RU2239372C1 - Method for treating hepaticocholedochal strictures - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with diseases and damages of extrahepatic biliary ducts. One should mobilize mesenteric edge of small intestine and perform complete mobilization of inferior horizontal duodenal branch which should be completely withdrawn from under mesentery into dextraposition against the upper mesenteric vessels to apply additional 2-4 sutures by paraductal tissues that enables to put indications and perform plasty of extrahepatic biliary ducts with "end-to-end" anastomosis without tension along the line of anastomosis' sutures that prevents the possibility for repeated development of strictures.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to surgery, and can be used for the surgical treatment of diseases and injuries of the extrahepatic biliary tract.

Relevance. The problem of surgical treatment of strictures of the main bile ducts remains unsolved to date, while they in 7.2-41.4% of cases are the cause of repeated interventions on the biliary tract (V.N. Klimov et al., 1980, Inbansi et al., 1984 and others).

Most authors speak about the advantage of reconstructive operations, in which the natural bile outflow is restored directly to the duodenum, and ideally, it is possible to maintain or restore the regulatory influence of the sphincter apparatus of the large duodenal papilla (Shalimov A.A. et al., 1993 and others).

A known method of plasty of hepatic choledoch by stitching its ends with an end-to-end anastomosis, despite the obvious physiological nature, according to most authors (Shalimov A.A. et al., 1993, Maistrenko N.A., Nechay A.I., 1999, Jarnagin WR et al., 1999 and others) is applicable only in a small number of cases. This is due to the technical difficulties of isolation and comparison without tension along the seams of the anastomosis of the ends of the bile ducts.

Thus, the development of new methods for plastic surgery of extrahepatic bile ducts is an urgent task of surgery.

The following surgical treatment methods were taken as analogues:

1. Hepaticoejunostomy according to A.A. Shalimov (Shalimov A.A., Shalimov S.A., Nichitailo M.E., Domansky B.V. Surgery of the liver and biliary tract. - Kiev: Zdorovya, 1993, p. 473-475).

After excision of the scar tissue and the release of the distal end of the common hepatic duct, it is mobilized in the proximal direction. The loop of the jejunum necessary for the anastomosis is turned off along Ru or Shalimov, and brought to the back surface of the duct so that the latter lies across the intestine along the length of its entire free part. With a small diameter of the duct (5 mm or less), a longitudinal section is made along the back surface of it with a length of 5-8 mm. Directly in front of the duct stump, the jejunum lumen is longitudinally opened in accordance with the diameter of the duct and its incision. Separate 3-4 sutures with an interval between them of 1.5 mm with a thread of non-absorbable tissue fix the lateral walls of the duct to the wall of the intestine across it. Also, the edges of the duct and intestines are sewn together with sutures from a absorbable material on an atraumatic needle with an exact comparison of the mucous membranes. Then, anastomosis is invaginated by sero-serous sutures into the fold of the intestine to reduce regurgitation reflux from the intestine.

Disadvantages:

a). The duodenum is turned off from the passage of bile, which significantly affects the quality of digestion.

2. Hepatico (choledocho) duodenostomy according to VV Vinogradov (Vinogradov V.V., Nifantiev O.V., Vishnevsky V.A. Postoperative diseases of the biliary tract. - Krasnoyarsk: Publishing House of Krasnoyarsk University, 1989. - P.137 and 138).

The supraduodenal part of the common bile duct is isolated and the duodenum is widely mobilized according to Kocher, which is then opened longitudinally (duct) and transversely (intestine). In this case, the duct is opened at the wall of the intestine, and the latter is dissected at the level of its post-bulbar sphincter. Such an opening of the intestine helps prevent intestinal contents from being thrown into the biliary tract during its peristalsis. The lumen of the duct and intestines is opened for 3-4 cm to create a wide anastomosis and to avoid its subsequent narrowing. Anastomosis is formed by interrupted sutures on atraumatic needles with nodules outward, making an injection of the needle from the outside, and its injection from the inside. The overlay seams are taken on the clamps, between which gauze napkins are placed. After application, all sutures are sequentially tied, which greatly simplifies the anastomosis. If necessary, the seam line can be peritonized or reinforced with biological glue.

