RU2264178C1 - Method for endolaparoscopic stoppage of hemorrhage at ulcerous gastric disease (variants) - Google Patents

Abstract

FIELD: medicine, endoscopic surgery.

SUBSTANCE: the present innovation deals with treating complicated forms of ulcerous gastric disease: one should perform preliminary endoscopic hemostasis followed by final hemostasis due to endoscopic technique. Moreover, with the help of a needle holder, performed gastrocentesis through trocar and a manipulator applied through instrumental canal of fibrogastroscope one should suture periulcerous mucus with single stitches within unaffected tissues to cover the ulcer. One should fix sutured ligature with a loop named "Dandi". According to one of the variants suggested one should tighten free ends of ligatures or fix them with a clip applied through gastroscope's instrumental canal. By the second variant, free ends of ligatures should be withdrawn outwards through mini-trocar that punctures the ulcerous bottom. Ligatures in tension should be fixed with an endoclip. Puncture foramens of gastric wall should be sutured and covered with omentum. The innovation provides improved prophylaxis for hemorrhage relapses.

EFFECT: decreased traumatism of operation.

2 cl, 10 dwg

Description

The invention relates to medicine, namely to endoscopic surgery, and can be used in the treatment of complicated forms of gastric ulcer.

A known method of surgical treatment of ulcerative bleeding of the stomach and duodenum, which consists in performing longitudinal gastroduodenotomy, revising the mucosa, stopping bleeding, separating the mucous-submucosal layer around the ulcer, implanting a nickel-titanium plate, suturing in the transverse direction of the gastro- or duodenotomy opening No. 21 / 14, Cl. A 61 B 17/00, publ. 12/27/2003).

The disadvantage of this method is the invasiveness of the operation.

Known methods of biendoscopic interventions are laparoscopic transerotic sclerosis of a bleeding vessel, transerose coagulation, clipping, and also flashing of a bleeding vessel to achieve temporary hemostasis under the control of intraoperative monitor intraluminal endoscopy. To achieve final hemostasis, a bleeding ulcer or a resection of the stomach is performed (Lutsevich E.V. et al. Combined laparoscopic and gastroscopic interventions for bleeding gastroduodenal ulcers. // III Congress of the Association of Surgeons named after N.I. Pirogov. - Moscow. - 2001.

The disadvantages of these methods are:

1) by affecting the source of bleeding and the adjacent tissues and vessels, temporary hemostasis is achieved;

2) the final hemostasis is achieved by performing traumatic operations - gastroduodenotomy with subsequent exposure to the source of bleeding, excision of a bleeding ulcer or resection of the stomach.

Closest to the proposed, in technical execution, is a method of laparoscopic intragastric intervention for gastric bleeding, including preliminary endoscopic hemostasis, laparoscopic percutaneous gastrostomy, intraoperative fibrogastroscopy and final hemostasis.

The main feature of this method is the use of multiple percutaneous puncture laparoscopic gastrostomy in combination with intraoperative fibrogastroscopy to perform hemostatic manipulations (preliminary or temporary hemostasis) endoscopically, and the final hemostasis is achieved by clipping or flashing of the bleeding source (Emelyanov S.I. et al. Concept laparoscopic intragastric intervention for gastric bleeding. // In J. Endoscopic surgery - 1996. - No. 1. P.13-16) - taken as a prototype.

The disadvantages of this method are:

1) multiple temporary gastrostomy (percutaneous laparoscopic gastrocentesis) using trocars for conducting working and auxiliary instruments into the lumen of the stomach;

2) a source of bleeding, open after all hemostatic manipulations, mechanical (peristalsis, food masses) and chemical (gastric secretion), the effect of which can contribute to the development of bleeding recurrence, which leads to a decrease in the quality of healing of ulcers, an increase in the treatment time for patients with peptic ulcer disease, and in general, reduces the effectiveness of the treatment of complicated forms of peptic ulcer.

The combination of two technical solutions in one application is due to the fact that the two proposed methods solve the same problem and are directed:

1) to improve the technical stages of the technique of combined intragastric intervention in relation to ulcerative bleeding;

2) to reduce operational traumatic effects;

3) to achieve adequate (final) hemostasis;

4) to use the technique for perforated gastric ulcers;

5) to reduce the healing time of ulcers.

The technical capabilities of the invention in comparison with the prototype can improve the effectiveness of treatment of complicated forms of peptic ulcer disease, speed up the healing process of ulcers, reduce the treatment time for patients with peptic ulcer disease.

