RU2261666C1 - Method for surgical treatment of complicated gastric ulcers - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should protrude gastric wall in ulcerous area, dissect serous and half of muscular layer of gastric wall stepping aside against the ulcer, apply a clamp onto protruded gastric wall in deserosing area to provide rigid and elastic organs' fixation, clips of elastic fixation should be on clamp's active branches and located towards the rest gastric walls, under clips of elastic fixation one should suture gastric wall with P-shaped uninterrupted suture, between fixing lips and clips of the instrument in the clamp it is necessary to cross gastric wall with ulcer, clap should be removed, then one should suture gastric wall with a blanket uninterrupted suture in back direction and the end and the beginning of the ligature should be tightened up, transfixion suture should be peritonized with uninterrupted serous-muscular one. So, the innovation suggested enables to dissect ulcers of anterior gastric wall due to close-type technique.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely surgery, and can be used when performing radical or conditionally radical surgical interventions for complicated gastric ulcer by excision of anterior wall ulcers or by combining it with antacid operations.

The traditional open method for excising an ulcer is known, when bordering incisions in the transverse or longitudinal direction, depending on the stomach section, excise its wall within healthy tissues. Perform hemostasis and suture the stomach with a nodular or continuous suture with the location of nodes in the stomach or outside it. The stitching seam is peritonized with serous-muscular sutures (G.E. Ostroverkhov, Yu.M. Bomash, D.N. Lubotsky. Surgical surgery and topographic anatomy. - Kursk: AL Кур Kursk ’; Moscow: JSC ZT Лит Litera’, 1995 - 720 s.).

With this method of excising a stomach ulcer, its lumen communicates with the abdominal cavity, which does not exclude the contents of the stomach entering its wound in the abdominal cavity and their infection. The stages of hemostasis and suturing of the wounds of the stomach require considerable time.

The objective of the invention is a method for excising ulcers of the anterior wall of the stomach by a closed method using a special gastric clamp and suturing the wall of the stomach with continuous double-row piercing muscle-mucous and continuous serous-muscular sutures.

The task is achieved in that after isolation from the fusion of the stomach, its front wall in the area of the ulcer is stitched with a ligature-holder and traction is produced for it. On the protruded wall of the stomach, the serous and half of the muscle layer are dissected, and the serous-muscular layer is stupidly displaced from the excised section of the stomach by 5 mm. Having retreated from the edge of the ulcer to 10 mm, a gastric clamp of our design is applied to the deserted zone in the transverse or longitudinal direction, depending on the stomach section.

The tool is a clamp, on the working branches of which two brackets are located for elastic convergence of the sutured walls of the stomach. Under the clamps of the clamp for elastic fixation, the walls of the stomach are stitched with a continuous U-shaped suture in a resorbable atraumatic suture material, then the stomach wall intersects between the fixing lips and the staples of the instrument, the stomach wall is removed, the instrument with the excised fragment of the stomach is removed, and the stomach is sutured with a continuous twisting stitch in the opposite direction, after which the beginning and the end of the ligature bind. The stitching row of the suture is peritonized with a continuous serous-muscular suture.

The invention is illustrated by figures (figures 1-4).

Figure 1. The front wall of the stomach with an ulcer is stitched with a retainer, the serous layer is dissected, and a gastric clamp is applied.

Figure 2. The muscular-mucous membrane of the wall of the stomach is stitched with a continuous U-shaped suture.

Figure 3. The stitching in the form of a stitching is finished, the beginning and end of the ligature are connected.

Figure 4. Peritonization of the stitching seam with a continuous serous-muscular suture.

The method is as follows.

After laparotomy or minilaparotomy, the anterior stomach wall with an ulcer is isolated from the adhesions, the stomach wall is stitched in the area of the ulcer with a ligature-holder, and the stomach wall is protruded behind it. Having departed from the ulcer by 10 mm, the serous and half muscle layers of the stomach wall are dissected, and the serous-muscular membrane is bluntly displaced by 5 mm from the excised site. When the ulcer is localized in the region of the stomach body, the portion of the stomach wall with the ulcer is clamped along the deserted area in the longitudinal direction, in the antrum and closer to the lesser or greater curvature - transversely. Fixation is made with the location of the brackets of elastic fixation in the direction of the remaining walls of the stomach (figure 1). Under the brackets of the instrument, the wall of the stomach is stitched with a continuous U-shaped suture, absorbable suture material (figure 2). The part of the anterior wall of the stomach with an ulcer that is fixed in the clip is cut off and the clip is removed. A continuous twisting stitching suture sutures the wall of the stomach in the opposite direction, after which the beginning and end of the ligature are connected (Fig. 3). The stitching seam is peritonized with a continuous serous-muscular suture (Fig. 4).

