RU2132650C1 - Method for closing duodenum stump - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves cutting the duodenum in the transverse direction. The mucous membrane is circularly separated. The mucous membrane and seromuscular collar are separately sutured. The suture line on the mucosa are closed with duplicature taken from seromuscular collar wall longitudinally cut at 2/3 of its height. Free wall edges are sutured to the muscular layer of the opposite wall, separated from ulceration defect fundus along the boundary of mobilized mucosa. The walls are put one over another. The walls are fixed with the second row of seromuscular sutures shifting the second row by one collar height. Ulceration defect fundus is insulated with omental strand with limb as it is the case when performing omentoplasty operation. EFFECT: prevented stump inconsistency.

Description

 The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of peptic ulcer of the duodenum, complicated by penetration into the pancreas, hepatic duodenal ligament, and other anatomical structures.

 As an analogue, Graham proposes a method for closing the stump of the duodenum (Matyashin I.M., Gluzman A.M. Handbook of Surgery. Kiev, Zdorovya, 1979, p. 75).

 The disadvantages of this method are the insufficient strength of the immersion seams formed in conditions of deficiency of the posterior wall of the intestinal stump; use to strengthen the stump of scar tissue of the bottom of the ulcer in the penetrated organ with weak plastic properties, and the possibility of injury to this organ in this case; regular formation of a direct wound channel between the individual rows of sutures of the intestinal stump with the submersible nature of the latter.

 These shortcomings in the postoperative period can contribute to the development of pancreatitis, the failure of the stitches of the duodenal stump, which greatly complicates the treatment, often requires repeated surgical interventions and naturally makes the prognosis worse.

 As an analogue, Montenegro offers a method for closing the stump of the duodenum (Matyashin I.M., Gluzman A.M. Handbook of Surgery. Kiev, Zdorovya, 1979, p.90).

 The disadvantages of this method include ischemic tissue due to the imposition of a purse string suture; the possibility of damage to the tissue of the pancreas when hemming the front wall of the stump of the intestine to the peritoneum of the pancreas with suturing the bottom of the ulcer; the formation of a direct wound channel between the rows of stump sutures with the submersible nature of the latter.

 These deficiencies can provoke the development of complications such as pancreatitis and failure of sutures of the duodenal stump in the postoperative period with all the consequences that follow.

 The closest in technical essence to the proposed method is the Sapozhkova method of "cuff" closing the stump of the duodenum (Navrotsky I. N. Suturing the stump of the duodenum. M .: Medicine, 1972, p. 109), including a transverse section of the wall of the duodenum along the edge of the penetrating ulcers, circular detachment of the mucous membrane of the formed stump from the serous-muscular "cuff", separate suturing of the mucous membrane and the serous-muscular "cuff" with sutures with insulation of the bottom of the penetrating ulcer are hemmed it stump formed to the upper edge of ulcers and peritoneum pancreas.

 There are common signs of this method of closing the stump of the duodenum with the claimed method, which are expressed in the following: a) the method is used in the surgical treatment of peptic ulcer of the duodenum complicated by penetration; b) the method provides for circular detachment of the mucous membrane of the formed stump from the serous-muscular "cuff"; c) the method includes separate suturing of the mucous membrane and the serous-muscular "cuff"; g) the method provides for the isolation of the bottom of the ulcer in a penetrated organ.

 However, the known method is not without some negative aspects: when forming the edge serous-muscular sutures of the “cuff”, the posterior wall of the duodenum is disconnected from the bottom of the ulcer defect by the size insufficient for reliable closure of the stump; the submersible principle of the formation of individual rows of stump sutures contributes to the creation of a direct wound channel between them; isolation of the bottom of the ulcer defect by stitching the stump to the edge of the penetrating ulcer on the pancreas does not increase the reliability of the stump due to the weak plastic properties of the scar tissue and poses a risk of trauma to the pancreas.

 These shortcomings in the postoperative period can lead to the development of pancreatitis, failure of the sutures of the duodenal stump and, as a consequence, peritonitis.

 The objective of the invention is the development of a method for closing the stump of the duodenum, which provides reliable prevention of insolvency of the stump and intraoperative damage to penetrated organs.

