EA010928B1 - Method for preventing a process of adhesion forming in the upper part of abdominal cavity after selective proximal vagotomy - Google Patents

Abstract

The invention relates to medicine, in particular, to surgical gastroenterology and can be used in surgical treatment of pyloroduodelnal ulcer of selective proximal vagotomy (SPV).For preventing forming ulcer relapse by performing prophylaxis of adhesion process in the upper part of abdominal cavity formed after SPV, a flap of a corresponding size from greater gastrocolic omentum of greater curvature of stomach is prepared, the prepared omentum flap is applied from the SPV area of the lesser curvature of stomach and attached mobile in three points to the posterior wall of stomach. In case the length of the omentum flap is not enough in the process of the stomach covering it is extended by separating thereof from the transverse colon.When performing the SPV operation with stomach drainage a flap of corresponding size is applied and spreaded on the seam line and fixed in several points.

Description

The invention relates to the field of medicine, namely to surgical gastroenterology, and can be used in the surgical treatment of pyloroduodenal ulcers selective proximal vagotomy (SPV).

In the past two decades, SST has taken a worthy place in the surgical treatment of pyloroduodenal ulcers. The “Achilles heel” of SPV is the frequent recurrence of an ulcer after its completion (7, 8, 10, 11).

One of the main causes of recurrence of ulcers after PWV is incomplete vagotomy, inadequate gastric drainage, undetected Zolinger-Ellison syndrome, impaired duodenal motor function (1, 4, 7, 9, 11). Among these causes, in 86% of relapses, incomplete vagotamia is noted. However, according to many authors, inadequate gastric drainage compared with incomplete vagotomy is in many cases a much more common cause of recurrent ulcers (6, 8, 9, 10, 14).

From the literature (2, 9, 11, 13, 14, 15), the role of the formation of recurrent ulcers is known due to the activation of gastrin stimulation of gastric secretion in the presence of gastrostasis as a result of impaired motor-evacuation function of the antrum and duodenum.

As a result of clinical observations and experience (archival materials, examination of re-operated patients), an increase in the development of adhesions in the upper abdominal cavity after PWV as a result of impaired motor-evacuation function of the stomach was revealed. After SPV (467 operated) with re-operation in 34 patients (7.2%), as a result of the recurrence of ulcers, the formation of a powerful adhesions process was found in the upper abdominal cavity between the stomach and the ventral surface of the liver, as well as the parietal peritoneum. As a result, the stomach undergoes deformation, the motor-evacuation function is disturbed, gastrostasis appears, which activates the humoral phase of gastric secretion and causes hypersecretion, and the soil for ulcer recurrence is created. Thus, it creates the need to prevent the formation of adhesive processes for indirect prevention of recurrence of ulcers.

The development of adhesions after PWV is confirmed by experiments conducted by the authors in the course of research and provides a scientific basis for the mechanism of its formation (9).

In the experiment of 5 episodes with 6 dogs each, the first series - laparotomy, revision of the abdominal organs, 2nd series - gastrectomy, 3rd series - SST + without stomach draining operation, 4th series - extended SST with a stomach draining operation, the 5th series - SPV + method of preventing the formation of adhesions. For each series, a second operation is carried out, after 7-14 days, 1, 3, 6 months and 1 year with the study of the degree of adhesions formation. It was found that in the third and fourth series a powerful array of adhesions was detected, gastric deformity, fixation of the latter in the inner surface of the liver along the lesser curvature, and major changes that prevent the rhythmic peristalsis of the stomach walls. The proposed method of prevention within the specified time after the SST (5th series) confirmed the absence of adhesions, the preservation of the normal motor-evacuation function of the stomach (visual assessment, photo documentation, histochemical, morphological studies).

In connection with the dissection of the motor fibers of the vagus nerve, the motor function of the stomach weakens. Evacuation of the food mass from the stomach is slowed down, intragastric pressure rises, and the stomach walls stretch. Since the vagus nerve is a mixed nerve and during vagotomy its sensitive and vegetative fibers are also dissected, the parasympathetic innervation is partially stopped, the sympathetic innervation tone and the development of vascular spasm of the stomach walls increase, and blood circulation decreases, which leads to disruption of trophism and ischemia. Consequently, the latter leads to activation and irritation of fibroblasts, an excessive amount of fibril protein formation (collagen, elastin). The release of peritoneal fluid, which is rich in these proteins between the stomach and neighboring organs, the parietal and visceral sheets of the peritoneum, increases, the fibrin network is invaded by fibroblasts, which become fibrous grains, and adhesions develop.