Disadvantages:

a). The method is not applicable for prolonged strictures and an extended defect of extrahepatic bile ducts.

b) The possibility of duodenobiliary reflux remains, which contributes to the development of cholangitis, an inflammatory process in the anastomotic zone, which can lead to scarring.

As a prototype, we used a method for plastic surgery of extrahepatic bile ducts by creating a biliary-biliary anastomosis of the end-to-end type (Shalimov A.A., Shalimov S.A., Nichitailo M.E., Domansky B.V. Surgery of the liver and biliary tract . - Kiev: Zdorovya, 1993, p. 457-460).

First, the proximal end of the bile duct is isolated ... After the distal section of the common bile duct is detected, it is opened for a short distance and the patency of the large duodenal papilla is ascertained ... The duodenum is mobilized according to Kocher ... The distal stump of the common bile duct should be mobilized together with pancreatoduodenal complex, and not try to isolate it from pancreatic tissue. After this, they begin to create an anastomosis of the “end to end” type. First of all, the back wall is sewn with separate stitches of thin threads from absorbable material or with synthetic threads on an atraumatic needle. Sutures impose nodules outward as a vascular suture. After the posterior wall is sutured, a frame drainage is installed in the duct lumen ... After the frame drainage is established, a suture is placed on the anastomosis anterior lip ... Usually we are limited to one row of sutures.

Disadvantages:

1. The method is not applicable for prolonged strictures and large diastasis of stitched ends (more than 30 mm).

2. Suture failure, anastomositis and stricture recurrence due to unrepaired tissue tension along the anastomosis line and suture eruption are not excluded.

Tasks:

1. To expand indications for plastic surgery of the bile ducts with an end-to-end anastomosis as the most physiological procedure for surgery.

2. Reduce the likelihood of a stricture recurrence.

The technical essence of the proposed method lies in a complex of precision technologies aimed not only at the mandatory exclusion of tension between the stitched ends, but the main thing is at the mandatory creation of compression in the stitched walls of the end-end hepaticoholedoch anastomosis.

The essence of the method lies in the fact that for the compression comparison of the stitched ends of the hepatic choledochus, which excludes tension along the suture line of the anastomosis, the root of the mesentery of the small intestine is mobilized and the lower horizontal branch of the duodenum is fully mobilized, which is completely removed from the mesentery to the dextration relative to the upper vessels, and then impose 2-4 compression-matching suture ligaments for paraprotective tissue.

The method is as follows.

The description of the method is illustrated in figures 1-5, where:

1 - the proximal end of the extrahepatic bile ducts (hepaticus);

2 - the distal end of the extrahepatic bile ducts (common bile duct);

3 - vertical branch of the duodenum;

4 - the head of the pancreas;

5 - level of the crossed ligament of the traits;

6 - celiac trunk;

7 - the inferior vena cava;

8 - mobilized ileocecal angle;

9 - dissected right triangular ligament of the liver;

10 - a round ligament of the liver;

11 - dissected left triangular ligament of the liver;

12 - a large duodenal papilla;

13 - superior mesenteric artery and vein;

14 - portal vein;

15 - sutures, ligaments;

16 - hepatic artery;

17 - single-row precision nodal biliary-biliary anastomosis.

A prerequisite is a precision technique for performing all stages of the operation, because surgical anatomy is extremely complex and requires advanced research.

Before surgery, endoscopic papillotomy is performed only in cases of stricture of the large duodenal papilla to ensure unhindered outflow of bile through it. Papillotomy is performed sparingly without destroying the hepatic sphincter of the papilla.

