RU2284769C1 - Method for creating terminolateral gastroduodenal anastomosis in making stomach resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves dissecting duodenum wall free of ulcer defect to semicircle to mucous membrane. The mucous membrane is separated from seromuscular cuff and dissected. The incision is continued from the open space side along the lower ulcer boundary. The mucous cylinder semicircle is closed. The detached mucous cylinder of the stump is sutured with interrupted sutures. Sutures line is directed in perpendicular to seromuscular cuff and gastroduodenal anastomosis suture lines. Free cuff wall edge is sutured to muscle edge of the opposite wall isolated from ulcer fundus. When forming the first row of seromuscular sutures of posterior anastomosis lip, the gastric wall, posterior seromuscular cuff stump semicircle, and anterior intestine wall are sutured in series. Duodenal stump duplicature is concurrently formed. Longitudinal duodenotomy is carried out. Internal row of posterior and anterior anastomosis lips are formed. External row of anterior anastomosis lip is formed.

EFFECT: avoided tissue strain in anastomosis zone, twist of pancreas head and invaginated portion in the stump.

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Description

The invention relates to medicine, namely to surgery, and can be used in surgical treatment of penetrating duodenal ulcers.

As an analogue, a Gaberera-Meshchaninov-Finney method is proposed for forming a longitudinal termolateral gastroduodenal anastomosis during gastrectomy [2]. The disadvantages of the method are:

a) a longitudinal nature, the absence of closure properties and, as a consequence, the gaping of anastomosis, which can lead to the development of a number of post gastroresection syndromes, such as dumping syndrome, biliary reflux gastritis, peptic ulcer anastomosis;

b) tension of the anastomosis and kink of the pancreatic head, which may result in motor-evacuation disorders and the development of postoperative pancreatitis.

As an analogue, Andreoiu proposes a method for forming a transverse termolateral gastroduodenal anastomosis during gastrectomy [3]. The disadvantages of the method are:

a) the possibility of the formation of invaginate in the lumen of the duodenal stump and the anastomosis zone when it is sutured by traditional invagination methods;

b) the tension of the anastomosis and the excess of the head of the pancreas.

These shortcomings lead to the development of motor-evacuation disorders and postoperative pancreatitis.

The closest in technical essence to the proposed method is Lokhvitsky S.V. et al. a method of forming a transverse terminolateral gastroduodenal anastomosis [1].

There are common features of this method with the claimed method:

- the method is used in the surgical treatment of peptic ulcer of the duodenum;

- the method involves maintaining the passage of food through the duodenum;

- the method models the pilor-like function of the anastomosis and protects the stump of the stomach from duodenogastric reflux;

- the method reduces the tension of the anastomosis and reduces the excess of the head of the pancreas.

However, the known method is not without some negative aspects: when suturing the duodenal stump with methods involving tissue invagination, an invaginate forms in it, often located in the projection of the anastomosis, which can provoke disturbances in evacuation from the stomach stump, and when it is located in the projection of the large duodenal nipple, it develops postoperative pancreatitis.

The objective of the invention is the development of a method for the formation of transverse terminolateral gastroduodenoanastomosis during gastrectomy, ensuring the absence of tissue tension in the anastomotic zone, bending of the pancreatic head and invaginate in the duodenal stump.

The solution of this problem allows to reduce the frequency of motor-evacuation disorders and postoperative pancreatitis, which is achieved by combining the last row of sutures of the sutured duplicator-plastic method of N.A. Nikitin of the duodenal stump (RF patent 2132650) with the first row of sutures of the gastroduodenal anastomosis.

Figure 1 and 2 presents a General diagram of the operation.

The method is as follows.

