RU2281703C1 - Method for surgical treatment of hernias in diaphragmatic esophageal foramen - Google Patents

Abstract

FIELD: medicine, surgery, gastroenterology.

SUBSTANCE: around esophagus one should apply and fix prosthesis out of polypropylene netting. In its center one should cut a circle of 2.5 cm diameter. Due to radial incision the circle is connected with external border. Then it is necessary to place esophagus in netting's foramen, the edges of incision should be sutured in, right-hand diaphragmatic pedicle and esophageal-diaphragmatic ligament should be captured into this suture, prosthesis should be fixed to a diaphragm to carry out fundoplication. In peculiar case, operation should be fulfilled with the help of laparoscopic low-invasive techniques. The innovation enables to prevent complications as a result of narrowed esophageal foramen, cuff's sliding off and improve anti-reflux properties of cardia.

EFFECT: higher efficiency of therapy.

1 cl, 2 dwg, 1 ex, 2 tbl

Description

The present invention relates to medicine, in particular to surgery, gastroenterology, and for the surgical treatment of hiatal hernia.

A known method of surgical treatment of reflux esophagitis and sliding hernias of the esophageal opening of the diaphragm, proposed in 1956 by R. Nissen. The author, after mobilizing the abdominal esophagus and lesser curvature of the stomach in the cardia region, sutured the anterior and posterior walls of the fundus in front of the esophagus, wrapped the esophagus around the entire perimeter as a cuff, and sewn the legs of the diaphragm to narrow the esophageal opening (Shali's Digestive Surgery A .A, Saenko V.F. Kiev, "Zdorovya". - 1987. - C.60-61).

A significant disadvantage of this method is that the seams placed on the legs of the diaphragm, ragged and inevitably injured during mobilization of the cardia, erupt. As a result, the esophageal opening turns out to be insolvent, which leads to the sliding and displacement of the fundoplication cuff in the posterior mediastinum and the recurrence of a hiatal hernia.

On the contrary, the desire of surgeons to conduct reliable diaphragmcrourography, stitching on unchanged tissues and thus capturing large portions of the legs of the diaphragm, can lead to excessive narrowing of the esophagus and doom the patient to persistent postoperative dysphagia ("Dangers and complications of Nissen fundoplication" V. V. Utkin , Ambalov G.A., Demchenko Yu.M. // Surgery. - 1986. - N3. - C.88-91).

Figure 1-2 presents the proposed method for the treatment of hernias of the esophageal opening of the diaphragm.

The technical result is the prevention of complications associated with pathological narrowing of the esophagus, as well as cuff slipping, and improving the antireflux properties of the cardia.

The method is as follows. Under intubation anesthesia, an upper median laparotomy (laparoscopy) is performed, the condition of the cardia, esophageal opening of the diaphragm is assessed (Figure 1) A thick probe is inserted into the patient’s stomach. The stomach is pulled in a caudal direction and the peritoneum is cut with scissors over the abdominal section of the esophagus and mobilized. Bypassing the esophagus, they pass a rubber tube around it and pull it in a ventrocaudal direction.

A synthetic explant is prepared (polypropylene mesh 8 × 12 cm), in the center of which a circle with a diameter of 2.5 cm is cut, communicating due to the radial cut with the outer border. The floor of the explant envelops the esophagus and the synthetic prosthesis is set so that the esophagus is in the cut hole of the explant. The floors of the polypropylene mesh are sewn together, while the right leg of the diaphragm and esophageal-diaphragmatic ligament are seized in the seam. By separate sutures (one or two) the explant is fixed to the diaphragm.

Next, the fundoplication cuff is formed by conducting the posterior wall of the bottom of the stomach behind the esophagus and is fixed at the lower point to the medial surface of the esophagus with one or two atraumatic seromuscular sutures, 2 cm higher from the anatomical cardia. Then, above this point, for at least 4 cm, the anterior wall of the fundus of the stomach is sutured with the posterior wall of the fundus of the stomach, held behind the esophagus, while a synthetic explant is taken into the suture. The esophagus in the sutures are not seized. To form the cuff, it is usually sufficient to apply 4-5 stitches. The operation in finished form is presented in Fig.2. The laparotomic wound is sutured.

