RU2188593C1 - Method for duodenoplasty at dissecting an inherent duodenal membrane - Google Patents

Abstract

FIELD: medicine, surgery. SUBSTANCE: a cross-sectional duodenotomy is carried out. Inherent membrane is dissected. One should dissect an anterior wall of proximal duodenal department as a truncated rhombus. The wound edges of proximal duodenal department should be fastened together in longitudinal direction. Against the middle of duodenotomic wound one should longitudinally resect an anterior wall of distal duodenal department. Then proximal and dissected distal duodenal departments are fastened in a cross-sectional direction. The method enables to improve motor-evacuatory functions of proximal duodenal department. EFFECT: higher efficiency. 2 dwg, 2 ex

Description

 The invention relates to medicine, namely to surgery, and can be used for excision of the congenital membrane of the duodenum.

 There is a method of excising a congenital membrane of the duodenum (duodenum), in which the mobilized duodenum is dissected in the longitudinal direction at the transition of the expanded part to the narrowed so that 2/3 of the incision falls on the expanded part. The found membrane is pulled into the duodenotomy opening and excised with scissors at the junction of the inner membrane into the intestinal wall. The duodenal wound is sutured in an oblique direction (Emergency surgery of children. GA Bairov, L., 1983, p. 150).

 The disadvantage of this method of excision of the membrane is the preservation in the early and long term after surgery of motor-evacuation disorders of the expanded proximal part of the duodenum, which supports the phenomena of duodenostasis, duodenogastric reflux and reflux gastritis; deformation of the internal lumen of the intestine with oblique suturing of the duodenotomy wound.

 The invention is aimed at solving problems: improving the motor-evacuation function of the proximal duodenum, prevention of duodenogastric reflux and reflux gastritis; approximation of the lumen diameters of the expanded proximal and narrowed distal duodenum when suturing the duodenotomy opening.

 Tasks are achieved by transverse dissection of the duodenum over the membrane, circular dissection of the membrane, excision of the anterior wall of the enlarged proximal duodenum, stitching of the edges of the incision with each other and stitching of the proximal and longitudinally dissected distal duodenum with each other.

 The novelty of the method lies in the fact that after performing transverse duodenotomy and circular excision of the membrane, the anterior wall of the proximal duodenum is excised in the form of a truncated rhombus, the wound edges of the proximal duodenum are sutured to each other, and the anterior wall of the distal duodenum is longitudinally dissected from the middle of the duodenotomy; direction proximal and longitudinally dissected distal duodenum.

 The method is depicted in the drawing, which shows a General diagram of the operation.

 In FIG. Figure 1 shows the dissection of the anterior wall of the proximal section and the longitudinal section of the anterior wall of the distal duodenum, Fig. 2 shows the longitudinal stapling of the edges of the proximal wound and the lateral stapling of the proximal and distal duodenum.

 The method is as follows: after mobilization of the duodenum according to Kocher, a transverse section of its front wall is made at the border of the expanded and narrowed part. Through the duodenotomy opening, the inner membrane is circularly excised with closure of the mucosal defect. The front wall of the expanded proximal section of the duodenum (1) is excised in the form of a truncated rhombus (2) (Fig. 1) so that the greatest distance between the corners (3) of the rhombus (2) falls on the section of maximum expansion of the proximal duodenum. Sew together in the longitudinal direction of the wound edges of the proximal duodenum (4) (figure 2). From the middle of the duodenotomy opening, the front wall of the distal duodenum (5) is longitudinally dissected (Fig. 1) to a depth of 1/2 the length of the incision. The proximal and longitudinally dissected distal duodenum are stitched together in the transverse direction (6) (Fig. 2).

 Examples of specific performance.

1. Patient Sh., Born in 1996, was admitted to the planned surgery department of the Children's Clinical Hospital, Perm, September 20, 1999 with complaints of vomiting with bile, up to 1 time per month, belching, regurgitation. Sick from birth, during the first year of life was disturbed by vomiting and regurgitation after almost every feeding. Subsequently, vomiting became less frequent, there was a lack of body weight. The condition is satisfactory. Low power. The tongue is coated in white. The abdomen is soft, painless. In a general blood test, anemia is detected: red blood cells 3.7 × ^{10 12} , hemoglobin 93 g / l. Biochemical analysis of blood without features.

