RU2143850C1 - Method for suturing duodenum stump - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves suturing duodenum stump lumen. The first row of stitches is put in between the anterior and posterior walls by suturing the inferior ulcer edge on the posterior wall and dissected edge of the anterior wall. Peritoneum is longitudinally dissected along the posterior wall of the round ligament of the liver. The first row of stitches and ulcer crater are covered with internal tissues of the round ligament of the liver. In putting-in the second row of stitches, the upper edge of the ulcer, tissues of the round ligament of the liver are sutured in subperitoneal way, and anterior wall of the duodenum is sutured. The internal tissues of the round ligament of the liver are sutured for the second time with the other ends of the ligatures. EFFECT: prevented inconsistency of duodenum stump sutures. 5 dwg

Description

 The invention relates to medicine, mainly to abdominal surgery and can be used in the surgical treatment of patients with complicated course of gastric ulcer and duodenal ulcer.

 Suturing the stump of the duodenum, especially with penetrating callous duodenal ulcers, is one of the crucial and difficult stages of surgery for peptic ulcer disease. The outcome of the operation depends on its reliability. Indeed, the failure of the sutures of the stump of the duodenum after resection of the stomach according to Billroth II is accompanied by a mortality rate of up to 60% / Salikhov I.A. et al. "Prevention and comprehensive treatment of insolvency of the duodenal stump." - Surgery, 1989, N 10, p. 23-26 /.

 Due to the complexity of the anatomical and morphological changes that occur in the area of the penetrating duodenal ulcer, a large number of ways to suture its stump have been proposed. Most of them involve the use of the walls of the duodenum and capsule of the pancreas. These are such methods as Nissen, Bsteg'a, Rusanov, the "snail", Navrotsky and others / Navrotsky I.N. "Suturing the stump of the duodenum" - M .: Medicine. - 1972. - p. 72-78, 92, 121-126 /. A common drawback of these methods is the need to mobilize the walls of the duodenum for the first row of sutures, which is not always feasible, for example, with kallous penetrating ulcers. In addition, with mobilization of the walls of the duodenum, extrahepatic bile duct damage is possible with the development of obstructive jaundice or the formation of bile fistula, as well as trauma to the pancreas. This can cause postoperative pancreatitis, which in turn is one of the reasons for the failure of the sutures of the duodenal stump, in addition, with these methods of suturing the duodenal stump, the first row of sutures is placed in the inflammatory modified ulcer crater, which creates conditions for infection of the first row ligatures and possible development of stump suture failure. The flap of the omentum used to seal the sutures, superimposed on the third row of ligatures, practically does not play the intended role: the infected ulcer cavity with sutures on the intestinal wall remains in the depth of the stitched surfaces.

 In recent years, plastic methods have become more widely used to shelter a duodenal stump. In particular, the use of a serous-muscle flap on a vascular pedicle cut out of the stomach wall / Patent No. 1836930 "Method for closing the duodenal stump during gastrectomy for an ulcer penetrating into the hepatoduodenal ligament with biliary duct arrosis", IPC A 61 B 17 / 00 bull. N 32 1993; Patent N 2016546 "Method for closing the stump of the duodenum during gastrectomy for penetrating into the pancreas with pancreatic duct arrosis", IPC A 61 B 17/00, bull. N 14 1994 /. With a significant deficit of tissue in the area of the sutured stump of the duodenum and low mobility of its walls, as well as with the failure of the stitches of the stump, a round liver ligament is additionally used. So, in the patent literature describes the "Method of closing the stump of the duodenum with the failure of its sutures after resection of the stomach and gastrectomy" / patent N 2113176, IPC A 61 B 17/00, bull. N 17 1998 /, which provides for the passage into the lumen of the duodenum of the crossed end of the round ligament of the liver with the subsequent introduction of a double-lumen PVC tube, as well as the invagination of the stump of the duodenum into the thickness of the ligament with fixation to the peritoneum with single sutures. Also known is a "Method of treating a penetrating duodenal ulcer complicated by choledochoduodenal fistula" / a.c. N 1598976, IPC A 61 B 17/00, bull. N 38 1990 /, according to which the round ligament of the liver is transversely crossed at the umbilical ring, and then it is tunneled and a drainage tube is drawn into it, which is led through the lateral surface of the round ligament at the lower edge of the liver. After this, an additional incision is made on the duodenum and the free end of the round ligament with the drainage tube is introduced into its lumen. Next, the drainage tube is passed through the fistula into the common bile duct, and the round ligament of the liver is laid on the fistula and sutured to the edges of the ulcer with separate sutures and fixed with polyurethane adhesive. The exit site of the round ligament from the duodenum is peritonized with separate sutures, as well as with a gland patch on the vascular pedicle and additionally glued with polyurethane adhesive. A common drawback of these methods is the immersion of the tissues of the round ligament of the liver in the lumen of the duodenum, where there is a very high activity of proteolytic enzymes that will corrode these tissues, which ultimately can lead to failure of the sutures on the duodenum and peritonitis.

