RU2200475C2 - Method for treating the cases of esophageal opening hernia - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves applying laparotomy techniques. 5 incisions are made on the anterior abdominal wall to set trocars. The left liver lobe is brought aside. The phrenicoesophageal ligament is transected. The abdominal esophageal segment is mobilized. Diaphragm pedicles are sutured with endosuture. His's angle is repaired. Seromyotomic incisions on the left lateral esophageal wall and stomach fundus are sutured. The anterior esophageal circle is corrugated. The esophagus and cardia are immersed using lateral invagination method between the anterior and posterior stomach fundus walls. The esophagus is fixed to the esophageal opening boundary. EFFECT: enhanced effectiveness of treatment; reduced risk of postsurgical complications. 1 dwg

Description

 The invention relates to medicine and will find application in the treatment of hiatal hernia.

 Hernias of the diaphragm are found in 30% of all diseases of the abdominal cavity. Clinically, the disease is manifested by symptoms of gastroesophageal reflux and pain in the epigastrium and behind the sternum (Chernousov A.F. Reflux esophagitis. - M., 1998, p.3).

 The principles of surgical treatment are fixation of the cardia and esophagus, sharpening the angle of His, extension of the abdominal esophagus. In the book "Endoscopic Surgery", 1998, the authors I.V. Fedorov, E.I. Seagal and V.V. Odintsov describe various surgical operations - esophagocardiography and diaphragmofundopexy, which include fixing the bottom of the stomach to the diaphragm, Nissen fundoplication - creating a “gastric cuff” around the esophagus, Tupa fundoplication - creating a fundoptic and other modifications of the operations of these authors.

 Descriptions of inventions on the treatment of hiatal hernia and their complications are found in the patent literature. So, copyright certificate 1650108 IPC A 61 B 17/00., B.I. 31., 1993, protected "Method for the treatment of reflux esophagitis."

 Copyright certificate 1683693, B.I. 38, 1991, IPC A 61 B 17/00, the “Method of repair for diaphragmatic hernias” is provided, which involves fixing the esophageal-gastric angle, moving the back of the stomach posteriorly and fixing it to the right diaphragm leg, the left edge of the esophagus, and also to the tendon parts of the esophageal opening of the diaphragm.

 Author's certificate 1785663, B.I. 1, 1993, IPC A 61 B 17/00, protects the "Method of surgical treatment of hiatal hernia", in which a probe with a bloated balloon is inserted into the cardial section of the stomach and an esophagofundorafito is produced. The method involves reducing postoperative complications by preventing the narrowing of the esophageal opening of the diaphragm.

 Copyright certificate 1806623, B.I. 13, 1993, IPC A 61 B 17/00, the "Method for the repair of the esophageal aperture of the diaphragm" is protected, which provides, in order to reduce the frequency of relapse, cutting out the flap on the leg from the triangular and coronary ligaments of the liver, holding it behind the esophagus and fixing it to the connective tissue formations of the lateral sections of the esophageal opening and to the stitched legs of the diaphragm.

 Copyright certificate 1836293. B.I. 32, 1993, IPC A 61 B 17/00, protected "Method for the diagnosis of cardia failure and devices for its implementation."

 RF Patent 2004197, B. I. 45-46, 1993, IPC A 61 B 17/00, protects the "Method for surgical treatment of hiatal hernia", providing for the intersection of the esophageal-diaphragmatic ligament at the site of the esophageal opening of the diaphragm and fixation of the esophagus to the edges of the esophageal opening of the diaphragm.

 Studies of the scientific and medical literature have also revealed various modifications of the methods of surgical treatment of hiatal hernia (Hill L.D. "An effective operation for hiatal hernia: eighth year appraisal." - Annals of Surgery, 1967, 166, p.681-682).