To achieve the specified technical result in a method including preliminary endoscopic hemostasis, and then laparoscopic percutaneous trocar gastrostomy, intraoperative fibrogastroscopy and final hemostasis, the needle holder is passed through the gastrocentesis trocar, the manipulator is passed through the instrumental channel of the fibrogastroscope and the single mucosa stitching is sewn within which the single mucosa stitches within cover the ulcer, while subsequent flashing is placed opposite the previous one, fixing yut stitched thread to the mucous loop "Dundee." According to the first embodiment of the invention, the free ends of the filaments, located opposite each other, alternately bind or the sections of the filaments stretched over the ulcer are fixed with a clip using an applicator passed through the instrument channel of the fibrogastroscope so that the formed mucous sheets are closed over the ulcer, the puncture openings of the stomach wall are sutured and covered oil seal.

According to a second embodiment of the invention, the free ends of the threads are brought out with the help of a manipulator needle through the minitrocar puncturing the ulcer bottom, the threads are uniformly pulled and at the same time the minitrocar is removed from the stomach, while the mucous membrane in the form of petals covers the ulcer and seals the puncture opening of the ulcer bottom, stretched from the side of the abdominal cavity the filaments are fixed with an endoclip, which is fixed by the wall of the stomach, the free ends of the filaments are cut off and removed, the puncture holes of the wall of the stomach are sutured and covered with an omentum.

The main feature of the proposed method is the use of temporary percutaneous laparoscopic gastrocentesis (“access gate”) and intraoperative fibrogastroscopy in order to perform all hemostatic manipulations in the lumen of the stomach and cover the source of mucosal bleeding (bioplasty). It should be noted that the trocar gastrostomy is performed so that the needle holder is located opposite the ulcer defect. After stopping the bleeding, pairwise (4, 6, 8, etc.) stitching of the mucous membrane along the circumference of the ulcer with single stitches (subsequent stitching of the mucosa should be opposite to the previous one) within the unchanged tissue using a needle holder held through the access gate trocar and the manipulator which is carried out through the instrument channel of the fibrogastroscope. Preliminarily, at the free end of the thread, a Dundee loop is formed. It should be noted that with this method, the mucosa closes above the ulcer in the form of paired petals ("bud effect"). The filaments are fixed in the first embodiment over the ulcer nodes or clip using an applicator held through the instrument channel of a fibrogastroscope (fibroduodenoscope). In the second option, the free ends of the threads are removed from the stomach to the outside with the help of a manipulator needle, which is carried out along the mini-acar, puncturing the bottom of the ulcer. Simultaneously with the removal of the minitrocar from the stomach, the ends of the threads are evenly stretched until the mucous membrane is completely closed over the ulcer, which seals the puncture opening and is fixed from the side of the abdominal cavity by the endoclipis, which in turn is fixed by the wall of the stomach.

The free ends of the threads are cut and removed. After removing the trocar (“access gate”) from the stomach, the puncture holes in the stomach wall are sutured using the EndoStitch tool.

The proposed method for endolaparoscopic arrest of bleeding in gastric ulcer is illustrated by the drawings shown in figures 1-10.

Figure 1 shows the flashing of the near ulcerous mucosa and fixation of the ligature with the help of the Dundee loop.

In Fig.2 - the binding of the filaments alternately opposite each other until the mucous membrane is completely closed over the ulcer.

Figure 3 - fixing the threads of the endoclipse using an applicator held through the instrument channel of the fibrogastroscope.

Figure 4 shows how the strained threads are fixed by the endoclipse, which is fixed by the wall of the stomach.

Figure 5 - location of the manipulator with respect to the ulcer.

Figure 6 shows gastrocentesis: through the bottom of the ulcer with a puncture needle and in the area of great curvature of the stomach ("access gate").

Figure 7 shows the flashing of the near ulcerous mucosa with puncture gastrocentesis through the bottom of the ulcer.

In Fig.8 - the withdrawal of the free ends of the threads to the outside using a manipulator needle.

Figure 9 shows the simultaneous uniform pulling of the thread and the removal of the minitrocar from the stomach.

In figure 10, the mucosa uniformly covers the ulcer ("bud effect"), sealing the puncture hole in the bottom of the ulcer.

