RU2277389C2 - Method for laparoscopic cholecystoduodenostomy - Google Patents

Abstract

FIELD: medicine, endoscopic surgery.

SUBSTANCE: the present innovation deals with periampular tumors. One should carry out perhepatic puncture of patient's gall bladder, connect gall bladder and duodenum with sero-serous suture. One should perforate the walls of gall bladder and duodenum with a needle to apply a vinyl chloride tube supplied with lateral opening at the level of gall bladder into duodenal lumen along a tube-conductor. Then it is necessary to apply uninterrupted anterior sero-serous suture. The ends of ligatures should be tightened with the help of special device for binding endoknots. The method provides physiological, reliable bile outflowing in case of mechanical jaundice of tumor genesis.

EFFECT: higher efficiency.

26 dwg, 1 ex

Description

The invention relates to medicine, namely to the field of endoscopic surgery, and can be used for palliative treatment of periampicular tumors.

From the moment N.D. Monastic (1887) cholecystejunostomy was proposed a large number of palliative operations for the treatment of periampicular tumors. They are mainly designed to eliminate obstruction of the bile and pancreatic ducts, to prolong the patient's life, reduce pain, improve the functional state of the liver and pancreas (V.V. Vinogradov et al., 1977; A.A., Shalimov et al., 1979; E.P. Halperin et al., 1982 and others), of which the most commonly used are the following:

1. Cholecystejunostomy with entero-enteroanastomosis and a plug of the leading end from entero-enteroanastomosis to cholecystejunostomy.

2. Cholecystoenterostomy with inter-intestinal anastomosis according to Mikulich.

3. Cholecysterostostomy with a Y-shaped enteroanastomosis with a leading gut according to Kausch.

4. Cholecystoenterostomy according to Peterson.

5. Cholecystoenterostomy according to Vinogradov.

6. Cholecystogastrostomy.

7. Choledochoduodenostomy.

8. The choledochoejunostomy according to A.A. Shalimov.

9. Operations for the removal of bile, stitching of subcapsular bile ducts into the intestine, etc.

10. Compression seamless cholecystogastroanastomoses using magnetic elements (M. Avaliani, 1995).

To perform most of the proposed operations, there is a need for laparotomy under endotracheal anesthesia for patients with severe condition and severe obstructive jaundice on the verge of disruption of the functional mechanisms of the liver. The most gentle of the proposed methods for palliative treatment of periampular tumors is compression seamless cholecystogastroanastomosis using magnetic elements, which is performed under the control of laparoscopy (M.V. Avaliani, 1995).

Characteristic of the prototype: as a prototype taken the method described in the work of M.V. Avaliani (Methodological aspects of performing compression cholecystogastroanastomoses under the control of laparoscopy. Abstracts of the VIII All-Russian Congress of Surgeons. Krasnodar, 1995, p. 321-322.) - Copyright certificate No. 1708313.

Compression seamless cholecystogastroanastomosis using magnetic elements is proposed as an alternative to traditional methods of palliative treatment of obstructive jaundice of tumor etiology with an occlusion level below the mouth of the cystic duct.

According to the prototype proposed two options for the operation:

The first version of the operation is performed under conditions of cholecystostomy decompression with simultaneous cholecystogastropexy under the control of laparoscopy.

The second variant of the operation is performed with combined gastrolaparoscopy, and the anastomosis is formed between the bottom of the gallbladder and the antrum of the stomach due to ring magnets located on the same axis of the decompressive nasovesicular catheter. In this case, the external bile fistula is absent, removal of a pair of magnets 8-9 days after their implantation is performed retrogradely on the drainage through the oropharynx, after a control fistulography confirming the formation of anastomosis.

Salient features of the prototype:

1. The choice of the least traumatic method of internal biliary elimination.

2. Temporary dosed external bile duct for 4-7 days, which allows you to adapt hepatocytes to lower intraductal pressure with simultaneous correction of KShchS.

3. The transition to internal bile duct in order to restore homeostasis.

4. The possibility of obtaining a sufficient clearance biliodigestive anastomosis (not less than 16-20 mm).

5. Providing external decompression for the period of formation of the anastomosis.

Prototype criticism

The main disadvantage of cholecystogastroanastomosis is the removal of bile into the stomach, in which the alkaline environment and bile acids change the pH of the gastric juice, dissolve the gastric mucus and cause damage to the mucous membrane with the formation of erosions or ulcers of the stomach. Alkalization of the contents of the stomach creates the prerequisites for the restructuring of the glands of the mucous membrane according to the intestinal type, which is a frequent cause of chronic gastritis, polyposis of the stomach and constant pain in the epigastric region.