To date, there are four groups of activities aimed at preventing adhesions in the abdominal cavity: 1) reduction of peritoneal injuries; 2) reduction of the inflammatory reaction in the area of operation; 3) reducing the likelihood of fibrin falling into the free abdominal cavity; 4) limiting damaged mesothelial surfaces.

The objective of the invention is to prevent the formation of recurrent ulcers by preventing adhesions in the upper abdominal cavity, formed after the PWV.

The task is achieved by a method of preventing the process of formation of adhesions in the upper abdominal cavity after selective proximal vagotomy, which consists in preparing a flap of an appropriate size from the greater omentum along the greater curvature of the stomach.

The made gland flap is held from the place of SST of small curvature and is fixed in mobile at three places to the back wall of the stomach.

In case of insufficient length of the omental flap during covering the stomach, it is lengthened by separation from the transverse colon.

- 1 010928

In the case of a draining operation, one edge of the flap is laid out on the suture line and fixed with several interrupted sutures.

When conducting SST, favorable conditions are created for the development of a powerful adhesions process in the upper part of the abdominal cavity. Thus, during the operation, a large section of the anterior and posterior leaflets of the visceral peritoneum of the lesser and greater curvature of the stomach is injured, 2530% impaired microcirculatory blood supply of the lesser curvature of the stomach, the occurrence of inflammation in the area of operation, migration of abdominal fibroblasts and fibrin subsidence factors. Hence, a new method of preventing adhesions after conducting the SST should, as a result of the measures taken, reduce injuries to the peritoneum, limit the inflammatory response in the area of operation, reduce fibrin sedimentation in the free abdominal cavity, and not disturb the motor-evacuation function of the stomach.

From scientific sources, the protective function of the great omentum, its plasticity, good reduction of suture materials, reduction of adhesive processes in the area of sutures (5, 12, 13) are known. Taking into account these features of the greater omentum, a new method for the prevention of adhesions after the PWV has been prepared.

The method is simple, easy to execute.

Due to the fact that you use your own material, which is not foreign to the body, there are no problems.

Due to the reliable prevention of adhesions in the long postoperative period, the motor-evacuation function of the stomach is not impaired, the occurrence of ulcers recurrence is prevented.

Explanations are made in graphic images on which are shown:

FIG. 1 shows a finished view of a selective proximal vogotomy (1) and a large omentum flap (2) made along the greater curvature in accordance with the SST of the lesser curvature of the stomach;

figure 2 - the stage of the fabricated flap (1);

FIG. 3 - shows the stage of the gland flap using the taped (2) and mobile fixation (1) it to the posterior wall of the stomach at three points (3);

FIG. 4 - completion and holding of the omental flap (1) to the posterior wall of the stomach (2 piloric part of the stomach, 3-transverse colon);

FIG. 5 - in the sagittal section, the stages of preparation and carrying out the omental flap through the small curvature in the place of SST to the back wall of the stomach (1 - liver, 2 - hepato-gastric ligament, 3 stomach, 4 - gastric - transverse colon ligament, 5 - transverse colon, 6 - the greater omentum, 7 - separation of the greater omentum from the transverse colon, 8 - spreading the released omentum onto the walls of the stomach);

FIG. 6 - the suture line (1) of the stomach draining operation in the course of SST and the flap manufacturing from the greater omentum (2), corresponding to the size of the suture line of the stomach draining operation;

FIG. 7 is a depiction of the final stage of the covering with a gland flap of the seam line (1) of the draining operation and its fixation;

Fig. 8 shows the stages of elongation of the greater omentum (6) with its short and fixed forms (1 - liver, 2 - hepato-gastric ligament, 3 - stomach, 4 - gastro-transverse ligament, 5 - transverse colon, 6); - a large gland, 7 - separation of the greater omentum from the transverse colon, 8 - spreading the released gland flap onto the stomach wall).

