RU2291672C1 - Method for carrying out fundoplication - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves carrying out video-assisted fundoplication with lesser omentum being mobilized. Omental bursa is entered. Right diaphragm pedicle is visualized. Esophagus mobilization begins with exposing medial fascicle of the right diaphragm pedicle. Gastrodiaphragmal ligament is retained as reference object separating the stomach into anterior and posterior wall. Esophagus is separated from posterior mediastinum and its abdominal position is restored. Esophagus and muscular loop mobilization is accomplished in moving behind the esophagus along the medial fascicle of the right diaphragm pedicle. Posterior stomach wall is approached at the lesser curvature side under the esophagus. Posterior stomach wall is moved behind the esophagus. Fundoplication collar is formed by attaching anterior and posterior stomach fundus walls to esophagus wall over some extent.

EFFECT: prevented esophagus rotation; enhanced abdominal position of the esophagus; avoided angular tension.

5 dwg

Description

The invention relates to medicine, surgery and gastroenterology and can be used to treat gastroesophageal reflux disease or its combinations with a hiatal hernia.

There are methods of open surgery for reflux esophagitis. “... for all the variety of operations aimed at creating an antireflux valve (in open surgery), four main can be distinguished. This operation is Thal, Belsey, Nissen, Collis. ”A.F. Chernousov, A.L. Shestakov, G.S. Tamazyan. Reflux esophagitis. - M.: Publishing House., 1999, p. 10-11. In open operations performed from abdominal access, the intersection of the gastro-diaphragmatic ligament is mandatory even at the stage of mobilization (see figure 1).

The disadvantage of open methods for the correction of gastroesophageal reflux is the incomparably greater injury compared to video-assisted operations (in cases where video-assisted operations are possible) with almost the same functional result.

In videoassisted surgery, a Nissen fundoplication method is known, which consists in forming from the front and back walls of the fundus of the stomach a circular cuff 360 ° enveloping the esophagus. At the same time, at the stage of installation of the esophagus retractor, the gastro-diaphragmatic ligament intersects. (K.V. Puchkov, VB Filimonov. Hernias of the esophageal opening of the diaphragm - M .: Medpraktika - M. - 2003. - P.96-98).

However, if during the formation of the cuff the gastric wall is captured too distally along a large curvature, the stomach may be rotated along its long axis with rotation around the line connecting the pylorus and cardia. In the case of even lower wall capture along the greater curvature, the stomach may rotate around the line connecting the middle of the greater and lesser curvature (mesenteric axillary inversion). Moreover, to apply a softer cuff, sometimes it is necessary to additionally mobilize the fundus by crossing short gastric vessels, which increases the risk of spleen injury.

A known method of video-assisted fundoplication according to Nissen-Rosetti, which consists in the fact that the anterior wall of the fundus of the stomach is carried behind the esophagus (in Nissen surgery, the posterior wall of the fundus of the stomach) is sutured to the anterior wall of the esophagus. At the same time, at the stage of installation of the esophagus retractor, the gastro-diaphragmatic ligament intersects (K.V. Puchkov, VB Filimonov. Hernia of the esophageal opening of the diaphragm - M .: Medpraktika - M. - 2003. - P.97-98).

The disadvantage of the described method is the formation of the cuff, which leads to the creation of tension forces directed laterally, and, as a result, to the kink of the cuff and the development of dysphagia.

There is also a method of video-assisted fundoplication according to Dor, namely, that the front wall of the fundus of the stomach is placed in front of the abdominal esophagus and fixed to its right wall, while the esophageal-diaphragmatic ligament is necessarily captured in the first row of sutures (K.V. Puchkov, V .B. Filimonov Hernias of the esophageal opening of the diaphragm - M .: Medpraktika - M. - 2003. - C.98-101).

The disadvantage of the described method is the insufficient clinical effect, this type of laparoscopic fundoplication is forced and is not used as an independent in antireflux surgery.

The closest to the claimed method of video-assisted fundoplication according to Toupet is known, which consists in the formation of a symmetrical cuff from the front and back walls of the fundal section of the stomach, enveloping the esophagus 270 °, leaving its antero-right surface free (localization of the left vagus nerve). At the same time, at the stage of installation of the esophagus retractor, the gastro-diaphragmatic ligament intersects (K.V. Puchkov, VB Filimonov. Hernia of the esophageal opening of the diaphragm - M .: Medpraktika - M. - 2003. - P.98-99).