 The solution of this problem allows us to almost completely eliminate the likelihood of developing insolvency of the sutures of the duodenal stump in the postoperative period and prevents the possibility of intraoperative damage to penetrated organs, which is achieved by closing the line of sutures of the mucous membrane with respect to it perpendicularly oriented duplicate formed from the walls of the serous-muscular “cuff” by suturing the edges of the free wall to the muscle layer of the opposite wall, disconnected from the bottom of the ulcer along the border of the mobilized mucous membrane; subsequent imposition of walls on each other and fixing them in this position by the second row of serous-muscular sutures, offset relative to the first by the height of the “cuff”; the need to mobilize the intestine from the penetrated organ, while the bottom of the ulcer defect is completely excluded by the strand of the omentum on the leg according to the type of omentoplasty.

 The main stages of the operation are presented in FIG. 1-4.

 The method is as follows.

 After mobilization of the stomach along both curvatures within the required limits and mobilization of the initial part of the duodenum to the penetrating ulcer, it is free from a ulcer defect, usually the anterior or anterolateral wall of the duodenum is dissected by the size of the semicircle of the intestine to the mucous membrane. Without opening the intestinal lumen in an acute way, the mucous membrane is separated from the serous-muscular "cuff" along the entire length of the incision to a height of 1.0-1.5 cm, after which the mucous membrane is dissected. An ulcerative defect is visualized from the side of the intestinal lumen, and the incision of the mucous membrane continues along the lower edge of the ulcer, closing the circumference of the “mucous cylinder”. The semicircle of the “cylinder” fixed to the serous-muscular “cuff” “exfoliates” from the latter, the remaining uncrossed part of the “cuff” intersects. Mobilization of it from the side of the serous cover in the aboral direction from the anatomical structures to perform the subsequent stages of the operation is not required. After separation of the mobilized distal part of the duodenum from the upper edge of the ulcer, a clamp is applied to the pylorus, and the stomach reclines up and to the left, while the bottom of the ulcer defect remains on the penetrated organ. The exfoliated "mucous cylinder" of the open stump of the intestine is sutured with separate nodal sutures, while the formed suture line should be oriented perpendicular to the subsequent suture lines of the serous-muscular "cuff". The “cuff” along the boundaries of the semicircles is longitudinally dissected into 2/3 of its height for better adaptation with the further formation of duplication. The edge of the free wall of the “cuff” is sewn with separate sutures along the border of the separated mucous membrane to the muscle layer of the opposite wall, disconnected from the bottom of the ulcer. The next stage, the walls of the "cuff" are superimposed on each other by the type of duplication and stitched in this position by serous-muscular sutures. Thus, the second row of sutures is shifted relative to the first by the height of the “cuff”, and the line of sutures of the mucous membrane is layer-by-layer closed by both walls of the latter. Depending on the localization of the ulcerative defect, the sutures of the walls of the “cuff” can be oriented both in the sagittal and in the frontal plane. A strand of the omentum on the leg is brought to the bottom of the ulcer on the penetrated organ and fixed with several sutures to its scar edges. The same strand can be additionally peritonized and the formed duodenal stump. A gastrectomy is performed according to one of the known methods. Drainage is provided to the duodenal stump, the abdominal cavity is sutured.

 According to the specified method, the duodenal stump was closed in 12 patients operated on for duodenal ulcer complicated by penetration into the pancreas or hepatic duodenal ligament. Insufficiency of a stump, the phenomena of postoperative pancreatitis is not noted in any case.

 Thus, the proposed method for closing the stump of the duodenum provides due to the duplicative principle of suturing the walls of the serous-muscular "cuff" double serous-muscular protection of the suture line of the mucous membrane and the formation of a displaced wound channel between the stitches of the stump, does not require mobilization of the intestine from the penetrated organ and protects it from the possibility of damage, provides isolation of the bottom of the ulcer defect by omentoplasty, and not the duodenal stump, creates f course finally Adequate conditions for healing of the stump and ensures reliable prevention of its failure.

 The method has passed clinical testing and can be recommended in wide surgical practice.

Claims (1)

 A method for closing a stump of the duodenum, including transverse dissection of the duodenum along the edge of the penetrating ulcer, circular detachment of the mucous membrane of the formed stump from the serous-muscular “cuff”, separate suturing of the mucous membrane and serous-muscular “cuff”, characterized in that the line of mucous sutures close perpendicularly oriented with respect to it by the duplicate formed from the walls of the serous-muscular “cuff” longitudinally dissected into 2/3 of the height by hemming the edges of the free of the wall to the muscle layer of the opposite wall, disconnected from the bottom of the ulcer defect, along the border of the mobilized mucous membrane, then applying the walls to each other and fixing them in this position with the second row of serous-muscular sutures, displaced relative to the first by the height of the “cuff”, the bottom ulcerative defect is isolated by a strand of an omentum on a leg according to the type of omentoplasty.

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