 As a prototype of the claimed invention taken "Method of closing the stump of the duodenum with the failure of its sutures after resection of the stomach and gastrectomy" / RF patent N 2113178, IPC A 61 B 17/00, bull. N 17 1998 /. The essence of the method, taken as a prototype, is that to seal the stump of the duodenum use a round ligament of the liver, through the peripheral part of which, after cutting and bougienage, a double-lumen polyvinyl chloride drainage tube is passed into the lumen of the duodenum, and the stump itself is invaginated into the thickness of the round ligament fixed to the peritoneum with single sutures. This method has the following disadvantages: 1 - the lumen of the duodenum with aggressive digestive juices released from there is immersed in the tissue of the round ligament of the liver not intended by nature for stability; 2 - bougienage of the round ligament and the passage of a double-lumen drainage tube through it additionally injures the tissue of the round ligament and, when the duodenal juice flows, will promote the spread of proteolysis and necrotic process to the anterior abdominal wall along the continuation; 3 - invagination of the duodenal stump into the thickness of the round ligament of the liver requires additional sutures, which against the background of inflammation of the tissues, including the peritoneum, around the stump caused by the expiration of duodenal contents from it, does not exclude flashing of the pancreatic tissue and extrahepatic bile ducts, which may lead to even more serious complications: obstructive jaundice, pancreatitis; 4 - the transverse intersection of the round ligament of the liver violates the fixation / ligament / apparatus of the liver, which can lead to displacement of it in the abdominal cavity. These disadvantages are eliminated in the proposed technical solution. The essence of the proposed method is that to increase the tightness of the sutures of the stump of the duodenum with penetrating giant callous duodenal ulcers on the first row of ligatures that suture the front and back walls of the stump of the duodenum, the internal tissues / adipose tissue and umbilical vein are laid and sutured ligaments of the liver, and the connection of the peritoneum of the round ligament of the liver with the peritoneum lining the posterior surface of the abdominal cavity occurs due to the returning sutures of the second row, simultaneously but fixing the internal tissues of the round ligament with the stump of the duodenum.

A detailed description of the proposed method and examples of its practical implementation
When performing a gastrectomy operation according to Billroth II in connection with a giant callous penetrating duodenal ulcer with a significant deficit of local tissues: the severity of infiltration and scar tissue changes around the ulcer, the inability to mobilize the walls of the duodenum as a result of penetration and gross cicatricial changes in the walls and bottom of the ulcer / Fig. 1 / produce a transverse intersection of the duodenum / 1 / 1.5-2.0 cm above the lower edge of the ulcer. The ulcer crater / 2 / is treated with antiseptic solutions, for example, a 0.5% alcohol solution of chlorhexidine. After that, the first row of sutures is applied between the lower edge / 3 / ulcer / 2 / along the posterior wall and along the cut off edge / 4 / of the anterior wall of the duodenum / 1 /. To do this, injected needles through the lower edge / 3 / ulcers / 2 / go into the lumen of the duodenum / 1 / 0.7-0.8 cm below this edge. Then, with the same needle, sero-muscular capture the front wall of the duodenum / 1 / along the cut edge / 4 / with a puncture on the serous membrane at a distance of 1.0-1.5 cm from this edge. The stitched seams / usually 3-4 / are tied, starting from the corner. As a result, FIG. 2 / the anterior wall of the duodenum / 1 / connects to its posterior wall along the lower edge / 3 / of the ulcer / 2 /, and the crater of the ulcer / 2 / is outside the lumen of the duodenum / 1 /. To cover the first row of sutures / 5 / and the ulcer crater / 2 /, internal tissues of the round ligament / 6 / liver / 8 / are used. For this, in the projection of the stump of the duodenum, the peritoneum / 7 / along the back wall of the round ligament / 6 / is dissected longitudinally for 5-6 cm, and then with a needle (Fig. 3, a view in the frontal plane / with a ligature / 9 / suture the upper edge / 10 / ulcers / 2 / and from left to right subperitoneally - internal tissues / 11 / round ligament / 6 /. Then, using the same needle, departing 1.0-1.5 cm from the first row of sutures / 5 /, stitch the sero-muscular anterior wall of the duodenum / 1 / for 0.8-1.0 cm. Then, the needle of the second end / 12 / ligatures / 9 / from left to right re-stitch round ligament / 6 /, making a returning tour. To do this, injected needles through the peritoneum / 7 / round ligament / 6 / at a distance of 1.0 cm from its left edge outperitoneally on the right side of the round ligament / 6 / with a puncture at a distance of 1.0 cm from the right edge of the peritoneum / 7 / and bring closer to the previously stitched end of the ligature / 9 /. Such seams are imposed 4-5. They are tied after applying all the ligatures sequentially, starting from depth to surface. As a result, FIG. 4, a view in the frontal plane / the first row of sutures / 5 / and the ulcer crater / 2 / are hermetically covered with adipose tissue and vessels of the round ligament / 6 / and its peritoneal cover / 7 / is simultaneously compared with the peritoneal cover of the duodenum / 1 /, hepatoduodenal ligament pancreas / 13 /. A general view of the sutured duodenal stump is shown in FIG. 5.