The disadvantage of the described method, as well as Nissen fundoplication, is that when the cuff is formed, the stomach wall can be captured too distally along the great curvature, which provokes the stomach to rotate along its long axis with rotation around the line connecting the pylorus and cardia. The intersection of the gastro-diaphragmatic ligament is one of the factors causing the cuff to move relative to the esophageal opening of the diaphragm.

The invention solves the problem of creating a method of fundoplication that does not rotate the esophagus, while maintaining the gastro-diaphragmatic ligament while reducing the severity of pain, reducing the frequency of complications of the postoperative period with dysphagia, esophageal vomiting.

The problem is solved due to the fact that in the method of video-assisted fundoplication, including mobilization of the esophagus and the formation of a symmetrical fundoplication cuff, they mobilize a small omentum, enter the stuffing bag, visualize the right leg of the diaphragm, mobilize the esophagus and begin to separate the middle bundle of the right leg of the diaphragm, save the diaphragmatic ligament as a guideline dividing the stomach into the anterior and posterior walls, the esophagus is secreted from the posterior mediastinum, restoring its abdomin moving to the rear of the esophagus along the medial bundle of the right leg of the diaphragm, they complete the mobilization of the esophagus and the muscle loop around it, approaching the posterior wall of the bottom of the stomach from the side of the lesser curvature, under the esophagus, after which the posterior wall of the stomach is behind the esophagus and form a fundoplication cuff by fixing the front and back walls of the bottom of the stomach to the wall of the esophagus throughout.

Thus, the back wall of the bottom of the stomach is not approached from above, above the arch of the stomach, but from the side of lesser curvature, under the esophagus. The preserved gastro-diaphragmatic ligament becomes a guideline that allows you to take exactly the posterior wall of the bottom of the stomach, thereby preventing the rotation of the esophagus.

The method is as follows.

After assessing the condition of the esophageal opening of the diaphragm, a small omentum is mobilized. When the right leg of the diaphragm is clearly visualized, focusing on its middle bundle, moving posteriorly (towards the spine), the accessible part of the lower portion of the posterior mediastinum is partially mobilized. Trunks front and rear n. vagus are controlled by vision and remain intact. The esophagus can be mobilized both laterally and medially from the anterior n. vagus. Moving behind the esophagus, along the medial bundle of the right leg of the diaphragm forward, complete the mobilization of the esophagus, the muscle loop around it and the posterior mediastinum. A 22 mm probe is inserted into the esophagus, the esophagus is taken to the holder and raised forward and to the left (see FIG. 2).

In the resulting window (relative to the operator: the upper wall is the esophagus, the right is the cardiac section and part of the bottom of the stomach, the lower is the gastro-diaphragmatic ligament, the left is the medial bundle of the right leg and the left leg of the diaphragm), focusing on the stomach (see figure 3) , while the gastro-diaphragmatic ligament does not intersect, but moves up, clearly separating the stomach into the anterior and posterior walls. Palpating the probe, moving posteriorly, enter the stuffing bag (see Fig.4-5). Assess the adequacy of the formed cuff. If necessary, perform rear crurography. A symmetric cuff is formed from the front and back walls of the fundus of the stomach, enveloping the esophagus by 180-270 °. Partial fundoplication is done with 4-6 sutures. Due to the lack of angular tension and stable fixation of the bottom of the stomach by the gastro-diaphragmatic ligament, there is no need to fix the first sutures on the cuff behind the esophageal-diaphragmatic ligaments (medial and middle bundles of the right diaphragmatic leg).

The technical result of the invention is that the method allows to avoid rotation of the esophagus, to increase the abdominal portion of the esophagus, to avoid angular tension and, therefore, optimizes the pressure in the lower esophageal sphincter. At the same time, in patients operated on using this technique, the severity of pain, the frequency of complications of the postoperative period with dysphagia, and esophageal vomiting are reduced. Thus, the proposed method improves the treatment of gastroesophageal reflux disease.

The invention is illustrated by examples.

Example 1

Prescribed epicrisis No. 6578

Patient K., 48 years old

Date of receipt: 09/27/2004

Date of discharge: 10/06/2004

The diagnosis of the main: Sliding hernia of the esophagus. Reflux esophagitis.

Concomitant diagnosis: Cystadenoma of both ovaries.