 Recently, more and more reports have begun to appear on the use of laparoscopic techniques in the treatment of hiatal hernia (Puchkov K.V. et al. "Comparative evaluation of open and laparoscopic fundoplication in the treatment of reflux esophagitis" - Endoscopic surgery, 1, 1997, p. 88-89; Jamieson GG, Watson DI, Britten-Jones R. “Laparoscopic Nissen rundoplication.” -Annals of Surgery, 1994, 220, p. 137-145; Hinder RA, FilipiC.J. “Laparoscope Nissen fundoplicftion an effective treatment of gastroesophageal reflux diseases. "- Annals of Surgery, 1994, vol. 220, 4, p. 472-483) and others.

 However, the above methods have a number of significant drawbacks: esophagocardiography, diaphragmofundopexy and diaphragmocrurography, often lead to recurrence of hiatal hernia and gastroesophageal reflux, Nissen fundoplication is a traumatic intervention, and cardiopulmonary bypass is often not justified in patients with mild cases.

 This determined the purpose of the present invention is the development of a method of surgical treatment of hiatal hernia, which allows to improve treatment results, reduce the number of postoperative complications and invasiveness of the intervention. In the journal "Herald of Surgery", 4, 1989, pp. 11-14. prof. A. G. Zemlyanom, A.I. Bugaev, V.I. Kulagin described the operation of lateral esophagofundoplication with sliding hernias of the esophageal opening of the diaphragm, which is the closest analogue taken as a prototype of the operation. This method involves performing an upper midline laparotomy. The cardiac section of the stomach is removed into the abdominal cavity and taken to a rubber holder. At the bottom of the stomach, by seromyotomy, a platform 2-2.5 cm long is formed, which serves as a guide for creating esophagofundoplication. The esophagus is rotated clockwise and the bottom of the stomach is sutured to its posterior wall along the posterior border of the site for 3-3.5 cm. Then the esophageal opening is narrowed by applying 2-3 sutures to the legs of the diaphragm in front of the esophagus. When hanging the bottom of the stomach to the anterior wall of the esophagus, the corrugation of the anterior circumference of the esophagus is performed.

 The method allows to achieve a full antireflux effect. The disadvantages of this method include great trauma, the need for wide surgical access with an operating wound length of up to 20-30 cm, the absence of cardia fixation, and the absence of a myotomy incision on the esophagus.

 The aim of the present invention is to reduce the morbidity, achieve a cosmetic effect, reduce the patient's stay in the hospital, reduce the number of postoperative complications.

 The method is as follows: under general anesthesia with the use of muscle relaxants, after preliminary processing of the surgical field, 5 trocars are introduced for the introduction of a laparoscope and instruments. The left lobe of the liver is retracted, the esophageal-diaphragmatic ligament is crossed, and the abdominal esophagus is mobilized. The legs of the diaphragm, which are stitched with the end seam, are exposed, behind the esophagus. A 5 cm long seromyotomy is performed on the left side wall of the esophagus and on the bottom of the stomach. The edges of the seromyotomy on the bottom of the stomach and on the left side wall of the esophagus are sutured with single interrupted sutures. The esophagus is fixed to the edges of the esophageal opening of the diaphragm with 3 sutures, as shown in the drawing, where 1 - the esophagus, 2 - legs of the diaphragm, 3 - the vagus nerve, 4 - the bottom of the stomach, 5 - seromyotomy, 6 - sutures that fix the esophagus to the edges of the esophageal opening of the diaphragm 7 - suture ligament; 8 - corrugation of the anterior wall of the esophagus.

 The proposed method is illustrated by the following examples.

