Методы пластики дефекта тазового дна после расширенных операций по поводу рака прямой кишки

Существенной доле пациентов с колоректальным раком требуются расширенные операции с формированием значительного «мертвого пространства» в полости таза. Одно из серьезных последствий таких вмешательств – промежностные грыжи, которые ухудшают качество жизни: вызывают болевой синдром, нарушения мочеиспускания, кишечной проходимости, образование свищей и язвенных дефектов кожи.
На сегодняшний день существуют различные методы устранения или профилактики данного осложнения. «Простое» ушивание промежностной раны наиболее доступно, однако при обширном дефекте оно не обеспечивает надежного закрытия и сопровождается повышенными рисками расхождения швов, инфекций и последующего формирования грыжи.
Аутопластика дефекта тазового дна включает использование лоскутов на основе прямой мышцы живота (vertical rectus abdominis myocutaneous flap, VRAM), тонкой мышцы (m. gracilis), большой ягодичной мышцы (односторонний или двусторонний вариант), а также кожно-подкожных лоскутов. Использование VRAM-лоскута демонстрирует низкую частоту промежностных грыж и приемлемую выживаемость, но требует высокой квалификации хирурга и не всегда подходит при лапароскопических доступах или формировании нескольких стом. Грацилопластика эффективна у ряда пациентов, в том числе при малоинвазивных операциях, однако может сопровождаться более высокой частотой осложнений, чем в случае с V RAM. Применение лоскутов большой ягодичной мышцы позволяет заместить дефект с сохранением хорошего кровоснабжения, но вызывает риски снижения функции мышцы и болевого синдрома. Кожно-подкожные лоскуты менее травматичны и иногда уменьшают вероятность грыжеобразования, но статистические данные об их применении пока ограниченны.
Аллопластика дефекта тазового дна выполняется с помощью синтетических или биологических сеток. Биологические сетки, судя по последним исследованиям, достоверно снижают частоту промежностных грыж в сравнении с «простым» ушиванием. В то же время они существенно увеличивают стоимость лечения. Применение синтетических материалов требует строгой изоляции петель кишечника от поверхности сетки для профилактики адгезий и инфекционных осложнений; опыт и долгосрочные результаты здесь пока ограниченны.
Таким образом, выбор способа реконструкции тазового дна зависит от размеров дефекта, общего состояния пациента, навыков членов хирургической команды и доступности необходимых материалов. Единого «золотого стандарта» такой операции до сих пор не существует. Необходимы дополнительные многоцентровые исследования и сравнения, которые помогут определить оптимальные показания к каждому методу и выработать единые клинические протоколы.

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