When X-ray contrast study of the gastrointestinal tract, the esophagus is freely passable, in the stomach on an empty stomach a large amount of food residues, the relief of the mucous membrane is coarse. After 12 hours in the stomach 1/2 of the received barium, the bulb and the descending part of the duodenum are sharply expanded. Conclusion: duodenal stenosis?
With fibrogastroduodenoscopy, the esophagus passes, the cardia closes. The stomach is sharply increased in size, the mucous membrane is hyperemic throughout. The gatekeeper is gaping. The lumen of the duodenum is sharply expanded, in the lumen of the remnants of food. Mucous duodenum is edematous, hyperemic. In the in / 3 of the descending branch, the lumen of the duodenum is covered by a membrane with an opening with a diameter of up to 0.6 cm along the medial edge. At the base of the membrane, a large duodenal papilla (BDS) is detected. Behind the membrane, the lumen of the duodenum is closer to normal. Conclusion: congenital duodenal membrane, chronic duodenal obstruction.

 Relaxation duodenography - after subcutaneous injection of 0.5 ml of atropine into the duodenum, a contrast is introduced through a probe. The vertical and lower horizontal branches of the duodenum were performed. The vertical section of the duodenum to the c / 3 level is sharply expanded to 8 cm, below there is a persistent concentric narrowing of the lumen. Peristalsis is sharply enhanced, is segmented in nature, the passage of contrast through the narrowed area is difficult. The lower horizontal section of the duodenum is not changed. Conclusion: Malformation of the duodenum. Congenital membrane of duodenum. Chronic duodenal obstruction.

 Operation 09.29.99. Upper median laparotomy. The stomach is enlarged, the pylorus is expanded to 3 cm. The duodenum in the upper horizontal and descending sections is expanded to 7 cm, its wall is hypertrophied. Palpation in s / 3 of the descending branch is determined by the internal septum. Distal to the obstacles, the lumen of the lower horizontal branch of the duodenum is up to 2.5 cm. There are pronounced planar adhesions of the descending branch of the duodenum with visceral surface of the right lobe of the liver, body and bottom of the gallbladder, hepatoduodenal ligament. All mergers are divided. Mobilization of the KDP by Kocher. Transverse duodenotomy at the border of the expanded and narrowed part of the duodenum. A transverse membrane with an opening up to 0.5 cm along the medial edge was revealed in the lumen. At the base of the membrane, the mouth of the BDS opens, which is passable for a probe with a diameter of 3 mm. A circular excision of the membrane was made, leaving a part of it in the BDS region. The mucosal defect is sutured with a single-row continuous continuous stitching (Vicryl 5/0). An excision of the anterior wall of the enlarged proximal part of the duodenum in the form of a truncated rhombus was performed. In this case, the largest distance between the corners of the rhombus accounted for the area of maximum expansion of the proximal section of the duodenum. The edges of the wound of the proximal section of the duodenum are stitched together in the longitudinal direction by a continuous twisting seam (5/0 vikril). The expansion of the lumen of the proximal duodenum was significantly reduced. From the middle of the duodenotomy orifice, the anterior wall of the distal duodenum is longitudinally dissected into 1/2 of the section length. The proximal and longitudinally dissected distal sections of the duodenum are stitched to each other in the transverse direction by a two-row seam (5/0 Vicryl). A nasogastric neural probe for enteral nutrition was performed in the jejunum. The abdominal cavity is drained. The surgical wound is stitched tightly in layers. The postoperative period was uneventful. Discharged in satisfactory condition on 09.10.99.

 Viewed after 6 months. The condition is satisfactory. There are no complaints. Added in the mass of 3 kg.