I was admitted to the hospital with complaints of aching pain in the upper abdomen after eating, constant heartburn, especially when lying down.

Anamnesis morbi: Sick, according to the patient, about 1.5 years ago, when the above complaints appeared. In April 2004 she was hospitalized in the department of gastroenterology, examined gastroscopically and radiologically. A sliding hernia of the esophageal opening of the diaphragm was revealed. Repeatedly treated conservatively outpatiently and in hospitals - without effect. Hospitalized for further examination and treatment in 2 h.o. Hospital Glavmosstroy.

Anamnesis vitae: Grew and developed normally. She suffered colds, flu. Vir. Hepatitis, tuberculosis, veins. denies the disease. Allergic history: not burdened.

Status praesens: General condition is relatively satisfactory. The consciousness is clear, the position is active. The physique is correct. The skin, visible mucous membranes and sclera are clean. The osteoarticular system without pathology. Peripheral lymph nodes are not enlarged. No swelling. Thoracic glands without pathology, regional lymph nodes are not changed. Breathing through the nose, free. Percussion-clear pulmonary sound. The vesicular breathing is carried out in all departments of the lungs. No wheezing. BH 16 in 1 min. The boundaries of the heart are within normal limits. Pulse 70 in 1 min, rhythmic. Heart sounds are clear, rhythmic, no noise. HELL 120 \ 80 mm Hg The tongue is wet. The abdomen is not swollen, participates in breathing. On palpation, the abdomen is soft, painless in all departments. Ortner's symptom is negative. The liver, spleen and gall bladder are not palpable. There are no peritoneal symptoms. Ripple of the abdominal aorta is carried out. There is no dullness of percussion sound in the sloping places of the abdomen. Peristalsis is heard. Gases go away, stool with a tendency to constipation. The kidney area is not changed. There is no dysuria. Pasternatsky’s symptom is negative on both sides.

Additional examination methods:

Intragastric daily pH-metry: ... single episodes of alkaline refluxes are recorded (14 per day). Hypoacidity. Duodenogastric refluxes.

Ultrasound 04/05/2004. Follicular cyst of the right ovary.

The treatment was carried out in accordance with the Moscow city standards of inpatient care

STANDARD CODE 72.410 DIAGNOSIS CIPHER K44.9

September 29, 2004, under endotracheal anesthesia, a combined operation was performed:

1. Laparoscopic posterior cruroraphy. Fundoplication was carried out, including mobilization of the esophagus by isolating the middle bundle of the right leg of the diaphragm without crossing the gastro-diaphragmatic ligament, taking the esophagus onto the retractor, entering the stuffing bag from the side of lesser curvature, taking the exact posterior wall of the stomach, applying a circular cuff and preserving the gastro-diaphragm . Abdominal drainage.

2. Right-sided adnexectomy.

3. Resection of the left ovary.

The postoperative period is favorable, healing by primary intention. It is discharged in satisfactory condition under the supervision of a surgeon, gastroenterologist, gynecologist at the place of residence.

Recommended: restriction of physical activity for 1 month, diet, restriction of the instantaneous amount of food taken, control endoscopy every 6 months, observation by a surgeon, gastroenterologist, urologist, prokinetics (motilium, coordinate) 10 mg 3 times a day after meals.

During the follow-up examination one month after the operation, the patient's condition is satisfactory, she does not observe the phenomena of reflux disease. Describes the result of treatment as satisfactory.

Example 2

Prescribed epicrisis No. 5552

Patient M., 34 years old

Date of receipt: 03/23/2004

Date of discharge: 03/29/2004

The diagnosis of the main: Sliding hernia of the esophagus. Reflux esophagitis.

The patient was admitted to the hospital with complaints of heartburn, belching, intense constant pain in the epigastric region.

Anamnesis morbi: considers himself ill for about 1.5 years when the above pains appeared. With satisfactory effect, he took H2 blockers, antacids without a significant effect. Hospitalized for further examination and treatment in the therapeutic department 47 MSC.

Anamnesis vitae: Grew up and developed normally. Past diseases: acute respiratory viral infections, acute respiratory infections. Vir. Hepatitis, tuberculosis, veins. denies the disease. Allergic history: not burdened.