In figures 1-8 shows the holding of the thread with the loop "Dundee" 1 through the tube of the trocar 2 using the needle holder 3, the manipulator 4, fibrogastroscope 5, stitch 6 (stitched peritoneal mucosa), applicator 7, the petals of peritumal mucosa 8, endoclip 9, the wall of the stomach 10, the manipulator needle 11.

The method of endolaparoscopic stop bleeding with gastric ulcer is as follows.

After a preliminary endoscopic stop of bleeding, a pneumoperitoneum from a puncture in the paraumbilical zone is applied. A 10 mm trocar is introduced. At the same time, abdominal laparoscopy and gastroscopy are performed to determine the localization of the ulcer both from the intragastric space and from the abdominal cavity. In the area of the right and left hypochondrium, two 5-mm trocars and manipulators are introduced to displace, rotate, traction and fix the stomach wall in the area of gastrocentesis. In the right hypochondrium, through an additional 5 mm trocar, a soft intestinal clamp is inserted into the abdominal cavity, with the help of which a temporary clamping of the lumen of the duodenum 12 is performed in order to prevent the discharge of insufflated air from the stomach into the intestine. Percutaneous gastrocentesis through the "access gate" is performed under endoscopic and laparoscopic control after a partial decrease in pressure in the abdominal cavity (method 1), followed by percutaneous puncture gastrocentesis through the bottom of the ulcer (method 2). Sewing of the mucosa and fixation of the threads around the circumference of the ulcer crater is performed under endoscopic intragastric control using a manipulator (grasping soft forceps like “duck beak”), conducted through the instrument channel of the fibrogastroscope to divert and fix the mucosa at the stitching site (stitch), and the needle holder, passed through trocar "access gate" (figure 1). The withdrawn free ends of the threads through a 5 mm gastrocentesis trocar are connected in pairs alternately (located opposite each other) until the mucous membrane is completely closed over the ulcer or the threads are fixed with an endoclip using an applicator drawn through the instrument channel of the fibrogastroscope so that all the formed mucous sheets are closed over the ulcer (method 1) (Fig.2, 3). To perform the above manipulations, a gastrostomy is preliminarily performed; for this, a needle holder 3 is inserted through the tube of the trocar 2 and, using the manipulator 4, passed through the instrumental channel of the fibrogastroscope 5, flashing of the ulcerous mucosa is carried out.

Figure 1 shows that the “Dundee” loop is pre-formed on the free end of the thread 1. By reverse movement, the needle is drawn through the loop, the thread is gripped by a clip near the loop and its short end is tightened in the opposite direction, thus fixing the thread to the stitched mucosa. When tying threads (figure 2), located opposite each other, the mucous membrane in the form of petals covers an ulcer (formation of petals). The free ends fixed to the ulcerous mucosa (Fig. 3) are excreted through the minitrocar passed through the tube of the trocar 2. The threads are simultaneously stretched, the mucous in the form of petals covers the ulcer, and the threads stretched over the ulcer are fixed with a clip using an applicator 7 passed through the instrument channel fibrogastroscope 5.

In another case, the free ends of the threads are brought out through the minitrocar puncturing the bottom of the ulcer crater using a manipulator needle. The filaments with the simultaneous removal of the minitrocar from the stomach into the abdominal cavity are stretched until the mucous leaves completely close over the ulcer and are fixed by endoclip 9 from the side of the abdominal cavity in the area of the puncture of the stomach wall 10, which in turn is a fixator for endoclips (method 2) (figure 4) . The free ends of the threads are cut and removed through the trocars to the outside. The puncture holes of the stomach wall are sutured using the EndoStitch tool. The peritonization of the omentum of the sutured openings is performed using an endo loop, which is fixed to the wall of the stomach with brackets using a stapler. In this case, the lock of the oil seal is passed through the loop, after which the loop is tightened. The end clamp is removed from the 12 duodenal ulcer. A laparoscopic checkup and rehabilitation of the gastrointestinal space is performed. In the area of sutured defects of the wall of the stomach through 5-mm trocars, control drains are carried out. Manipulators and trocars are removed from the abdominal cavity. Wounds of the anterior abdominal wall are sutured. The fibrogastroscope is removed. A probe is administered orally to the stomach.

An example of a specific implementation of the method of endolaparoscopic stopping bleeding with gastric ulcer in the experiment.

The technical implementation of intragastric manipulations in relation to the tasks of the final stop of ulcerative gastric bleeding was carried out in an experiment in an open way on human corpses.

