RU2290875C1 - Method for widening duodenoplasty of pyloroduodenal ulcer complicated with perforation and stenosis with seroso-muscular flap due to duodenotomy and tunnelization - Google Patents

Abstract

FIELD: medicine, urgent abdominal surgery.

SUBSTANCE: one should carry out longitudinal duodenotomy up to mucous membrane through the center of perforative opening through stenosis, make incisions of serosa being parallel to circular fibers, fulfill tunnelization through incisions in muscular layer, cut out a seroso-muscular flap out of seroso-muscular membrane of anterior gastric wall and apply it through the tunnel, apply a flap onto the ulcer with serous membrane. Due to applying the flap in distal direction one should transform longitudinal duodenotomy into transverse one till the juncture of edges and in this position the flap should be fixed up. Gastric defect should be covered due to suturing up the strand of greater omentum; longitudinal duodenotomy should be fulfilled for the length of about 2-4 cm; serosal incisions should be made at 0.5-1 cm against duodenotomy edge upwards and downwards. The innovation enables to remove duodenal stenosis, increase reliability and hermetic sealing of sutures, improve circulation in this area, exclude deformation of organ's wall and disorders in gastric evacuatory function.

EFFECT: higher efficiency.

2 dwg, 1 ex

Description

The invention relates to medicine, namely to emergency abdominal surgery, and can be used for dilating duodenoplasty of pyloroduodenal ulcers, complicated by perforation and stenosis, a serous-muscular flap by duodenotomy and tunneling.

There is a method of expanding duodenoplasty with severe post-ulcer duodenal stenosis, which produce a longitudinal duodenotomy of 1.5-2 cm through stenosis, then the longitudinal incision is sutured in the transverse direction, thereby eliminating the narrowing of the duodenum (see Onopriev V.I. Etudes of functional ulcer surgery diseases, Krasnodar, 1995)

The reasons that impede the achievement of the technical result indicated below when using the known method include the fact that ligatures remain on the duodenal mucosa, which inhibit regeneration. This method causes deformation, violates peristalsis and evacuation function of the stomach.

The closest method of the same purpose to the claimed invention according to the totality of features is a method of plasticizing a perforated gastroduodenal ulcer by tunneling, in which cuts of the serous membrane 2-3 cm long are made, through which they stupidly tunnel to the perforated gastroduodenal ulcer, two sections of the serous membrane are made in parallel circular fibers, a flap on a leg is cut out from the serous-muscular membrane of the anterior wall of the stomach, the mentioned flap is dissected, e about through the tunnel and impose on the perforated gastroduodenal ulcer with the serous membrane, then fix the flap on the leg with the serous-muscular membrane of the stomach wall and duodenum with interrupted sutures along the edges of serous sections and along the perforation edge, and the defect in the stomach wall resulting from the preparation is closed a large omentum and hemmed with interrupted serous-muscular sutures (see RF patent No. 2251984, publ. 05.20.2005), adopted as a prototype.

The reasons that impede the achievement of the technical result indicated below when using the known method adopted for the prototype include the fact that it is not applicable for the combined complications of perforation and stenosis of the pyloroduodenal zone, since it does not eliminate the narrowing of the duodenum.

The object of the invention is to provide a method of spreading duodenoplasty piloroduodenalnoy ulcers complicated by perforation and stenosis, sero-muscular flap by duodenotomii and tunneling, provides a technical result consisting in the elimination of restriction duodenum, increasing the reliability and integrity of joints, improving the blood supply in this area, deformation exclusion walls of the organ and violations of the evacuation function of the stomach, and on the mucous membrane of the stomach and duodenum not a single ligature that would impede regeneration.

The specified technical result in a method of expanding duodenoplasty of a pyloroduodenal ulcer complicated by perforation and stenosis, a serous-muscular flap by duodenotomy and tunneling is achieved by cutting the serous membrane parallel to the circular fibers through which the incision is bluntly performed -muscular flap on a leg from the serous-muscular membrane of the anterior wall of the stomach, the said flap is dissected, passed through the tunnel and imposed on a pyloroduodenal ulcer with a serous membrane, a sero-muscular flap is fixed on the leg, and a defect in the stomach wall resulting from the preparation is closed by suturing a lock of a large omentum.