The method is as follows.

Under endotracheal anesthesia, extended or isolated SPV is produced with and without a stomach draining operation (Fig. 1-1). From the greater omentum along the greater curvature of the stomach, a flap of an appropriate size is prepared (Figures 1–2). The made gland flap is carried out from the place of the SST of small curvature (Fig. 2-1, Fig. 3-1) and is fixed in mobile at three places to the back wall of the stomach (Fig. 4, 5). When conducting SPV with a stomach draining operation (Fig. 6-1), a flap of the appropriate size is prepared from the gland (Fig. 6-2) to the seam line of the draining operation and spread onto this area, fixed in several places (Fig. 7-1). In the variants of fixation of the greater omentum, due to its mobilization, elongation and release are carried out (Fig. 8).

Literature

1. Bely I.S., Vakhtangishvili R.Sh., Chalaya L.V. "Prevention and treatment of postvagotomic complications." Wedge. hir 1986, №8, pp. 72-73.

2. Bulgakov G.A., Kubyshkin V.A. "Modern problems of surgical treatment of uncomplicated duodenal ulcer". Surgery. 2001, No. 5, pp. 31-36.

3. Gervaziev V.B., Lubyansky V.G., Chilikidi K.Yu. Surgery. 1993. №11. pp. 39-41.

4. Dzhumbaev S.U., Meh'anov A.M. Surgery. 1999. №4. pp. 25-28.

5. Isaev GB, Aliyev S.I. - it. Baku. 1994. p. 342.

6. Kuzin M.I. Topical issues of surgery of gastric ulcer and duodenal ulcer. Surgery. 2001. №1. pp. 27-32.

- 2 010928

7. Pantsyrev Yu.M., Siderenko V.I., Chernyakevich S.A. and others. Surgery. 1993. № 3, p.45-49.

8. Rustamov E.A., Manafov S.S. Radiographic characteristics of the motor-evacuation function of the stomach after selective proximal vagotomy. Bulletin of radiology and radiology, 1988. №2. p. 10-14.

9. Ki81ashou, EA, Matthayou, K.V., / aupa1ou, Ν.Ο., Viyap, AK - Paide818 about! ayye81ue rgosezez ayyg 8e1siyue rgoh1ta1 uadototot apy go oh oh! ’sgaypd gesiggep! i1segz - Sopdgezz o! ’Zigdeopz apy Oaz1goe1oβΐδδ - А181а818. 2-4 1, 2005, Tbn1, Geogg1a.

10. Rzayev N.M. Seidov V.D., Rustamov E.A. Surgery, 1993, No. 3, pp. 62-67

11. Rustamov G.A. Recurrent ulcers. Baku, p. 160.

12. Rychagov G.P., Nekhoev A.N., Kerezev P.I., Kremen V.E. Relaporotamia in the treatment of postoperative ita. Surgery. 1971, №1, p.45-48.

13. Isaev GB, Aliyev SI. - it. Baku, 1994, p. 342.

14. Hatzatyanov Z.Kh. Colon Surgery Ufa, 1976, p. 279.

15. Chernousov A.F., Shestakov A.L. Selective proximal vagotomy. Ed. AT Moscow. 2001, p. 160

16. 1.e1ig V., Tgaiue K., 81i1i e1. a1. As1a syg. Zeapy, 1990: 156: 9: 621-624.

Claims (3)

CLAIM 1. A method of preventing the process of adhesions formation in the upper abdominal cavity after selective proximal vagotomy (SPV), characterized in that a flap of an appropriate size is prepared from the greater omentum along the greater curvature of the stomach, which is spread onto the anterior wall of the stomach, carried out through the small curvature of the stomach above the line the suture and the corresponding SPV of small curvature, mobile fixed on the back of the stomach in three places. 2. The method according to claim 1, characterized in that in the case of an insufficient length of the omental flap during the covering of the stomach, it is lengthened by separation from the transverse colon. 3. The method according to claim 1, characterized in that in the case of a draining operation, one edge of the flap is laid out on the seam line and fixed with several interrupted sutures.