 Example I. B-Noah I-in, 40 years old / b. N 1020 / was admitted to the surgical department of BSMP, N 1, Rostov-on-Don with a diagnosis of peptic ulcer of the duodenum, subcompensated pyloroduodenal stenosis, penetration of the ulcer.

 Fibrogastroscopy revealed an ulcer occupying the entire dome of the duodenal bulb. After preoperative preparation, the patient was operated on. During the operation, a callous ulcer with a diameter of 3.5 cm was detected in the duodenal bulb with penetration into the hepatoduodenal ligament and the head of the pancreas. The edges of the ulcer are dense with a pronounced inflammatory shaft. When processing the stump of the duodenum, it was difficult to suture it due to tissue deficiency, cicatricial changes in the ulcer area and the inability to mobilize the walls of the duodenum. In this regard, the proposed method is applied. The first row of sutures and crater ulcers were sealed and peritonized with tissues of the round ligament of the liver, during the postoperative period without complications. 9 days after surgery, the patient was discharged from the hospital. Pathological diagnosis: chronic duodenal ulcer with exacerbation against the background of chronic duodenitis / analysis N 13035-049 /.

 Example 2. B-No Eo, 56 years old / b. N 2742 / was admitted to the surgical department of BSMP N 1 in Rostov-on-Don with a diagnosis of exacerbation of duodenal ulcer, pyloroduodenal stenosis of the III degree, gastric bleeding of the I degree. Fibrogastroscopy revealed 2 ulcers: one on the front wall of the duodenal bulb with a diameter of 0.8 cm, the other with a diameter of 2.4 cm on the back wall of the duodenal bulb, with cicatricial changes in the walls, causing a narrowing of the lumen of the duodenum. After preoperative preparation, the patient underwent resection of the stomach according to Billroth II in the modification of Hoffmeister-Finsterrer. Due to the presence of two ulcers, technical difficulties arose when suturing the duodenal stump. Therefore, the proposed method is applied. The anterior wall of the duodenum is crossed below the ulcer located on it, the posterior wall is along the lower edge of the ulcer located on it. The first row of sutures was laid between the anterior and posterior wall of the duodenum along the lower edge of the ulcer. Shelter of the first row of sutures and ulcers by the internal tissues of the round ligament of the liver with four sutures according to the proposed method. The postoperative course is smooth. The patient was discharged from the hospital after 8 days. Pathological diagnosis: chronic duodenal ulcer / analysis N 42458-470 /.

 The proposed method for suturing the stump of the duodenum was used in 12 patients. There was no failure of the duodenal stump, and no other complications were noted. Compared with the prototype, the proposed method has the following advantages: 1 - the application of the first row of stitches prevents the aggressive action of duodenal contents on the tissue of the round ligament of the liver; 2 - the first row of sutures and the ulcer crater is covered with viable tissues of the round ligament of the liver, which increases the integrity of this row of sutures and isolates it from the infected ulcer crater; 3 - the ulcer crater is completely covered and peritonized by the tissues of the round ligament, which prevents infection of the abdominal cavity; 3 - the penetrated organ and the edges of the stitched walls of the duodenal stump are not injured, and a biological swab from the internal tissues of the round ligament with preserved blood supply is placed on the penetrated surface of the ulcer, which prevents the development of postoperative pancreatitis; 4 - additional sutures are not imposed on the infiltrated tissue around the ulcer, which prevents trauma to the pancreas and damage to the extrahepatic bile ducts; 5 - the ligamentous apparatus of the liver is not disturbed, since the round ligament does not intersect in the transverse direction.

Claims (1)

 A method of suturing a stump of the duodenum, involving the transverse intersection of the duodenum, suturing the front and back walls with single sutures with the removal of the ulcer crater beyond the lumen of the digestive tract and sealing the stitches of the stump with a round ligament of the liver, characterized in that suturing of the lumen of the duodenum of the first row of the duodenum between the back and the front walls by flashing through the lower edge of the ulcer on the back wall and along the cut-off edge on the front wall f with a puncture on its serous membrane at a distance of 1.0-1.5 cm from the edge, longitudinal dissection of the peritoneum along the posterior wall of the round ligament of the liver for 5-6 cm, closing of the first row of sutures and ulcer crater with internal tissues of the round ligament with restoration of continuity peritoneum by applying the second row of sutures by first suturing the upper edge of the ulcer, and then from left to right subperitoneally of the tissues of the round ligament of the liver and serous-muscular-anterior wall of the duodenum, departing 1.0-1.5 from the first row of sutures, followed by re-stitching we eat the inner tissues of the circular ligament with the second ends of these ligatures by tapping the needle on the peritoneum of the left surface of the circular ligament at a distance of 1.0 cm from the dissected edge and by puncturing the peritoneum of its right surface at the same distance from the dissected edge with sequential tying of the ligatures from the depth.

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