Clinical example. Patient X., 38 years old (medical history N429 / 05), was admitted to the hospital with complaints of epigastric pain, belching, painful heartburn. Radiologically revealed displacement of the cardia in the posterior mediastinum, gastroesophageal reflux. According to fibroendoscopy - cardia failure, erosive reflux esophagitis. According to the results of pH-metry in the abdominal esophagus in a horizontal position, acidification is pH 2.5, episodes of reflux take 10% of the time of the study. Esophagomanometry: the gradient of the esophageal-gastric transition is reduced to 60 mm water column Surgical intervention performed. Under endotracheal anesthesia performed upper median laparotomy. During the revision of the abdominal cavity organs, a shift of the cardia to the posterior mediastinum, periesophagitis, and expansion of the esophageal opening to 5 cm were revealed. A probe was inserted into the stomach. The abdominal esophagus was mobilized and held on hold. The stomach is pulled in a caudal direction and the peritoneum is cut over the abdominal part of the esophagus with scissors and its mobilization is carried out. A synthetic explant was prepared (polypropylene mesh 8 × 12 cm), in the center of which a circle with a diameter of 2.5 cm was cut, communicating due to the radial cut with the outer border. The explant floors are circled around the esophagus and the synthetic prosthesis is positioned so that the esophagus is located in the cut out hole of the explant. The floors of the polypropylene mesh are stitched, while the right leg of the diaphragm and the esophageal-diaphragmatic ligament were captured into the seam. With two separate sutures, the explant is fixed to the diaphragm.

Further, the fundoplication cuff is formed by conducting the posterior wall of the bottom of the stomach behind the esophagus and fixing at the lower point to the medial surface of the esophagus with one or two atraumatic seromuscular sutures, 2 cm higher from the anatomical cardia. Then, above this point, for at least 4 cm, the anterior wall of the fundus of the stomach is stitched with the posterior wall of the fundus of the stomach, held behind the esophagus, while a synthetic explant is trapped in the suture. 4 seams were applied to form the cuff. Laparotomic wound sutured.

The postoperative course is smooth, discharged on the 8th day after the operation. Examined, after 6 months no complaints. According to fluoroscopy and fibroendoscopy, there are no abnormalities, the pH-metry of the abdominal esophagus revealed a normocidal state (pH 7.0), esophagomanometry: the gradient of the esophageal-gastric transition was restored (180.0 mm water column).

The proposed method of surgical correction was used in a clinic in 14 patients with reflux esophagitis. No complications associated with the use of the method were noted. Evaluation of treatment results up to 2 years after the operation was carried out according to clinical and instrumental (fluoroscopy, pH-metry, esophagomanometry, fibroendoscopy) examinations in comparison with 46 patients operated on by the traditional method (Nissen fundoplication with cruroraphy).

As can be seen from table 1 in group II, dysphagia occurs in 13%, “Blowing” syndrome 17%, pain syndrome 15%, gastrostasis and intestinal paresis in 13%. In group I complications were not observed, which clearly proves the advantages of the proposed method for surgical correction of hiatal hernia in comparison with the Nissen fundoplication with cruroraphy.

The data of pH-metry and esophagomanometry, as the most sensitive and specific for identifying the pathology of the esophageal-gastric transition techniques, in the operated patients are presented in table 2.

The data presented in table 2 with a high degree of reliability (p <0.05) prove that the antireflux effect of the proposed fundoplication is higher than the traditionally used Nissen fundoplication in the treatment of reflux esophagitis. Thus, the results of clinical studies show that the proposed fundoplication increases the reliability of fixation of the gastroesophageal cuff, thereby providing a pronounced antireflux effect.

Table 1
Types and frequency of complications in the immediate postoperative period in two groups of patients using the proposed method for the treatment of hiatal hernia (group I) and using Nissen fundoplication with crurography (group II) Type of complication I group (n = 14) II group (n = 46) dysphagia - 7 Blowing Syndrome - 8 pain syndrome - 7 Gastrostasis, intestinal paresis - 5

table 2
PH-metrics and esophagomanometry before and after surgical treatment of patients using modified fundoplication (group I) and using Nissen fundoplication with crurography (group II). Study indicators I group (n = 14) II group (n = 30) before surgery After operation Before surgery After the operation pH of the abdominal esophagus 3.6 ± 0.2 6.5 ± 0.2 4,5 ± 0,2 6.5 ± 0.2 The pressure gradient of the esophageal-gastric junction (mm water column) 60.5 ± 5.0 180.5 ± 5.0 70.5 ± 5.0 170.5 ± 5.0

Claims (2)

1. A method of surgical treatment of hiatal hernia, including fundoplication, characterized in that a prosthesis is made around the esophagus and fixed from a polypropylene mesh, in the center of which a circle with a diameter of 2.5 cm is cut, communicating due to the radial section with an external border, set it in this way that the esophagus is located in the mesh opening, the edges of the mesh incision are sutured, while the right leg of the diaphragm and esophageal-diaphragmatic ligament are taken into the suture, after which the prosthesis is fixed to the diaphragm. 2. The method according to claim 1, characterized in that the operation is performed using laparoscopic mini-invasive technologies.

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