Access. An extended upper mid laparotomy is performed with dislocation of the right costal arch by the M.Z. Seagal. Go around the navel on the right. If previously there was an oblique incision in the right hypochondrium, access is made along the scar with an extension to dislocate the right costal arch with the M.Z. Seagal.

After a laparotomy, the cicatricial-adhesive field of the previous operation is gradually investigated. Mostly hepatoduodenal ligament is examined. As a rule, it is shortened, tightened with scars with a dense infiltrate on the right edge, in which enlarged pancreatoduodenal lymph nodes are involved. The walls of the duodenal bulb and the pylorus are soldered to the liver, a large omentum with the root of the mesentery of the colon is often involved here. The right corner of the colon is retracted, soldered into the cicatricial bed of the gallbladder. The Winslow hole is walled up with scars and the hepatoduodenal ligament is fused to the posterior abdominal wall.

Units are cut in stages from the periphery to the hepatoduodenal ligament and the hepatoduodenal ligament is exposed. The right half of the omentum is first removed from the bed of the gallbladder and hepatoduodenal ligament, then mobilized from the right half of the colon. The hepatic angle is mobilized together with the ascending part of the colon, the ileocecal angle and the peritoneum of the lower part of the root of the mesentery of the small intestine. The pancreatoduodenal complex is fully opened: the head of the pancreas along with duodenum and shortened scarring of the hepatoduodenal ligament. The Vinslov hole is opened from below and the hepatoduodenal ligament is taken to the holder.

Depending on the existing pathology, the proximal (1) and distal (2) ends of the extrahepatic bile ducts are isolated and prepared for anastomosis. The fundamental point in this case is a thorough and complete excision of scar tissue at the ends of the ducts.

To ensure free convergence of the ends of the bile ducts isolated from the scar tissue of the hepatoduodenal ligament, an extensive counter mobilization of the pancreatoduodenal complex and liver is performed.

To facilitate the mobilization of the vertical branch of the duodenum (3) together with the head of the pancreas in order to hydraulically prepare the tissues and reduce the morbidity of the manipulation, a sufficient amount of novocaine solution is administered paraduodenally and parapancreatically. The peritoneum is cut along the vertical branch of the duodenum and the fascial sheets between the duodenum, the posterior surface of the pancreatic head (4) and perinephric tissue, the inferior vena cava (7).

Next, mobilization of the lower horizontal branch of the duodenum is performed. Dissect the peritoneum in the area of the duodenojejunal transition (5), the ligament of the trait. The section line of the parietal peritoneum is extended down along the root of the mesentery of the small intestine towards the ileocecal angle (8). The latter is also fully mobilized from the posterior abdominal wall. Thus, the entire intestine becomes mobile relative to the posterior abdominal wall.

After that, the lower horizontal branch of the duodenum is completely removed from under the mesenteric vessels (13) and the entire duodenum is in dextraposition with respect to the superior mesenteric vessels (Fig. 1). The mobility of the pancreatoduodenal complex becomes sufficient to bring even a very short (1.5-2 cm long from the intrapancreatic part) distal end of the duct into the liver gate without tension almost to the level of bifurcation of the common hepatic duct.

The liver is mobilized by crossing the round (10), sickle, coronoid, right (9) and left (11) triangular ligaments (figure 2). This stage becomes more difficult with the fusion of the diaphragmatic surface of the liver and diaphragm, resulting from previous operations (often accompanied by biliary peritonitis), but it is always possible to carry out. Produce a phased separation of the adhesions between the diaphragm and the liver in a blunt and sharp way, trying not to damage the capsule of the liver. However, it should be remembered that during rough manipulations, accompanied by damage to the peritoneal cover and diaphragm tissues, an opening of the right pleural cavity is possible. After mobilization of the liver, several napkins are laid for its right lobe to shift the organ down and bring the gate area into the wound and achieve a better exposure.

Between the visceral surface of the liver and the duodenum, an omental flap is placed on the vascular pedicle. At the final stage of the intervention, he carries out biological sealing of the anastomosis, omentoplasty of the liver gates and the entire restored shortened hepaticoholedoch.