The second no less significant drawback of the method is the technical difficulty in conducting a magnetic element into the gallbladder lumen. For this, there is a need to make a hole in the wall of the gallbladder, equal to the diameter of the magnetic element, which often causes leakage of bile into the free abdominal cavity and the development of bile peritonitis. To implement the method, two endoscopic methods are simultaneously used (laparoscopy, fibrogastroscopy) and X-ray control, which is also cumbersome for the patient and for endosurgeons.

As a rule, patients with obstructive jaundice of tumor origin are in a state of activity, the plastic properties of the tissues are sharply suppressed, in the abdominal cavity in 70% of cases there is ascitic fluid. Under these conditions, there is a danger of the failure of the compression anastomosis created with the help of magnetic elements, i.e. tissue necrosis from compression occurs earlier than the adhesion process outside the compression zone. There is a high risk of developing biliary peritonitis.

Thus, the identified disadvantages of the prototype include the following:

1. Antiphysiological method of internal removal of bile.

2. Technical complexity and bulkiness.

3. Insecurity and high risk of developing biliary peritonitis.

In this regard, it is relevant to search for a more physiological, reliable and less cumbersome method of endoscopic internal removal of bile with obstructive jaundice of tumor origin.

The purpose of the invention

The aim of the invention is to improve the results of palliative treatment of periampular tumors by developing a more physiological and reliable endoscopic method of internal bile diversion.

SUMMARY OF THE INVENTION

According to the proposed method, the internal removal of bile is carried out by cholecystoduodenostomy under video-laparoscopic control, and not by cholecystogastrostomy (prototype). To implement the method, we use the devices developed by us (figa and figb). Laparoscopic transhepatic puncture of the gallbladder is performed with a needle with a diameter of 2.5 mm and a thin-walled plastic tube put on it (Fig. 1), the contents of the bladder are gradually evacuated along the needle. The next step is a gray-serous continuous suture, connecting the walls of the gallbladder and duodenum for 3-4 cm (Figures 2 and 3). Then a puncture needle, which is already in the cavity of the bubble, perforate the wall of the bubble, deviating from the suture line by 5 mm, and then the wall 12 p / gut (Fig. 4.). A plastic tube is drawn into the lumen of the bladder and then through the holes in the wall of the bladder and duodenum into the lumen of the latter (Fig. 5). The puncture needle is removed (Fig.6). In the lumen of the duodenum through a plastic tube is a silicone tube with a side opening, which should be in the cavity of the gallbladder (Fig.7). The plastic tube after holding the silicone tube into the lumen of the duodenum is removed (Fig. 8). Next, impose a front continuous gray-serous suture and their ends are fixed with clamps and stretched (Fig.9, 10, 11).

For tying the ends of the threads, the device developed by us is used, application No. 99105 517/14, priority certificate from 1999 (Fig. 1B). For a better understanding of the process of tying endo nodes, we designate one of the ends of the threads “thread-B”, and the other “thread-C”.

The working end of the device with the rod folded away from the hook is inserted into the gap between the threads and rotated so that the thread "B" wrapped once around it in a section above the portion of the rod hinge (Fig. 12). After this, the thread “C” is hooked and it is stretched in a folded double form through the loop formed in the thread “B” (Fig. 13). In this case, the lumen of the hook is closed due to the fact that the loop in the thread "B", slipping along the base of the hook, touches the free end of the rod and throws it onto the tip of the hook (Fig. 14). The first knot is tightened, this is ensured, on the one hand, by tensioning the loops of thread “C” (pulling is done by hook) and, on the other hand, by tensioning the free ends of threads “B” and “C” (pulling is done by hand or by a clamp in which these ends still fixed) (Fig. 15). After that, the lumen of the hook is opened, folding the end of the rod to the base of the hook. To do this, without removing the tool from the cavity, the free end of the rod is hooked to the tensioned threads “B” and “C” or it is tipped back with a tool. Release the hook from the loop of the thread "C" and form the loop described above, but already double, around the base of the hook from the adjacent threads "B" and "C" (Fig.16). Crochet a loop of thread “C” and carry it into a double loop of threads “B” and “C”. Tighten the second node, while the thrust is performed for the loop of the thread "C" (hook) and a double loop of thread "B" and "C" (with a clamp or hand). The third and subsequent knots are tied in the same way, if necessary. Excessive ends of threads “B” and “C” are cut off. Then, in the manner described above, using a device for knitting endo nodes, knots are also tied at the other end of the anastomosis (anastomosis between the gallbladder and duodenum (Fig. 17, 18, 19, 20, 21, 22, 23). .

