EA022830B1 - Method of conducting splenoconservative gastrectomy in stomach cancer - Google Patents

Abstract

The invention relates to medicine, abdominal surgery, and can be used in splenoconservative gastrectomy with extended lymphodissection in stomach cancer. The invention is aimed at shortening postoperative complications by providing an improved method of conducting the splenoconservative gastrectomy. The assigned task is solved by that in the method of the splenoconservative gastrectomy in stomach cancer comprising conducting mobilization at lesser curvature of stomach, ligation of right and left gastric veins, cutting off duodenum, cutting off esophagus, according to the invention, after cutting off the esophagus mobilization at greater curvature of stomach, ligation of right gastroepiploic veins are conducted, and finally mobilization of the distal part of pancreas and dissection of lymphatic glands along splenic veins and splenic hilum are conducted.

Description

The invention relates to medicine, abdominal surgery, and can be used for splenopreservation gastrectomy with expanded lymphadenectomy for gastric cancer.

Known modified in 2005-2007. in the Russian Science Center named after N.N. Blokhin’s technique of splenopreservation gastrectomy with the removal of 10 and 11 groups of lymph nodes (Kttiga T. Mopua, Ma 1. s1 a1.

8p1eei-rge8egushd Y181a1 raistea1es1otu \ νί11ι sopketuayop οί 1st 8p1ets ayegu apb ust. // \ Uog1b 1. SaigoeShegok 2007. Uo1. 14; 13 (10), p. 1493-1499). The average number of all removed lymph nodes and the number of lymph nodes of group 10 did not differ significantly from the control group, which consisted of patients operated on in the volume of Ό2 gastrectomy with splenectomy. The operation is technically complicated and leads to an average increase in the duration of the intervention of splenoplasty surgery by 71 min in comparison with gastrectomy with splenectomy (Stilidi I.S., Nered S.N., Ryabov A.B., etc. surgical treatment of cancer of the body and proximal stomach. // Oncological surgery. 2008, No. 1, p. 37).

A known method of video laparoscopic access to the spleen vessels, gates of the spleen and gastro-splenic ligament, which can be used for video laparoscopic splenopreservation gastrectomy with advanced lymphadenectomy for cancer of the proximal and middle third of the stomach, for video laparoscopic distal resection of the stomach with expanded lymphadenectomy. Mobilize a small omentum. Bandage the left and right gastric arteries and veins. Cross the gastro-pancreatic ligament. Raise the stomach with a retractor. A laparoscope and working instruments are inserted through the hole formed in the small omentum. A laparoscope is advanced along the upper edge of the pancreas and splenic vessels to the gates of the spleen (patent KI 2363415, IPC АВВ 17/94, publ. 08/10/2009). Performing such an intervention is accompanied by a number of technical difficulties and the ensuing dangers of developing intraoperative complications.

With the well-known classical technique of splenopreservation gastrectomy (Chissov V.I., Trakhtenberg A.Kh., Paches A.I. Atlas of oncological operations. / Moscow. Publishing Group GEOT AR-Media, 2008. S. 301-310), the mobilization of the stomach begins with the intersection of the gastrointestinal ligament. An omental bursa opens, and the gastro-pancreas ligament intersects with the anterior leaf of the mesocolon and peritoneum covering the anterior surface of the pancreas. Next, a large omentum is mobilized to the hepatic corner of the colon with access to the wall of the duodenum with ligation of the right gastro-omental vessels with lymphadenectomy of the sub-pyloric and right gastro-omental lymph nodes (groups 6 and 4b). Then, the left half of the greater omentum is mobilized to the gastro-splenic ligament with the intersection and ligation of the short gastric vessels with the collection of 4ga lymph node group. The left gastro-omental vessels are ligated directly at the place of departure from the splenic vessels, while the left gastro-omental lymph nodes dissect and shift to the preparation (groups 4b). The mobilization of the stomach along the greater curvature ends with the intersection of the diaphragmatic gastric ligament. At the same time, the right paracardiac lymph nodes depart to the drug (group 2). Then proceed to lymphatic dissection in the pool of branches of the celiac trunk, which runs in the direction from right to left. Fiber and lymph nodes are mobilized along the common hepatic artery (group 8) in the direction of the celiac trunk. Next, the peritoneal fold between the pylorus and the head of the pancreas is dissected in the projection of the gastro-duodenal artery, and the capsule of the pancreas is opened in this area, followed by its detachment from the pancreas in the direction of the tail. Lymphatic dissection is performed along the spleen vessels and gates of the spleen (10p, 10b and 11 groups) with subsequent displacement of the fiber block on the drug. The celiac trunk is skeletonized (group 9), the mouth of the left gastric artery is released, which intersects and bandages, and the tissue along (group 7) is displaced to the drug. Next, a small omentum intersects towards the esophagus. At the same time, the right paracardial and lymph nodes of lesser curvature depart to the drug (groups 1 and 3). The peritoneum covering the elements of the hepatoduodenal ligament is dissected, lymphodissection is performed along the anteroposterior margin of the hepatoduodenal ligament, displacing fiber (group 12) towards the small omentum. At the same time, the right gastric artery is exposed, which intersects, bandages, and the supra-jugular group (5) of the lymph nodes departs to the drug. At the final stage of lymphatic dissection, fiber and lymph nodes are removed from under the hepatoduodenal ligament along the portal vein (11p) and, together with the posterior group of lymph nodes, are displaced along the common hepatic artery (8p) to the drug. Next, the duodenum and esophagus intersect, and the drug is removed in a single block.