2. Patient O., born in 1998, was admitted to the department of planned surgery of the Central Clinical Hospital on August 23, 2001 with complaints of periodic vomiting of stagnant contents, nausea, belching, and poor weight gain. From the age of 1 year, they began to be bothered by profuse vomiting up to 1-2 times a day, belching, scanty stools and weight loss. The condition is satisfactory. Low power. The abdomen is soft, painless. In the general analysis of blood, moderate anemia is detected: red blood cells 3.8 × ^{10 12} , hemoglobin 107 g / l. In a biochemical blood test, an increase in the level of alkaline phosphatase is noted.

 When X-ray contrast study of the gastrointestinal tract, the esophagus is freely passable, the stomach and duodenal bulb are expanded, the contrast is long delayed in the initial section of the duodenum and enters in the distal direction in small portions. After 24 hours, the level of contrast medium is maintained in the duodenum. Conclusion: duodenal stenosis (ring-shaped pancreas?, Inner membrane?). Chronic duodenal obstruction.

 With fibrogastroduodenoscopy, the cardia closes, a large amount of food masses and bile in the stomach, the gastric mucosa is swollen, hyperemic, the stomach is sharply enlarged, the pylorus is gaping. In the lumen of the sharply expanded bulb of the duodenum, food masses are also detected. The lumen of the descending branch is blocked by a membrane with a hole with a diameter of 0.3 cm. Conclusion: Congenital membrane of the duodenum. Chronic duodenal obstruction.

 Operation 08.29.2001 - Transverse laparotomy in the right hypochondrium. The stomach is significantly enlarged. The bulb and the initial section of the descending branch of the duodenum are sharply expanded to 10-12 cm, the intestinal wall is hypertrophied. In the middle third of the descending branch there is a narrowing of the lumen to 1 cm, below which the duodenum is folded in the form of several "double-barrels". The cecum is located high, from the dome of the cecum to the parietal peritoneum of the right lateral canal, duodenum, the bottom of the gallbladder extend wide fibrous adhesions, all fusion are divided. Mobilization of the duodenum according to Kocher, commissures along the descending branch of the duodenum are divided. Transverse duodenotomy at the border of the expanded and narrowed part. A membrane with an opening up to 0.5 cm in diameter was detected in the lumen. BDS is detected on the medial wall of the membrane. The membrane is circularly dissected with the preservation of its site in the BDS. The mucosal defect is sutured with a continuous continuous suture (Vicryl 5/0). The front wall of the proximal section of the duodenum is excised in the form of a truncated rhombus so that the largest distance between the corners of the rhombus falls on the section of maximum expansion of the duodenum. The edges of the wound of the proximal section of the duodenum are stitched together in a longitudinal direction by a double-row seam. After this, the expansion of the proximal section of the duodenum decreased significantly. From the middle of the duodenotomy orifice, the anterior wall of the narrowed distal duodenum is longitudinally dissected into 1/2 of the incision length. The proximal and dissected longitudinally distal ends are stitched together in the transverse direction by a double-row seam. A nasogastric neural probe for early enteral nutrition was performed. The surgical wound is stitched tightly in layers. The postoperative course is smooth. Discharged in satisfactory condition on September 11, 2000.

 Viewed after 6 months. Satisfactory condition, no complaints. In the mass added.

 The positive effect of using the proposed method consists in improving the motor-evacuation function of the duodenum, prevention of duodenogastric reflux and reflux gastritis by excision in the form of a truncated rhombus of the anterior wall of the enlarged proximal duodenum, as well as in approximating the lumen diameters of stitched duodenum with longitudinal dissection of the distal duodenum and subsequent stitching of the proximal and distal duodenum in the transverse direction.

Claims (1)

 The method of duodenoplasty for excision of the congenital membrane of the duodenum (duodenum) by duodenotomy, excision of the membrane, crosslinking of the proximal and distal duodenum, characterized in that transverse duodenotomy is performed, after excision of the membrane, the anterior wall of the proximal duodenum is dissected, the incised margin is excised, excised The duodenum is stitched together in the longitudinal direction, from the middle of the duodenotomy wound, the anterior wall of the distal duodenum is longitudinally dissected and stitched in the transverse The direction of the proximal and distal portions dissected duodenum.

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