Status praesens: General condition is relatively satisfactory. The consciousness is clear, the position is active. The physique is hypersthenic. The skin, visible mucous membranes and sclera are clean, moderate hyperemia, trophic changes on the front surfaces of the legs. Peripheral lymph nodes are not enlarged. No swelling. Breathing through the nose, free. Percussion-clear pulmonary sound. The vesicular breathing is carried out in all departments of the lungs. No wheezing. BH 16 in 1 min. The boundaries of the heart are within normal limits. Pulse 70 in 1 min, rhythmic. Heart sounds are clear, rhythmic, no noise. HELL 120 \ 80 mm Hg The tongue is wet, coated. The stomach is not swollen, participates in breathing. On palpation, the abdomen is soft, painless in all departments. The liver, spleen and gall bladder are not palpable. Gases depart. The kidney area is not changed. There is no dysuria. Pasternatsky’s symptom is negative on both sides.

On examination:

With polypositional fluoroscopy of the esophagus and stomach, a sliding hernia of the esophageal opening of the diaphragm was diagnosed. Cascading stomach. X-ray signs of gastritis, distal esophagitis.

Endoscopy: Cardia deficiency. Sliding hernia of the esophageal opening of the diaphragm - 2 tbsp. Reflux esophagitis 1 degree.

The treatment was carried out in accordance with the Moscow city standards of inpatient care

STANDARD CODE 72.410 DIAGNOSIS CIPHER K44.9

March 24, 2004 the operation was performed: Laparoscopic selective proximal vagotomy, posterior crurography. Fundoplication with preservation of the gastro-diaphragmatic ligament and fixation of the anterior and posterior walls of the fundus of the stomach to the wall of the esophagus throughout.

Under the ETN in the paraumbilical region, a 10 mm trocar was installed, a pneumoperitoneum of 10 mm Hg was applied, a laparoscope was inserted. When revising the abdominal cavity, there is no concomitant pathology. The esophageal opening of the diaphragm is expanded to 5-6 cm, a sliding axial hernia is determined. The trocars were established: 10 mm along the anterior midline in the epigastric region itself, in the left mesogastrium along the midclavicular line, 5 mm in the right hypochondrium along the anterior axillary and midclavicular line, in the right mesogastrium along the midclavicular line. A 60 Fr probe was inserted into the stomach. The front leaf of the gastrohepatic ligament between the wall of the stomach and the vagus nerve is mobilized. Branches of the vagus nerve, suitable for the body of the stomach along the lesser curvature, are intersected between the clips with the preservation of the Letarget nerve. Gland bag opened. The back leaf of a small epiploon and an epiploon bag is dissected. The legs of the diaphragm were isolated, the esophagus was isolated from the posterior mediastinum, its abdominal position was restored. The legs of the diaphragm are sutured with separate sutures behind the esophagus to the normal size of the esophageal opening of the diaphragm. The bottom of the stomach is mobile, a fragment of the posterior wall is taken, held behind the esophagus. The upper pole of the fundus of the stomach is hemmed to the posterior wall of the esophagus. The next step is the peritonization of small curvature with separate interrupted sutures. A fundoplication cuff was formed by fixing the front and back walls of the bottom of the stomach to the wall of the esophagus throughout.

The postoperative period is favorable, healing by primary intention.

Recommended: restriction of physical activity for 1 month, diet, restriction of the instantaneous intake of food. Control endoscopy every 6 months, observation by a surgeon, gastroenterologist, prokinetics (Motilium, Coordax) 10 mg 3 times a day after meals.

During the control examination after 6 months. after surgery, the patient's condition is satisfactory, does not note the phenomena of reflux disease. Describes the result of treatment as satisfactory.

Claims (1)

The method of video-assisted fundoplication, including mobilization of the esophagus, the formation of a symmetrical fundoplication cuff, characterized in that they mobilize the small omentum, enter the stuffing bag, visualize the right diaphragm leg, mobilize the esophagus by isolating the middle bundle of the right diaphragm leg, and maintain the gastro-diaphragm landmark separating the stomach into the anterior and posterior walls, the esophagus is secreted from the posterior mediastinum, restoring its abdominal position, moving behind the esophagus along the medial bundle of the right leg of the diaphragm, complete the mobilization of the esophagus and the muscle loop around it, approaching the posterior wall of the bottom of the stomach from the side of the lesser curvature, under the esophagus, after which the posterior wall of the stomach behind the esophagus is drawn and a fundoplication cuff is formed by fixing the front and back walls of the bottom stomach to the wall of the esophagus throughout.

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