 Example 1. Patient S., 40 years old. was admitted to the 1st surgical department of the SKZhD hospital with a diagnosis of cardiac hernia of the esophageal opening of the diaphragm, catarrhal reflux esophagitis, gastroesophageal reflux of 3 degrees. The diagnosis was established on the basis of clinical, endoscopic, radiological and esophagomanometric research methods. On admission, he complained of constant belching, regurgitation of food eaten, aggravated by straining and tilting the body, epigastric pain, heartburn. The patient underwent laparoscopic lateral esophagofundoplication. Five trocars were administered under endotracheal anesthesia. The left lobe of the liver is allotted. The left and right legs of the diaphragm are stitched with an end seam. A 5 cm long seromyotomy was performed on the left side wall of the esophagus and on the bottom of the stomach. Next, lateral esophagofundoplication and corrugation of the anterior circumference of the esophagus were performed. The esophagus and cardia are immersed between the anterior and posterior walls of the fundus of the stomach by lateral intussusception. The cardiac section of the stomach is brought into the abdominal cavity and fixed to the edges of the esophagus 3 sutures. The bottom of the stomach is captured in an unbound seam. Control of places of introduction of trocars. Hemostasis. Stitches to the skin.

 Aseptic dressing.

 Examined at a long time after surgery, no complaints, with a control endoscopic examination - reflux of gastric contents into the esophagus is not determined.

 X-ray and esophagoscintigraphic studies were performed - there were no signs of recurrence of a hiatal hernia, no reflux. Anatomical structures are in a physiological position.

 Example 2. Patient K., 54 years old, was admitted to the 1st surgical department of the hospital with a diagnosis of esophageal esophageal hernia of the esophageal opening of the diaphragm, erosive reflux esophagitis, gastroesophageal reflux grade 3. The diagnosis was established on the basis of clinical, endoscopic, radiological, esophagotonometric research methods.

 Upon admission, she complained of periodic burping, epigastric pain, aggravated by physical exertion, heartburn.

 The patient performed lateral esophagofundoplication.

 Under endotracheal anesthesia, 5 trocars were introduced on the anterior abdominal wall. The retractor assigned the left lobe of the liver. The blunt preparation of the exposed legs of the diaphragm, which are sewn by the end seam. At the bottom of the stomach and on the left side wall of the esophagus, 5 cm seromyotomy was performed, starting from the lower part of the seromyotomy sections, esophagofundoplication was performed with non-absorbable suture material. Corrugation of the anterior circumference of the esophagus. The esophagus and cardia are immersed between the anterior and posterior walls of the fundus of the stomach by lateral intussusception. The cardiac section of the stomach is brought into the abdominal cavity and is fixed to the edges of the esophagus diaphragm with 3 sutures. Stitching the bottom of the stomach. Control of places of introduction of trocars. Hemostasis. Stitches to the skin.

 Aseptic dressing.

 Postoperative course without complications. The patient was discharged on the 4th day.

 No complaints. When conducting endoscopic and radiological examinations - there are no signs of recurrence of a hiatal hernia, there is no reflux zsophagitis.

 The described technique of laparoscopic lateral esophagofundoplication was used in 18 patients with hiatal hernia. In all patients, the postoperative period was uneventful, with control studies there were no signs of recurrence of a hiatal hernia, no reflux esophagitis.

 Compared with the prototype, the claimed method is less traumatic, the patient’s hospital stay is reduced, the risk of postoperative complications is reduced, a good cosmetic effect is achieved, as incisions for introducing trocars of 1-2 cm heal almost without scarring.

Claims (1)

 A method for the treatment of hernia of the esophageal opening of the diaphragm, including the creation of an artificial esophageal-diaphragmatic ligament and an areflux esophagocardiogastric valve, characterized in that the surgical procedure is performed using laparoscopic technique, for which 5 incisions are made on the anterior abdominal wall to install trocars, trocars and paws are inserted for insertion instruments, remove the left lobe of the liver, cross the esophageal-diaphragmatic ligament, mobilize the abdominal esophagus, en the legs of the diaphragm are sutured together, then the His angle is restored by stitching seromyotomy sections on the left side wall of the esophagus and the bottom of the stomach, while the front circumference of the esophagus is corrugated, and the esophagus and cardia are immersed between the front and back walls of the bottom of the stomach using the esophagus and cardia, and the esophagus is fixed to the edges of the esophagus diaphragm holes with 3 seams.