The disadvantage of this method is the frequency of complications leading to an increase in the length of hospital stay of patients.

The objective of the invention is to reduce the frequency of postoperative complications by creating an improved method for splenopreservation gastrectomy.

The problem is solved in that in the method of conducting splenopreservation gastrectomy in case of gastric cancer, including mobilization along the lesser curvature of the stomach, ligation of the right and left gastric vessels, cutting off the duodenum, cutting off the esophagus, according to the invention, after cutting off the esophagus, mobilization along the large curvature, ligation right

- 1 022830 gastro-omental vessels, and ultimately they mobilize the distal part of the pancreas and dissect the lymph nodes along the spleen vessels and gates of the spleen.

A comparative analysis was conducted between the main and control groups.

In a pathomorphological study of the removed drug in the main group, 112 lymph nodes were removed from the spleen gate, which is an average of 3.73 per patient. In the control group, the total number of examined lymph nodes is 124, which is 3.87 on average for each patient.

The nature and frequency of complications leading to an increase in the length of hospital stay of patients is more pronounced in the control group. In the main group, 10% of patients noted the presence of the investigated complications, while in the control group 25% (p <0.05).

Thus, as a result of the study, it was found that the proposed method for splenopreservation gastrectomy complies with the rules of oncological radicalism and improves the immediate results of treatment. Moreover, the long-term results in the studied category of patients are almost the same.

The present invention proposes, after mobilization along the lesser curvature of the stomach, ligation of the right and left gastric vessels, clipping of the duodenum 12, and clipping of the esophagus. In the classical technique, esophageal intersection is the final stage of drug removal. Next, mobilization is carried out along a large curvature, ligation of the right gastrointestinal vessels. Ultimately, the distal part of the pancreas is mobilized and the lymph nodes are dissected along the spleen vessels and spleen gates.

As a result of the implementation of the proposed method, the duration of the operation is reduced by an average of two times compared with the classical method of performing splenopreservation gastrectomy, torsion with subsequent splear infarction in the postoperative period is excluded, the likelihood of technical damage to the spleen vessels decreases.

Examples confirming the possibility of implementing the invention.

Example 1

Patient N., 51 years old, and / b 6195/09. The diagnosis is cancer of the body of the stomach, ρΤ2Ν1Μ0. The patient underwent surgery Gastrectomy, lymph node dissection Ό2. A pathomorphological study of the removed preparation: adenocarcinoma of medium differentiation, damage to the serous membrane, metastasis of 6 lymph nodes out of 25, metastasis of 1 lymph node of the spleen gate from 4. The postoperative period was uneventful. The patient is under dynamic control, relapse and metastasis of the disease are not observed.

Example 2

Patient A., 49 years old, and / b 8036/10. The diagnosis is stomach cancer, ρΤ3Ν0Μ0. The patient underwent surgery Gastrectomy, lymph node dissection Ό3. Pathomorphological study of the removed preparation: adenocarcinoma of low differentiation, damage to the serous membrane, 40 lymph nodes were examined, metastatically damaged nodes were not found, 3 of them were at the gates of the spleen. The postoperative period was uneventful. The patient is under dynamic control, relapse and metastasis of the disease are not observed.

Example 3

Patient M., 59 years old, and / b 2570/11. The diagnosis is cancer of the antrum, ρΤ3Ν1Μ0. The patient underwent surgery Gastrectomy, lymph node dissection Ό3. A pathomorphological study of the removed preparation: a low differentiation adenocarcinoma, damage to the serous membrane, metastasis in 5 out of 38 lymph nodes, 4 of them are intact lymph nodes at the spleen gate. The postoperative period was uneventful. The patient is under dynamic control, relapse and metastasis of the disease are not observed.

Claims (1)

CLAIM The method of conducting spleno-preserving gastrectomy in gastric cancer, including mobilization along the lesser curvature of the stomach, dressing of the right and left gastric vessels, cutting off the duodenum, cutting off the esophagus, characterized in that after cutting off the esophagus they are mobilized along the greater curvature, dressing of the right gastrointestinal vessels then mobilization of the distal part of the pancreas and dissection of the lymph nodes along the splenic vessels and the spleen gates are performed.