After mobilization of the stomach along both curvatures within the required limits and the initial part of the duodenum to the penetrating ulcer, the wall of the intestine free from the ulcer defect is dissected by the size of the semicircle to the mucous membrane. Without opening the intestinal lumen, the mucous membrane is separated from the serous-muscular cuff to a height of 1 cm in an acute way, after which the mucous membrane is dissected. From the side of the intestinal lumen, a ulcerative crater is visualized and the incision of the mucous membrane is continued along the lower edge of the ulcer, closing the circumference of the “mucous cylinder”. The semicircle of the “mucous cylinder”, fixed to the serous-muscular “cuff”, is peeled off from it. The remaining uncrossed semicircle of the “cuff” is crossed (Fig. 1a). After separation of the distal part of the duodenum from the upper edge of the ulcer, a clamp is applied to the pylorus, the stomach is thrown up and to the left, the bottom of the ulcer defect remains on the penetrated organ. The exfoliated “mucous cylinder” of the open duodenal stump is sutured with separate interrupted sutures, while the suture line is oriented perpendicular to the subsequent suture lines of the serous-muscular “cuff” and gastroduodenoanastomosis (Fig. 1b). The “cuff” along the boundaries of the semicircles is cut longitudinally at 2/3 of the height. The edge of the free wall of the “cuff” is sewn with separate sutures along the border of the separated mucous membrane to the muscular edge of the opposite wall, disconnected from the bottom of the ulcer (Fig. A strand of the omentum on the leg is brought to the bottom of the ulcer on the penetrated organ and fixed with sutures to its edges according to the type of omentoplasty. After this, a gastrectomy is performed with the formation of lesser curvature by known methods. From the side of the large curvature of the stomach stump, the first row of serous-muscular sutures of the transverse termolateral gastroduodenal anastomosis is formed. In the seams, the stomach wall is sequentially captured at a distance of 0.5 cm from the resection line, the posterior semicircle of the serous-muscular "cuff" of the duodenal stump and its anterior wall (Fig. 2a). The seams when laying are taken on the holders and then sequentially tied. With this technique, duplicature of the duodenal stump and the outer row of the posterior lip of the gastroduodenoanastomosis are simultaneously formed. The threads are cut, leaving the side as holders. Next, a transverse duodenotomy is performed on one third of the intestinal circumference at a distance of 0.5 cm from the line of the outer row of sutures. The inner row of sutures of the posterior lip of the anastomosis is formed by separate nodular serous-submucosal sutures (Fig.2b). Then, similarly, but in the reverse order, the inner row of the anastomosis anterior lip is first formed with nodular serous-submucosal sutures, and then the outer one is formed with nodular serous-muscular sutures (Fig.2c). In this case, the number of sutures on the anterior and posterior lips of the anastomosis, not counting the lateral ones, should be the same to exclude its deformation.

The proposed method was studied in an experiment on outbred dogs in a comparative aspect with traditional methods and was used in a clinic in 21 patients with penetrating duodenal ulcer. All patients had a smooth postoperative course with normal levels of blood amylase and the absence of motor-evacuation disorders.

Thus, the proposed method for the formation of a transverse terminolateral gastroduodenal anastomosis during gastrectomy, due to the combination of the last row of sutures of the sutured duodenal plastic stump with the first row of sutures of the anastomosis, eliminates tissue tension in its area, bending of the pancreatic head and the formation of invaginate in the duodenum stumps. This helps to significantly reduce the frequency of motor-evacuation disorders and postoperative pancreatitis. The method was studied in an experiment, was tested in the clinic and can be recommended in wide surgical practice.

LITERATURE

1. Lokhvitsky S.V., Proshin A.V., Turgunov E.M. Surgical prophylaxis of post-resection reflux gastritis. - Surgery, - 2001. - No. 4, p.22-26.

2. Matyashin I.M., Gluzman A.M. Handbook of surgical operations. Kiev, "Health". - 1979. - S. 71.

3. Myshkin K.I., Frankfurt L.A., Chernyshev N.V. Terminolateral gastroduodenal anastomosis in surgery of peptic ulcer. - Surgery. - 1982. - No. 3, p. 3-6.

Claims (1)

A method of forming a termolateral gastroduodenal anastomosis during gastrectomy, including suturing of the duodenal stump, transverse duodenotomy, formation of an anastomosis, characterized in that after mobilization of the stomach, the wall of the duodenal ulcer-free defect is dissected by the semicircle to the mucous membrane of the buccal membrane cuffs ", after which the mucous membrane is dissected, the incision of the mucous membrane along the lower edge of the ulcer is continued from the side of the lumen, I am the circumference of the “mucous cylinder”, the semicircle of the mucous cylinder fixed to the serous-muscular “cuff”, is peeled off from it, the remaining non-intersected semicircle of the “cuff” is crossed, the exfoliated “mucous cylinder” of the open duodenal stump is sutured with separate sutures, orienting the line of sutures to the perpendicular lines of suture of the serous-muscular cuff and gastroduodenoanastomosis, the “cuff” along the boundaries of the semicircles is cut longitudinally, the edge of the free wall of the “cuff” is hemmed along the border of the separated mucus after the resection of the stomach and the formation of lesser curvature, the first row of serous-muscular sutures of the posterior lip of the gastroduodenal anastomosis is formed, seizing the wall of the stomach, the posterior semicircle of the serous-muscular “cuff” of the duodenal stump, into the sutures. the intestine and its front wall, while simultaneously forming the duplicature of the duodenal stump, after which transverse duodenotomy is performed and the inner row of the anterior and posterior lips is formed omoza, then form the outer row of the front flaps.

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