To completely eliminate tension along the seam line of the anastomosis, a “ligamentous apparatus” is created by forming 3-4 “ligament-sutures” before its formation (15). In this case, sutures are applied to the paraprotective tissues without directly capturing the duct walls at a distance of 1.5-2 cm from its stitched ends. Sutures are most often located on the back, side and front walls of the duct. First impose the rear and side seams, not tying knots (figure 3). After tightening the side seams, the back seam is tied. In this way, the unobstructed contact of the ends of the duct is achieved, ideally even in excess. After this, they begin to form an anastomosis.

Anastomosis (17) between the distal (2) and proximal (1) ends of the duct is formed by a single-row precision submucosal suture without trapping the mucous membrane (Fig. 4). Use only the finest synthetic absorbable monofilament monofilament suture 6/0 on an atraumatic needle (PDS, Biosin, etc.), which creates the best conditions for wound healing by primary intention with minimal inflammatory reaction. If possible, all sutures are knotted with nodes outside the lumen of the duct. In a difficult technical situation, the number of seams with nodes inward should be minimal.

Before suturing the anastomotic anterior wall, in some cases, to ensure unobstructed bile duct in the immediate postoperative period, a “hidden” thin silicone perforated drainage is installed throughout the duct (diameter 3-4 mm), one end of which is carried out above the anastomosis to the right or left lobar duct, the second - into the duodenum. Drainage is fixed to the posterior wall of the anastomosis with the finest synthetic absorbable suture material. The “controllability” of drainage in the postoperative period was ensured by means of endoscopic access to the large duodenal papilla: drainage was removed on days 14-30 with duodenoscopy. It must be emphasized once again that the purpose of drainage is not the implementation of a frame function, but only decompression in the early postoperative period. In a favorable technical situation, the operation is completed without drainage of the bile ducts.

After the formation of a precision single-row anastomosis, the anterior suture ligament is imposed and tied (Fig. 5). The subhepatic space is carefully identified with a lock of the omentum. Another flap of the greater omentum, cut from its right part, envelops the removed duodenum, with the end of the omentum located between the inferior vena cava and the posterior surface of the pancreatic head. Thus, the pancreatoduodenal complex appears in the “stuffing box”, which helps prevent gross interorgan fusion between the duodenum, liver, and abdominal wall. This allows you to create good conditions for unhindered peristaltic activity of the entire duodenum.

The operation is completed by installing double-lumen drainages in the subhepatic space and, if necessary, in the right subphrenic space. The abdominal cavity is sutured tightly.

The method was used in a clinic in 34 patients.

Example:

Patient Ch., 50 years old, was admitted May 17, 1999 with a diagnosis of post-traumatic stricture of the middle third of the common bile duct, cholangitis. From the anamnesis, it is known that on December 17, 98, a traditional cholecystectomy was performed in a nodal hospital. The postoperative period was complicated by biliary peritonitis, probably due to iatrogenic damage to the common bile duct during the operation. Performed relaparotomy, debridement, drainage of the abdominal cavity. In the future, attacks of cholangitis with obstructive jaundice developed three times, and was treated conservatively. For further treatment, it is paired with RCSC. Examination (ultrasound, RCP) revealed a complete stricture of the middle third of the common bile duct and pathological choledochoduodenal fistula through an abscess of the subhepatic space.

