RU2071277C1 - Method to form distal-lateral interintestinal anastomosis - Google Patents

Abstract

FIELD: medicine, surgery at operational treating diseases of stomach, biliary passage, pancreas, small intestine. SUBSTANCE: adductory intestines are formed at distal department of invaginational trunk with mesogastrium strip with supplying vessels but from back intestinal wall, frontal intestinal wall is cut at trunk's length, trunk and mesogastrium strip are put into abducent intestine lumen through cross-sectional cut of its wall at one third of circle length to form T-shaped cross-invaginational distal-lateral anastomosis of sufficient valve properties. The method inhibits reflex development and keeps adequate passage of intestinal content that provides optimal functional properties of anastomosis. EFFECT: more simplified method for surgical application. 3 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of diseases of the stomach, biliary tract, pancreas, small intestine.

 As an analogue, C. Roux proposes a method for forming an end-lateral inter-intestinal anastomosis (Mariev A. I. Gastrointestinal and inter-intestinal anastomoses. Petrozavodsk, 1990, p. 28). The disadvantages of this method are: gaping of the anastomosis, violation of evacuation in its area, reflux of intestinal contents in both the adducting and the abducting intestines, impaired blood supply and innervation of the mesenteric edge of the anastomosis, which is caused by longitudinal dissection of the wall of the abducting intestine with the intersection of circular muscle fibers, transverse vessels and nerve fibers.

 These shortcomings can provoke complications such as failure of the anastomosis, infection of the overlying sections of the gastrointestinal tract, bile ducts, and the development of stasis in the adducting gut.

 As an analogue, M. Kasi proposes a method for the formation of an end-lateral inter-intestinal anastomosis (Mariev A. I. Gastrointestinal and inter-intestinal anastomoses. Petrozavodsk, 1990, p. 28). The disadvantages of this method are: the weakness of the valve properties of the anastomosis, the possibility of reflux, which can lead to infection of the overlying sections of the gastrointestinal tract, bile ducts, and the development of stasis in the adrenal gut.

The closest in technical essence to the proposed method is I. Yu. Ibadova method of forming the lateral-lateral inter-intestinal anastomosis, including the intersection of the small intestine below the Treytz ligament by 35-40 cm, the creation of an invaginal proboscis in the distal portion of the adducting intestine 2-2.5 cm long with a flat mesentery carrying the supply vessels, transverse dissection of the wall of the abdomen along the line of the intended site of the anastomosis, immersion of the "proboscis" together with the strip of the mesentery into the lumen of the abducting intestine and fixing it in this position alone single knotted serous-muscular sutures [1]
There are common signs of this method of forming the end-lateral inter-intestinal anastomosis with the claimed method, which are expressed in the following:
a / the method is used in abdominal surgery;
b / the method provides for the creation in the distal section of the adducting intestine of the invagination "proboscis" with a strip of mesentery carrying the supply vessels;
in / c method includes immersion of the invagination "proboscis" in the lumen of the abducting intestine through a transverse incision of its wall;
g / method is aimed at the formation of a T-shaped transverse invagination anastomosis with sufficient valve properties.

 However, the known method is not without drawbacks: an invagination proboscis with a strip of mesentery carrying the supply vessels, in the distal section of the adducting intestine is formed from the entire cylinder of the intestinal tube with the participation of both its walls, when it is immersed in the discharge intestine by 2-2.5 cm the clearance of the latter is significantly reduced, which can lead to disruption of passage through the anastomotic zone, up to the development of obstruction in the most severe cases.

 The objective of the invention is the development of a method of forming an end-lateral inter-intestinal anastomosis with optimal functional properties.

 The solution of this problem allows us to exclude evacuation disorders in the anastomosis zone, prevents reflux of intestinal contents, which is achieved by creating in the distal section of the adducting intestine a 2.5-3 cm long proboscis with a strip of mesentery carrying the supply vessels only from the posterior wall of the intestine, the anterior the wall of the intestine is excised by the length of the "proboscis" by immersion of the "proboscis" together with the strip of the mesentery into the lumen of the abducting intestine through an incision of its wall transverse by 1/3 of the circumference, as a result of which Т-о is formed clear transverse invagination anastomosis with quite pronounced valve properties.

 The main stages of the operation are presented in FIG. 1-3.

 The method is as follows.