Thus, we propose a completely new endoscopic operation, which is carried out by sequentially performing the following main steps:

1. Transparent transhepatic puncture of the gallbladder. This puncture is carried out by a special device that we use in the implementation of many methods of diagnosis and treatment of diseases of the biliary tract of our own design.

2. Endosurgical gray-serous continuous silk suture between the walls of the gallbladder and duodenum.

3. The formation of holes on the walls of the gallbladder and duodenum in front of a continuous suture equal to the cross section of the plastic tube (conductor).

4. Carrying into the lumen of the duodenum along the conductor of the silicone tube with a side opening at the level of the gallbladder for simultaneous external decompression.

5. Endosurgical gray-serous continuous silk suture between the walls of the gallbladder and duodenum in front of the formed openings and the silicone tube drawn into the lumen of the duodenum.

6. Tying the ends of the threads using a device for knitting end nodes.

Concrete example

Patient I., 73 years old, No. 11/0839, was admitted to the General Surgery Clinic of Dagmedakademia on April 13, 1999 with the diagnosis: Pancreatic head tumor, moderate obstructive jaundice, liver failure without encephalopathy, ischemic heart disease, hypertensive b -n. Sick three months ago, when there was yellowness of the skin and sclera. He was hospitalized for 42 days in an infectious diseases hospital for Botkin's disease. The skin and sclera are yellow, traces of scratching on the skin. In the lungs, weakened vesicular breathing, cardiac arrhythmic tones, single extrasystoles, pulse 78 per minute, A / D 150/90 mm Hg. Art. The abdomen is of the correct form, it participates in the act of breathing evenly, with palpation in the right hypochondrium, an enlarged, tense and painless gall bladder is determined. Ortner's symptom is negative. The liver protrudes from under the costal arch at 2 p / fingers. The spleen is not palpable. A chair in a day, acholic. Pasternatsky’s symptom is negative on both sides, urination is free, painless, and urine is dark in color.

Blood test: hemoglobin 92 g / l; erythrocytes 3.2 · 10 ¹² / l, white blood cells 6.7 · 10 ⁹ / l, ESR 54 mm / h; total bilirubin 378 μmol / l, direct 306 μmol / l, indirect 72 μmol / l, total plasma protein 64 g / l, ALT 0.68 mmol / (tsp), AST 0.86 mmol / (tsp ), thymol sample 8 units; creatinine 136 μmol / l, urea 12 mmol / l; Urinalysis: ud.weight 1010, leukocytes 4-6 in n / a., The reaction to bile pigments is positive.

Ultrasound of the gallbladder with dimensions of 15.6 · 6.4 cm, the content is heterogeneous, stones in the lumen of the bladder are not detected. The common bile duct is enlarged, its diameter is 20 mm, the intrahepatic bile ducts are enlarged, the bile “lakes” are determined in places, the head of the pancreas is enlarged 5.4 · 4.4 cm, hyperechoic formation 4.2 × 3.3 cm in size is projected, free fluid in the sloping places of the abdominal cavity.

Under local anesthesia (Sol Novocaini 0.25% -40.0), pneumoperitoneum 12 mm Hg was applied. Art. and introduced 11 mm trocar through paraumbilical access. With a review laparoscopy, the gallbladder is tense and enlarged, up to 200 ml of a yellowish liquid in the flat places of the abdominal cavity. The liver is enlarged, greenish in color. For a better view of the gallbladder and duodenum, the head end of the operating table is raised and the table is tilted to the left by 30 °. Produced transparietal transhepatic puncture of the gallbladder with a needle with a diameter of 2.5 mm worn on it with a plastic tube (Fig-1), while dark stagnant bile was evacuated in an amount of 200 ml.