The peculiarity lies in the fact that preliminary they make a longitudinal duodenotomy through the center of the perforated hole of the pyloroduodenal ulcer to the mucous membrane through stenosis with economical excision of the necrotic perforation edges, after applying a serous-muscular flap on the leg to the longitudinal duodenotomy, they transversely transverse to the longitudinal duodenotomy until the edges touch and in this position, the sero-muscular flap is fixed.

In addition, a feature of the method is that they make a longitudinal duodenotomy 2-4 cm long.

Also a feature of the method lies in the fact that incisions of the serous membrane are made by stepping back 0.5-1 cm up and down from the edge of the duodenotomy.

The invention is illustrated in figures 1 and 2.

Figure 1 illustrates the cutting of a serous-muscular flap on the pedicle and longitudinal duodenotomy through the perforated hole, figure 2 - serous-muscular flap is made into the tunnel and fixed, and the longitudinal duodenotomy is transversal until the edges of the incision come into contact, while the defect of the anterior wall of the stomach is closed a lock of a large oil seal.

The method is as follows.

Through the center of the perforated hole 1 of the pyloroduodenal ulcer (Fig. 1), a longitudinal duodenotomy 2 is made up to the mucous membrane 2 to 4 cm long through stenosis with economical excision of the necrotic perforation edges. Having retreated 0.5-1 cm up and down from the edge of duodenotomy 2, incisions are made 3 of the serous membrane 2-3 cm long parallel to the circular fibers. Through sections 3 in the muscle layer stupidly tunnel to the edge of the section. A sero-muscular flap 4 on the leg is cut from the wall of the stomach so that the leg is 1 cm higher than the upper incision, it is dissected, passed through the tunnel (Fig. 2) and superimposed on the longitudinal duodenotomy 2 by the serous membrane. The serous-muscular flap 4 is pulled in the distal direction until the edges touch, as a result of which the longitudinal duodenotomy 2 becomes transverse 5. In this position, the serous-muscular flap 4 is fixed on the leg along the edges of the dissected serous membrane. After this, the serous-muscle flap 4 on the leg is sutured along the perimeter with the wall of the duodenum with interrupted sutures, without capturing the mucous and submucous membranes. Then, the defect is covered in place of the cut serous-muscular flap 4 on the leg by stitching the locks of the greater omentum 6.

Clinical example.

Patient Zh., 43 years old, was admitted to the 6th surgical department of the Ulyanovsk City Clinical Hospital for Emergency Medicine on November 12, 2004, at 3 p.m. with the diagnosis: Duodenal ulcer complicated by perforation. Upon admission, the patient complained of "dagger" pain throughout the abdomen, nausea, repeated vomiting (eight times) of food. Sick for 26 hours. The last two months after eating, they were worried about a feeling of fullness, heaviness in the stomach. Self-induced vomiting, which brought relief. I did not seek medical help. At 13 hours on 11.11.2004, suddenly, after eating, dagger pains appeared throughout the abdomen (without clear localization), nausea, and vomiting of food. He took alcohol as an anesthetic. He applied for an ambulance at 15:00 on November 12, 2004, and was taken to the admission department of the Ulyanovsk City Clinical Hospital for Emergency Medicine.

Since 1992, suffers from peptic ulcer of the duodenum, has repeatedly undergone conservative treatment in hospitals of the city. On examination: the general condition of the patient is severe. The skin is dry, normal color. The pulse is satisfactory filling and voltage of 102 beats per minute. Blood pressure 90/60 mm Hg The tongue is dry, clean. The abdomen is regular in shape, not swollen, symmetrical, is not involved in the act of breathing. Palpation is intense and sharply painful in all departments. Hepatic dullness is absent. There is dullness in the sloping places of the abdominal cavity. Intestinal motility is sluggish. The symptom of Shchetkin-Blumberg is positive in all parts of the abdominal cavity. An R-graph of the abdominal cavity was performed for the presence of free gas; free gas was not detected on the lateral pattern of the abdominal cavity. Done - esophagogastroduodenoscopy, protocol 12.11.2004. The esophagus is freely passable. There is a small amount of clear fluid in the stomach cavity. Mucous pink. The lumen of the duodenum is narrowed to 0.3 cm. On the front wall of the duodenal bulb there is a perforation with a diameter of 1.0 cm. Conclusion: perforated ulcer and stenosis of the duodenum. Diagnosed with peptic ulcer of the duodenum, complicated by perforation and decompensated stenosis. Secondary disseminated peritonitis.

