some surgeons recommend imposing And. river «at the level of skin» with a podshivaniye of a mucous membrane of a gut to skin. At impossibility to finish perineal amputation of a rectum with bringing down it to the area of an anus suggested to impose single-barreled And. river on site the resected top of a sacrum (anus sacralis). In a crust, time almost all surgeons refused this technique.
At highly located cancer of a rectum at the weakened and elderly patients Hartmann (N. of Hartmann, 1924) suggested to make instead of amputation of a rectum its resection with removal of the bringing loop in the form of single-barreled And. river, and the distal piece of a gut which is sewn up tightly to immerse under a pelvic peritoneum. In these cases And. the ruble remains to constants because to recover passability of a large intestine, considering a condition of the patient and the nature of a disease, in most cases it is not possible.
At the acute intestinal impassability caused by obturation a tumor of direct or sigmoid guts the «obstructive» resection of the struck gut [F. W. Rankin] at a cut giving a piece of a gut is preferable remove as single-barreled And. rubles, and the taking-away end which is sewn up tightly lower in an abdominal cavity. At strong abdominal distention previously from crossed have the guts for garters contents. After 6 months by a repeated laparotomy it is possible to recover passability of a large intestine an anastomosis the end in the end, i.e. so-called three-stage operation on Shloffer (1902) (a cecostomy, bowel resection with a tumor, closing of a tsekostoma) replace two-stage (primary resection with imposing And. river, recovery of a continuity of a large intestine.) At torsion of a sigmoid gut with her gangrene make a resection of the changed site of a gut and also impose single-barreled And. rubles, and the taking-away piece sew up tightly and lower in an abdominal cavity. After 3 — 6 months by repeated operation recover a continuity of a large intestine.
At an atresia of an anus or a rectum soon after the birth symptoms of intestinal impassability develop. If at the same time internal fistulas are found in the child (enterovesical, enterourethral, enterovaginal), it is necessary to make difficult reconstructive operations, and then begin them with imposing temporary single-barreled or double-barreled And. river.
At gunshot and chipped wounds of a sigmoid gut solitary foramens sew up. However at multiple wounds and at extensive ruptures of a gut both at gunshot wounds, and at a stupid injury the destroyed site of a gut is resected and imposed single-barreled And. river. The sewn-up taking-away piece is lowered in an abdominal cavity. Also arrive at ruptures of a rectum and at extensive wounds of a crotch with injury of a rectum or its sphincters. After recovery recover normal passability of a gut.
Double-barreled And. rubles impose at the nonresectable tumors of a rectum narrowing its gleam, especially at the developed impassability of intestines. It is shown also at sharp narrowing of a rectum (e.g., at a lymphogranuloma, at hems after burns of final department of a gut). Double-barreled And. rubles sometimes impose as the first stage of operation at various options of a double-stage belly and perineal extirpation or amputation of a rectum.
For imposing double-barreled And. rubles make a slanting section with a section of muscles in the left ileal area at the level of a navel; take a mobile part of a sigmoid gut, in its mesentery make an opening and carry out to it a rubber or glass tube, edges lays down across a wound and holds a gut from the return retraction in an abdominal cavity (fig. 1). Around both knees of a gut and between them partially sew an aponeurosis and skin, sew a parietal peritoneum to skin to avoid infection of hypodermic cellulose and development of phlegmon of an abdominal wall. Instead of a rubber tube it is possible to use a piece of leather (fig. 2) what make a special section for.
In two days cut in transverse direction an intestinal loop on 3/4 circles, keeping an integrity of mesenteric edge in order to avoid an uskolzaniye of a gut in an abdominal cavity. The final section is made in several days then two are formed lying openings nearby: through upper the gut is emptied, through lower it is possible to wash out a rectum.
If double-barreled And. the ruble was imposed temporarily, after need make a laparotomy, separate both knees of a gut from a front abdominal wall and, having refreshed the ends, anastomose them among themselves.
Sigmotomiya in an original form, with formation of a spur, in a crust, time is not applied.
For creation of the switching mechanism single-barreled And. river Kurttsan (H. F. Kurtzahn, 1919) developed plastic surgery. It was improved by Kappis (M. Käppis, 1924): the end of the loop brought to an abdominal wall kept within under skin so that it was possible to squeeze a gut a soft clip. Lambre (O. of Lambret) shrouded the end of the removed gut in the skin rag found on an abdominal wall, creating thus a proboscis. Keeping of fecal masses was reached by squeezing of a proboscis.
Unsatisfactory results of plastic surgeries led to the offer everything new modifications which number reached many tens. However any of them did not find broad application.
H. N. Petrov in 1939 the first refused difficult modifications, recommending to impose idle time And. river through the small section sufficient only for passing of an intestinal loop. In a crust, time plastic methods of formation And. rubles are practically not applied.
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B. A. Petrov.