 After mobilization of the mesentery and the intersection of the small intestine at the required distance from the Treitz ligament in the distal section of the adducting intestine (1), a strip of mesentery with feeding vessels (2) is cut, equal in length to the size of the future proboscis (3). The back wall of the adducting intestine, 2.5-3 cm away from the free edge, is sutured in the strictly transverse direction with individual serous-muscular sutures (4) to the abduction intestine (5) 0.5 cm above the line of the intended site of the anastomosis (6). Moreover, the first sutures are placed on the mesenteric and peri-mesenteric edges, then the rest. The front wall of the adducting intestine is excised to the length of the formed "proboscis" (3), making longitudinal sections along the mesenteric edge and 0.5-0.7 cm above the cut mesentery strip, both sections are connected in the transverse direction, the dissected front wall is removed, bleeding vessels are ligating. Dissect the wall of the abducting intestine along the line of the intended site of the anastomosis (6) in the transverse direction, departing up to 1 cm from the mesenteric edge, by 1/3 of the circumference of the intestine. The choice of the size of the incision to 1/3 of the circumference of the intestine is not accidental, this allows you to maintain a sufficient closure function of the anastomosis and, along with the "proboscis" invaginated at the next stage of the operation (3), protects the adductal gut from reflux of intestinal contents.

 The formed "proboscis" (3) together with a strip of mesentery (2) with tweezers is immersed in the lumen of the abducting intestine (5), fixed in this position with two angular sutures-traps and then the front lip of the anastomosis is formed by double-row interrupted nylon sutures: the first row of sutures is serous submucosal, second serous-muscular. The window in the mesentery between the adducting and abducting intestines is sutured. The free end of the abducting intestine is anastomosed with other organs, depending on the nature of the intervention.

 Example No. 1. Patient S. 72 years old was hospitalized on 9 / V-93, according to emergency indications with a clinic of profuse gastrointestinal bleeding in a moderate state. With urgent fibrogastroscopy in the stomach, a large amount of blood, in / 3 of the body along the lesser curvature of the ulcer-cancer under a loose thrombus with signs of ongoing bleeding. The patient was taken to the operating room. By performing laparotomy under endotracheal anesthesia, the following was revealed: the stomach was large, filled with blood clots, in the cardiac section, the saucer-shaped tumor was 5x6 cm in size, enlarged dense l / y along the left gastric artery and in the gastrointestinal ligament. The small and large intestines are filled with blood, in the area of duodenojejunal transition pronounced periprocess. The liver with a fine-cirrhotic cirrhotic structure, the spleen is reduced in size. No distant metastases were detected. It was decided to perform a gastroectomy. Mobilization of the stomach with large and small omentums and part of the abdominal esophagus. The duodenum 12 below the pylorus is sewn with the UO-40 device, the stomach is cut off, the duodenal stump is immersed in two half-purse sutures and peritonized by a series of gray-serous sutures. Gastroectomy with 2 cm of the abdominal esophagus. The duodenojejunal transition is mobilized from adhesions, a dissection of the Treitz ligament is performed. Below the duodenojejunal junction, 20 cm, the lean skin is mobilized and, after flashing the outlet end with the UO-40, is crossed. The line of stitching sutures is peritonized by a series of nodular gray-serous sutures, the abducting intestine is transferred to the upper floor of the abdominal cavity through a window in the mesentery of the transverse colon. Between the transverse esophagus and the loop of the abducting intestine, an end-lateral transverse muft-shaped esophageoejunoanastomosis is formed. A strip of the mesentery with feeding vessels of 3 cm in length was cut in the distal section of the adducting intestine. The posterior wall of the adducting intestine, 3 cm away from the free edge, is sewn in the transverse direction to the abducting intestine with individual sero-muscular sutures 40 cm below the esophageojejunoanastomosis. The anterior wall of the distal portion of the adducting gut is excised 3 cm in length. Thus an invagination proboscis is formed. The wall of the abducting intestine along the line of the planned anastomosis is dissected in the transverse direction to 1/3 of the circumference of the intestine. The “proboscis” with tweezers is immersed in the lumen of the abducting intestine, fixed with two edge traps, then the front lip of the anastomosis is sutured with two-row knotted nylon seams. The window in the mesentery between the adducting and abducting intestines is sutured. The diverting intestine is fixed in the window of the mesocolon.

 The abdominal cavity is drained. Trapping drainage into the left subphrenic and subhepatic spaces. The wound of the abdominal wall is sutured in layers tightly. A histological examination of the tumor has small cell anaplastic cancer in the presence of a chronic ulcer in one of the lymph nodes of the cancer metastasis. There is no tumor growth in the esophagus.

 The postoperative period was uneventful, antibacterial, infusion therapy, transfusion of single-group blood, erythromass, plasma, and protein preparations were carried out. Liquid intake through the mouth is allowed from the 5th day, food from the 6th day. The wound healed by primary intention. During the control x-ray examination, the function of both anastomoses is satisfactory, there is no contrast reflux into the adducting gut.