The bladder was rinsed with novocaine solution. However, the flow of dark bile through the needle does not stop. Under local anesthesia (Sol Novocaini 0.25% -20.0), a 5 mm trocar was inserted along the white line of the abdomen 3 cm below the xiphoid process. A trocar was inserted into the abdominal cavity with a needle holder with an atraumatic thread from polysorb and the walls of the gallbladder and duodenum were connected with a continuous sero-serous suture (Figs. 2, 3). The working end of the needle, which is located in the lumen of the bladder, perforated the wall of the gallbladder and then the duodenum in front of the superimposed gray-serous continuous suture between the gallbladder and the duodenum (Fig. 4). Next, through the needle conductor into the lumen of the duodenum held a hollow tube (figure 5) and the needle is removed (figure 6). A thin vinyl chloride tube with a lateral hole at the level of the gallbladder cavity for partial external decompression of the biliary tract (Fig. 7) is passed through the hollow tube into the duodenal lumen and the conduit is removed (Fig. 8). Then a gray-serous continuous suture was applied, connecting the walls of the gallbladder and duodenum in front of these holes (Figs. 9, 10, 11). Under local anesthesia (Sol Novocaini 0.25% -20), a 5 mm trocar was inserted into the abdominal cavity in the mesogastric region on the right along the midclavicular line (at the level of the navel). A clamp is inserted into the abdominal cavity along the trocar and the end of the thread is clamped. The needle holder is removed and a second clamp is held in the abdominal cavity and the other ends of the threads are clamped (Fig. 11). A third 5 mm trocar was introduced in the right hypochondrium 4 cm below the costal arch and the ends of the strings were tied in stages by a device for knitting endo nodes (Figs. 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22). The ends of the threads are cut off and the drainage tube is fixed to the skin of the anterior abdominal wall (Fig.23, 24). Trapping drainage is introduced into the subhepatic space through the trocar and is fixed to the skin of the anterior abdominal wall. Air released, trocars removed, sutures on wounds, aseptic dressing.

The postoperative period is smooth. A drain tube removed from the abdominal cavity of 6 ^th day. Jaundice gradually decreased. For drainage from the gall bladder during the first 5-6 days daily received bile in an amount of 200 to 250 ml. Starting from the seventh day, the amount of bile supplied through the drainage began to decrease and on the 14th day amounted to 20 ml. On the nasogastric tube in the first day began to flow liquid stained with bile. The nasogastric tube was removed on day 5. Two weeks after the operation, fistulography was performed. At the same time, a satisfactory contrast of the duodenum, a slight casting of contrast into the common bile duct, and a complete filling of the gallbladder with contrast material are determined on the fistulogram. However, the size of the gallbladder significantly decreased compared to the original values.

The drainage tube was removed after training on day 22, the total bilirubin is 33 μmol / L and on day 24 after the operation - laparoscopic cholecystoduodenostomy - the patient was discharged for further outpatient treatment in satisfactory condition. Comparative characteristics of the essential features of the prototype and invention are presented in the table.

Prototype invention one. Minilaparotomy, cholecystostomy . one. Laparoscopy , transhepatic puncture of the gallbladder, the introduction of a plastic tube into the lumen of the bladder by a puncture needle. 2. Cholecystogastropexy under the control of a laparoscope . 2. Cholecystoduodenopexy by the application of an endoscopic continuous gray-serous suture. 3. Combined gastrolaparoscopy. 3. The formation of holes for anastomosis on the walls of the gallbladder and duodenum. four. The formation of an anastomosis between the bottom of the gallbladder and the antrum of the stomach due to ring magnets. four. Conducting a drainage tube into the lumen of the duodenum for simultaneous external and internal removal of bile. 5. Nasovesical drainage 5. Shelter of the anastomosis with a gray-serous continuous endosurgical suture. 6. Removing a pair of magnets 8-9 days after their implantation retrograde through the oropharynx. 6. Cholecystostomy . 7. Control fistulography 7. Control fistulography. 8. External removal of bile in the first stage, and then the second stage of internal removal of bile. 8. Removal of drainage after the formation of persistent anastomosis between the gallbladder and duodenum and after the complete elimination of jaundice. 9. 9. Simultaneous external and internal abduction of bile.

As can be seen from the table, the same features of the prototype and invention (underlined) are:

1. Laparoscopy.

2. Cholecystostomy.

3. Endoscopic formation of biliodigestive anastomosis.

4. External decompression of the biliary tract during the formation of the anastomosis.

5. Control fistulography.

Distinctive features of the invention and prototype are:

1. Biliodigestive fistula is formed between the gallbladder and duodenum, and not with the stomach.

2. Transhepatic puncture, microcholecystostomy instead of minilaparotomy and cholecystostomy.

3. Formation of anastomosis by applying gray-serous continuous endosurgical sutures and reliable tying of the ends of the threads with a special device for knitting endodes instead of ring magnetic devices.

4. Antegrade drainage of the gallbladder instead of retrograde.

5. Laparoscopy instead of gastrolaparoscopy.

6. Simultaneous external and internal drainage of the biliary tract instead of external at the first stage and internal at the second stage.

7. The possibility of decompression of the biliary tract to the complete elimination of jaundice and persistent formation of anastomosis instead of decompression for 8-9 days.