1. After the upper middle laparotomy, gastrotomy determine the localization of the ulcer. Then determine the "access gate" (section of the wall of the stomach) in order to conduct a trocar for the needle holder (manipulator) into the lumen of the stomach. To create effective conditions, “access gates” should be located on the opposite side of the wall of the stomach or opposite a peptic ulcer, i.e. the trocar for the needle holder (manipulator) with localization of the ulcer on the lesser curvature is performed percutaneously in the lumen of the stomach in the region of great curvature (Fig. 5). The mucous membrane is flashed with single stitches (ligatures) around the circumference of the ulcer defect within the invariable tissue so that the subsequent flashing of the mucosa is located opposite the previous one. Preliminarily, at the free end of the thread, a Dundee loop is formed. The ligature with the thread is stretched to the loop, the needle is threaded through the loop with the reverse movement, the thread is grabbed with the end clamp at the loop and its short end is tightened in the opposite direction at the level of the mucosa. Thus, the threads are fixed to the mucosa and their free ends are brought out through the trocar. The threads are connected alternately, located opposite each other, until the mucous leaves ("bud effect") are completely closed over the ulcer. To fix the filaments of the closed sheets of the mucous membrane over the ulcer, you can clip with the help of an applicator held through the instrument channel of the fibrogastroscope. The free ends of the threads are cut and removed. Thus, bioplasty of a peptic ulcer of the gastric ulcer is made. After removal of the trocar from the stomach, the puncture hole of its wall is sutured.

2. Perform two percutaneous gastrocentesis: the first through the bottom of the ulcer (artificial perforation) with a puncture needle, which is also a conductor for a mini-acar, and the second in the region of large curvature of the stomach (Fig. 6.). Technical aspects of mucosal flashing and fixation of threads perifocal ulcer defect described above (method 1). The needle puncturing the bottom of the ulcer is removed from the minitrocar (Fig. 7). Then, a manipulator needle 11 is passed through it into the lumen of the stomach, which allows the free ends of the threads to be brought out (Fig. 8). The threads are evenly pulled and at the same time remove the minitrocar from the stomach (Fig.9-10). The mucous membrane in the form of petals uniformly covers the ulcer defect ("bud effect") and seals the puncture opening of the ulcer bottom. From the side of the abdominal cavity, the strained threads are fixed with an endoclip, which in turn is fixed by the wall of the stomach. Gastrotomy incision and puncture holes (the area of the bottom of the ulcer and large curvature) are sutured from the side of the abdominal cavity.

Claims (2)

1. A method of endolaparoscopic stopping of bleeding in gastric ulcer, including preliminary endoscopic hemostasis, and then laparoscopic percutaneous gastrostomy, intraoperative fibrogastroscopy and manipulations aimed at final hemostasis, characterized in that to achieve final hemostasis using a needle holder carried out through trocar gastrocene the manipulator, conducted through the instrument channel of the fibrogastroscope, is stitched with single stitches in the In the case of unchanged tissue, the near-ulcerous mucosa, which covers the ulcer, while the subsequent stitching is opposite to the previous one, the stitched thread is fixed to the mucous membrane with a Dundee loop, the free ends of the threads located opposite each other are sequentially tied or fixed with a clip using an applicator through the instrumental the channel of the fibrogastroscope, so that all the formed sheets of the mucosa close above the ulcer, the puncture holes of the stomach wall are sutured and covered with an omentum. 2. A method for endolaparoscopic stopping bleeding in patients with gastric ulcer, including preliminary endoscopic hemostasis, and then laparoscopic percutaneous gastrostomy, intraoperative fibrogastroscopy, and manipulations aimed at final hemostasis, characterized in that to achieve final hemostasis using a needle holder carried out through trocar gastrocene the manipulator, conducted through the instrument channel of the fibrogastroscope, is flashed with single stitches the ulcerative mucosa, which covers the ulcer, while the subsequent stitching is opposite to the previous one, the stitched thread is fixed to the mucous membrane with a Dundee loop, the free ends of the threads are brought out using a manipulator needle through a minitrocar puncturing the ulcer bottom, the threads are uniformly pulled and simultaneously removed from the stomach minitrocar, while the mucous membrane in the form of petals covers the ulcer and seals the puncture opening of the ulcer bottom, from the side of the abdominal cavity the stretched threads are fixed with an endoclip, which is fixed by the wall of the stomach, the free ends of the filaments are cut off and removed, the puncture holes of the wall of the stomach are sutured and covered with an omentum.

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