Operated on 05.06.99. An upper middle laparotomy was performed with excision of the old postoperative scar, dislocation of the right costal arch and hardware correction of access by Sigal-Kabanov expanders. Intraoperative research: in the subhepatic space - a pronounced adhesive process. The diaphragmatic surface of the liver is soldered to the diaphragm. The mobilization of the round, sickle-shaped ligament of the liver and its entire diaphragmatic surface was performed with the aim of removing the liver gate region into the wound. When separating the adhesions in the subhepatic space, it was revealed that in the area of the portal of the liver there was an abscess, the cavity of which was represented by the walls of the colon, duodenum and hepatoduodenal ligament. When separating the above organs, about 1 ml of pus was released. A point defect was opened in the hepatoduodenal ligament, from which "white" bile comes from. KDP is completely separated from the hepatoduodenal ligament. Parapancreatic and pre-duodenally injected 100 ml of 0.5% solution of novocaine. The mobilization of the vertical and lower horizontal branches of the duodenum together with the head of the pancreas was performed. Dissected the ligament of the traits, the peritoneum of the root of the mesentery root of the small intestine, the ileocecal angle and the ascending colon. The intestine is completely separated from the posterior abdominal wall. The lower horizontal branch of the duodenum is completely removed from under the root of the mesentery of the small intestine and transferred to dextraposition, thereby achieving maximum mobility of the pancreatoduodenal complex. In cicatricial elements of the hepatoduodenal ligament with technical difficulties, the common hepatic artery and its left branch are differentiated and isolated (the impression is that the right branch is ligated), the portal vein. Enlarged lymph nodes were removed from the ligament elements. The defect in the bile duct wall was enlarged, 2 nodules were extracted during intraductal examination, the choledoch proximal was expanded to 1, 3 cm, the defect is 1 cm below the hepaticus bifurcation. There is no distal patency of the duct. With further research, it was not possible to differentiate the distal part of the common bile duct.

Performed excision of the scar-changed and narrowed front wall of the duodenum, formerly the abscess wall. A large duodenal papilla was found through the duodenotomy opening, a button probe was inserted through it, with the help of which the distal segment of the common bile duct is differentiated in the hepatoduodenal ligament, which is interrupted immediately above the intrapancreatic part. The distal end of the duct is prepared for the anastomosis. The proximal end of the duct is highlighted. 3 suture ligaments were laid for paraprotective tissue from the side of the posterior and lateral walls of the ducts. The back wall of the anastomosis is formed by nodal monofilament absorbable sutures PDS 6/0. The choledochus is drained by "hidden" drainage, which is carried out in the duodenum through the papilla and is fixed to the posterior wall of the anastomosis with an absorbable thread. Stitches were placed on the front wall of the anastomosis. A bridge-like duodenoplasty with a monofilament suture was performed. The subhepatic space is identified by a lock of the omentum. Installed drainage in the subhepatic space and subphrenic space. The abdominal wall is sutured in layers tightly.

The postoperative period was uneventful. Primary healing. “Hidden” drainage was removed from the large duodenal papilla during duodenoscopy on day 30 after surgery.

Surveyed in September 2002. No complaints. In the control retrograde cholangiography, the area of biliary-biliary anastomosis with a width of 6 mm is freely passable. Biochemical parameters of blood and urine are within normal limits. Performs homework.

Using the method allows you to more widely testify and perform plastic surgery of the extrahepatic bile ducts with an end-to-end anastomosis without tension along the anastomotic suture line, which prevents the possibility of re-development of stricture. The restoration of the bile outflow into the duodenum naturally affects the digestion process and its regulation. Preservation of the function of the large duodenal papilla prevents the reflux of the duodenal contents into the bile ducts, thereby preventing the development of cholangitis. Thus, the application of the method leads to a reliable recovery of patients, returning them to a full life and work.

Claims (1)

A method of treating extrahepatic bile duct strictures, including restoring the continuity of hepatic choledochus with a single-row end-to-end anastomosis after preliminary counter mobilization of the liver and the vertical branch of the duodenum together with the pancreatic head, characterized in that the mesentery root of the small intestine is mobilized and completely mobilized branches of the duodenum, which is completely removed from under the mesentery to dextraposition in relation to the superior mesenteric m vessels, and then 2-4 compression-matching suture-ligaments are applied for the para-duct tissues, while the sutures are applied without capturing directly the duct walls at a distance of 1.5-2 cm from its stitched ends.

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