 Example No. 2. Patient M., 62 years old, was hospitalized in the hospital on 18 / V-93 for emergency indications in a moderate state with a preliminary diagnosis: acute cholecystic pancreatitis. For about a year, periodic pains in the epigastrium and the right hypochondrium worry. Nausea, sometimes vomiting. Over the past week, the pain intensified, began to radiate in the lower back, vomiting became permanent after each meal.

 According to the results of ultrasound, data for cholecystic pancreatitis have not been confirmed. With fibrogastroscopy of 21 / V-903, at the border of the upper and middle tertiary of the stomach, a small ulcer and pronounced pyloric edema were revealed by small curvature. When x-ray examination of the stomach 24 / V-93, the stomach is hypotonic, contains an empty stomach a large amount of fluid and mucus. By a small curvature at the border of the upper and middle third of the body, a deep niche of 2.0x1.5 cm is determined, the small curvature is shortened, the ant calving is deformed, narrowed. The relief of the mucosa is rough. Gastric evacuation is not delayed.

 Despite intensive therapy with the use of analgesics and antispasmodics, the pain syndrome persisted, vomiting was repeated. An ulcer penetration is suspected, a large surgical treatment is suggested. 25 / V-93 g. - operation: resection of 2/3 of the stomach according to Ru in the modification, dissection of the Treitz ligament.

 By performing laparotomy under endotracheal anesthesia, the following was revealed: a stomach of normal sizes, at the border of the upper and middle third of the body along the lesser curvature, the infiltrate is 5x5 cm, in the center of which a ulcerative defect of 2.5x3 cm is palpated, penetrating into the small omentum. The pylorus is sharply hypertrophied, the lower horizontal branch of the duodenum 12 is expanded to 3.5–4 cm, and the moderate periprocess is in the area of the duodenojunal junction. The stomach was mobilized along both curvatures with ligation of the left gastric artery at the base. Below the pylorus, the duodenum 12 is stitched with the UO-40 device, the stomach is cut off, the stump of the duodenum 12 is immersed in two half-netted and a series of gray-serous sutures. The dissection of the Treitz ligament, below the duodenojejunal transition by 20 cm, the jejunum is mobilized and after suturing the discharge end with the UO-40 device, it is crossed. The line of stitching seams of peritonizirvoan, the diverting intestine is transferred to the upper floor of the abdominal cavity through a window in the mesentery of the transverse colon. Resection of 2/3 of the stomach with the treatment of minor curvature by the UO-40 apparatus and the formation of a transverse end-lateral gastroenteroanastomosis between the stump of the stomach and the abducting intestine in our modification. A strip of the mesentery with feeding vessels of 3 cm in length was cut in the distal section of the adducting intestine. The posterior wall of the adducting intestine, 3 cm from the free edge, is hemmed laterally to the outlet intestine by nodal nylon sutures 35 cm below the gastroenteroanastomosis. The anterior wall of the distal portion of the adducting intestine is excised to the length of the feeding leg, thus forming an invagination proboscis. The wall of the abducting intestine along the line of the planned anastomosis is dissected in the transverse direction to 1/3 of the circumference of the intestine. The invagination "proboscis" is immersed in the lumen of the abducting intestine, fixed by angular sutures, traps, after which the anastomosis anterior lip is formed by 2-row interrupted sutures.

 The window in the mesentery between the adducting and abducting intestines is sutured. The abdominal cavity is drained. The wound of the abdominal wall is sutured in layers tightly. The postoperative period was uneventful, the wound healed by first intention. During the control x-ray examination, evacuation from the stump of the stomach is rhythmic, portioned. The area of the intestinal anastomosis without features, there is no contrast reflux into the adducting intestine.

 Thus, the proposed method for the formation of an end-lateral inter-intestinal anastomosis prevents reflux, maintains an adequate passage of intestinal contents, is reliable in terms of insolvency, which ensures optimal functional properties of the anastomosis. The method is quite simple in technical execution, and can be recommended in surgical practice.

Claims (1)

 A method of forming an end-lateral inter-intestinal anastomosis, including crossing the small intestine at a distance necessary from the Treitz connection, creating in the distal section of the adducting intestine a proboscis with a strip of mesentery carrying the supply vessels, dissecting the wall of the abducting intestine along the line of the intended site of the anastomosis, immersion of the invagination proboscis "into the lumen of the abducting intestine and fixing it in this position with sutures around the circumference of the anastomosis, characterized in that they form an invagination" proboscis "2.5 3 cm long with a polo of the mesentery, carrying the supply vessels, in the distal section of the adducting intestine only from the posterior wall of the intestine, the anterior wall of the intestine is excised by the length of the proboscis, and the abducting intestine is cut into 1/3 of the circumference.

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