Positive effect

1. Laparoscopic fistula between the bile ducts and the gastrointestinal tract is formed more physiologically by applying an anastomosis between the gallbladder and duodenum, and not with the stomach.

2. External drainage of the biliary tract is carried out in a less traumatic way - by applying a laparoscopic transhepatic microcholecystostomy throughout, rather than contact cholecystostomy by minilaparotomy.

3. The external and internal drainage of the biliary tract is carried out at the same time, most of the bile enters the intestines, the loss of electrolytes is minimal, the digestion process and absorption of the breakdown products of food masses through the intestinal membrane are restored on the first day after the operation, while in the known method, the bile is delivered in the intestine occurs only on the 9th day after the operation, all this time the patient, along with bile, loses electrolytes, especially potassium, hypokalemia occurs (a serious complication of postoperative period) and the digestion process is restored only on 9-10 days after the formation of biliodigestive anastomosis.

4. When performing biliodigestive anastomosis according to the proposed method, the risk of anastomotic insolvency is minimal, i.e. the anastomosis is formed by an endosurgical suture, and not by magnetic devices. Naturally, the mortality rate is very low.

5. The creation of biliodigestive anastomosis of the proposed method allows you to program the process of monitoring the formation of anastomosis.

6. Performing an anastomosis according to the proposed method allows not to remove the drainage tube until the jaundice disappears completely and the function of hepatocytes and bile canaliculi is restored.

Clinic Application

Our method of laparoscopic cholecystoduodenostomy, based on the formation of an anastomosis between the gallbladder and duodenum using endosurgical sutures, simultaneous external and internal decompression of the biliary tract after an experimental operation on 20 animals (outbred dogs of both sexes), was used in the clinic for the treatment of 12 patients with periampicular tumors.

Of the 20 experimental animals, 3 dogs died on the first day after the operation, the cause was an overdose of narcotic substance, 2 dogs died on the 7-8th day, the cause was peritonitis due to bile leakage into the free abdominal cavity due to premature drainage from the gallbladder cavity. We did not observe the failure of endosurgical sutures.

Among 12 patients with periampicular tumors, the process in the head of the pancreas was localized in 9 patients, a tumor of the terminal part of the common bile duct occurred in 3 patients.

Complications in the form of bile leakage into the free abdominal cavity or the failure of endosurgical sutures, an increase in jaundice and liver-renal failure were not noted. All patients underwent control fistulography 2-3 days before removal of the drainage tube, the function of the anastomosis was assessed as satisfactory.

When studying the results after 1.5-2 months after performing biliodigestive anastomosis, the condition of the patients is quite satisfactory, complaints of aching pain in the epigastric region and in the lower back, associated with the tumor process; jaundice in all patients passed completely. With ultrasound, the intrahepatic and extrahepatic ducts are not dilated. Feces of the usual color, are treated for the underlying disease.

Characterization of medical and economic efficiency

1. It is expected to reduce the number of complications that occurred when using the prototype.

2. It is assumed that mortality is reduced primarily among patients with severe jaundice, hepatic-renal failure, and ascites.

3. The relatively small consumption of material and medicines.

Information sources

1. Avaliani M.V. et al. Compression biliodigestive anastomoses using magnetic elements in palliative treatment of obstructive jaundice of tumor etiology. Current Problems of Surgical Hepatology: Proceedings of the Fourth Conference of Hepatologist Surgeons, Tula, 1996.

2. M.V. Avaliani. Methodological aspects of the implementation of compression cholecystogastroanastomoses under the control of a laparoscope. Abstracts of the VIII All-Russian Congress of Surgeons. Krasnodar - 1995.P. - 321-322 - prototype.

3. V.V. Vinogradov, P.I. Zima, V.I. Kochiashvili. Bile duct obstruction. Moscow “Medicine” 1977 - C 228-272.

4. Device for tying endo nodes. Application for invention No. 99105517/14.

5. A.A.Shalimov, A.P. Radzikhovsky, V.N. Polupan. Atlas of operations on the liver, biliary tract, pancreas and intestines. Moscow, "Medicine", 1979 - S. 179-184.

Claims (1)

The method of laparoscopic cholecystoduodenostomy, including transhepatic puncture of the gallbladder, the imposition of a gray-serous suture connecting the walls of the gallbladder and duodenum, perforation of the gallbladder and duodenal wall with further deepening of the puncture needle, passing through the intestinal tube needle through the lumen of the conduit conductor into the lumen of the intestine of the vinyl chloride tube with a side opening left at the level of the gallbladder, the imposition of an anterior continuous gray-serous suture, etc. covering anastomosis, tying the ends of the threads with a device for knitting endodes.

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