In the preoperative period, the patient was given infusion therapy, 40 mg of quamatel was administered intravenously.

Operation: November 12, 2004 16 h 15 min - 17 h 20 min. During the operation, a perforated ulcer was found on the anterior wall of the duodenal bulb 1.0 cm in diameter, cicatricial deformity and circular narrowing of the duodenal bulb. In the abdominal cavity about one liter of gastric contents with pus, fibrin. The parietal peritoneum is hyperemic, edematous, covered with fibrin in all departments. Loops of the small intestine are expanded to 5.0 cm, the serous membrane is hyperemic, edematous, covered with fibrin in all departments. An expanding duodenoplasty was performed with a serous-muscular flap by duodenotomy and tunnelization, debridement and drainage of the abdominal cavity.

The postoperative period was uneventful, smooth, throughout the patient received conventional antiulcer therapy.

Esophagogastroduodenoscopy protocol November 26, 2004. The esophagus is freely passable. There is a small amount of clear fluid in the stomach cavity. Mucous pink. The duodenal bulb is moderately deformed, freely passable, no narrowing. On the front wall of the duodenal bulb there is a scar, the mucous membrane is pale pink. Biopsy. Conclusion: Condition after duodenoplasty, stage of cobblestone scar.

Pathological examination. Biopsy material. Stage cobblestone scar, a large number of pseudopiloric glands is determined.

In satisfactory condition on November 26, 2004, the patient was discharged from the hospital under the supervision of a surgeon in the clinic at the place of residence. Examined on December 20, 2004. His condition is good. No complaints. It works in the same place. Esophagogastroduodenoscopy protocol December 20, 2004. The esophagus is freely passable. There is a small amount of clear fluid in the stomach cavity. Mucous pink. The duodenal bulb is moderately deformed, freely passable, no narrowing. Conclusion: Condition after duodenoplasty.

Examined on May 18, 2005. His condition is good. No complaints. It works in the same place. Esophagogastroduodenoscopy protocol 05/18/2005. The esophagus is freely passable. There is a small amount of clear fluid in the stomach cavity. Mucous pink. The duodenal bulb is moderately deformed, freely passable, no narrowing. Conclusion: Condition after duodenoplasty.

Thus, the use of the proposed method of expanding duodenoplasty of pyloroduodenal ulcers, complicated by perforation and stenosis, serous-muscular flap by duodenotomy and tunneling provides:

elimination of narrowing of the duodenum,

increased reliability and tightness of joints,

improvement of blood supply in this area,

the exception of the deformation of the organ wall and violation of the evacuation function of the stomach,

no ligature remains on the mucous membrane of the stomach and duodenum.

Claims (1)

A method of expanding duodenoplasty of a pyloroduodenal ulcer complicated by perforation and stenosis, a serous-muscular flap by duodenotomy and tunnelization, which consists in producing longitudinal duodenotomy through the center of the perforated orifice of the pyloroduodenal ulcer and closing the mucosa in the opposite direction membranes through stenosis with economical excision of necrotic perforation edges, incisions of the serous membrane are made in parallel to the circular m fibers through which tunneling is stupidly carried out in the muscle layer, a sero-muscle flap on the leg is cut out from the serous-muscular membrane of the anterior wall of the stomach, the flap is dissected, it is passed through the tunnel and the serous membrane is applied to the pyloroduodenal ulcer, after the sero-muscular flap is applied on the peduncle, longitudinal duodenotomy by means of tension in the distal direction, the longitudinal duodenotomy is transformed to the transverse until the edges touch and in this position serous-muscular los the heel is fixed, and the defect in the wall of the stomach resulting from the preparation is closed by suturing the locks of the greater omentum, while longitudinal duodenotomy is performed 2-4 cm long, and the serous membrane is cut back 0.5-1 cm up and down from the edge of the duodenotomy.

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