Experimental Example

Chronic experiments were carried out on 5 sexually mature dogs from 5 to 9 kg. Under calypsol anesthesia, a laparotomy was performed, the anterior wall was stitched in the area of the stomach body, serosa was dissected and half of the muscular membrane at a distance of 10 mm from the ligature, the serous-muscular membrane was bluntly shifted by 5 mm and superimposed longitudinally on the protruded fragment of the stomach wall in the deserosation zone in the longitudinal direction gastric clamp with rigid and elastic fixation of the organ. Under the brackets of elastic fixation, the walls of the stomach were stitched with a continuous U-shaped seam of vicryl, the wall of the stomach crossed in the clamp and it was removed, and the stomach continued to be sutured by the stitched seam in the opposite direction. The beginning and end of the ligatures were connected. The consumption of absorbable atraumatic suture material for continuous continuous double-row suture corresponds to the consumption of material for two interrupted sutures. Thus, with an increase in the length of the sutured wound of the stomach, the economic effect of using a continuous double-row stitching seam increases.

The stitching seam was peritonized with a continuous serous-muscle seam of vicryl. The duration of the stage of excision and suturing of the wall of the stomach was 17 ± 4 min. After 3 weeks, the animals were removed from the experiment. There were no phenomena of peritonitis and inflammation in the area of the sutured wall of the stomach. The seam line was elastic. From the side of the mucosa there are no changes.

Clinical Example

Patient K., 53 years old, medical history 5618/520, was admitted to the clinic on 05.26.00, 7 hours after the onset of the disease with a diagnosis of peptic ulcer, chronic ulcer of the lower third of the anterior wall of the stomach, complicated by covered perforation and bleeding of the III degree.

Concomitant diseases: right-sided lower lobar pneumonia, chronic obstructive bronchitis, diffuse peribronchial pneumosclerosis, I-II class HLS with signs of cardiac asthma.

05/26/00 was produced by FGDS. A chronic ulcer of the anterior wall of the lower third of the body of the stomach was found closer to the lesser curvature, 1.8-2 cm in size. There are blood clots in the stomach.

Ultrasound of the abdominal cavity revealed fluid along the right lateral canal and pelvic cavity. May 26, 00, 1 hour after admission, an operation was performed - laparotomy, excision of an ulcer of the anterior wall of the lower third of the stomach, debridement and drainage of the abdominal cavity.

During the audit of abdominal organs, diffuse serous-fibrinous peritonitis was found. The perforation hole with a diameter of 4 mm is covered by a strand of a large gland. The small and large intestines are filled with dark blood. Given the severity of the patient's condition, it was decided to limit the amount of surgery by excision of a stomach ulcer. The wall of the stomach in the area of perforation is stitched with a Z-stitch. The abdominal cavity is sanitized. At a distance of 10 mm from the ulcer, serosa is dissected and the muscle membrane is half the thickness, and bluntly, serosa is shifted 5 mm from the ulcer. Perpendicular to the lesser curvature of the stomach, a gastric clamp is applied to the deserted area to excise its wall. Below the staples of elastic fixation, the deserted walls of the stomach are stitched with a continuous stitching V-shaped stitch with Vicryl. In the clamp, the ulcer was excised and the stomach wound was sutured in the opposite direction by a stitching stitching seam. The beginning and end of the ligature are connected. Hemostasis is wealthy. A continuous serous-muscular suture produced peritonization of the stitching suture. The abdominal cavity is drained by glove-tubular drainages in the iliac regions and the right hypochondrium. The postoperative period was uneventful. There was no relapse of peptic ulcer for 3 years.

According to this technique, 12 patients were operated on. The time of surgical intervention during excision of an ulcer in the clamp was reduced more than two times. The time of postoperative inpatient treatment was 10 days.

Thus, the task is solved by applying the technique of closed excision and suturing of complicated ulcers of the anterior wall of the stomach in a special gastric clamp and using a continuous double-row stitching and continuous serous-muscular suture for suturing.

Claims (1)

A method for excising complicated ulcers of the anterior wall of the stomach, characterized in that they protrude the wall of the stomach in the area of the ulcer, dissect the serous and half of the muscle layer of the wall of the stomach, departing from the ulcer, apply a clamp to the protruded wall of the stomach in the deserting zone, which provides rigid and elastic fixation of the organ, working jaws of which two brackets are located for elastic rapprochement of the sutured walls of the stomach, the brackets of elastic fixation are placed in the direction of the remaining walls of the stomach, under the brackets of the elastic fixation they suture the wall of the stomach with a continuous U-shaped suture, intersect the wall of the stomach with an ulcer between the fixing lips and staples of the instrument in the clamp and remove the clamp, after which the stomach wall is sutured with a continuous suture in the opposite direction, linking the beginning and end of the ligature, peritonize the stitching seam with continuous serous muscle suture.

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