RU2308895C1 - Method for applying making gastrostoma from stomach mucous membrane - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves exposing submuco-mucous layer of frontal stomach wall as 3-4 cm high cone by pulling the mucous membrane through incision in seromuscular layer along the stomach axis in body region. The cone is brought outside through separate 3 cm long transrectal incision. The frontal stomach wall is fixed near the cone base by attaching it to peritoneum and direct abdominal muscle sheath back wall near the internal ends of access zone with two sutures. Exposed cone tip is slightly cut. The mucous membrane is sutured to skin incision edges forming slit-like fistula.

EFFECT: high quality of stoma sealing; full-valued nutrition; reduced risk of traumatic complications.

3 dwg

Description

The invention relates to medicine, namely to surgery, and can be used to create an artificial fistula of the stomach for feeding patients with obstruction of the esophagus of various etiologies as a palliative operation or as a stage of esophagoplasty.

According to modern views, the operation of applying a permanent gastrostomy should meet the following requirements: technically, it should be simple, short in time, airtight, not distort the stomach.

Currently, all methods used in the clinic for the formation of the gastric fistula are divided into temporary and permanent gastrostomy.

Temporary gastrostomy is formed when a tubular fistula is formed from the front wall of the stomach around the rubber tube, one end of which is inserted into the opening of the stomach, and the other end is brought out through the front abdominal wall (Witzel, Stam-Sen-Kader methods and their modifications). (Topographic anatomy and operative surgery under the editorship of Yu.M. Lopukhin, vol. 2, 2002). The wall of the fistula is the serous membrane of the stomach and granulation tissue in the abdominal wall. When the tube is removed, the stoma closes itself.

The disadvantages of a temporary gastrostomy are the constant wearing of a rubber tube, leakage of the gastric contents between the tube and the wall of the fistula, which leads to irritation of the skin around the stoma and makes it difficult to care for the patient and self-care.

It is preferable to impose a temporary gastrostomy for a short period, but due to the simple technique of fistula formation in oncological practice, it is used as the main palliative operation.

A constant gastrostomy is formed when a non-closing lip-shaped fistula is formed, its closure occurs operatively. Nutrition of the patient is carried out by introducing into the stomach through the fistula a dense rubber or silicone tube at the time of feeding.

The advantage of this type of gastrostomy is the ability to provide a more complete nutrition for the patient, and the absence of a tube between feedings psychologically favorably affects the patient's condition.

The most widespread was the creation of a permanent gastrostomy according to G.S.Topover (1934) and its modifications (topographic anatomy and surgical surgery, edited by Yu.M. Lopukhin, volume 2, 2002).

According to the methodology of Toprover and other authors, access to the stomach is carried out by a left-side transrectal incision. A cylindrical tube 4-5 cm high is formed from the front wall of the stomach in the area of the body or the greater curvature of the stomach with three rows of purse-string or semi-purse-string sutures. The tube is fixed to the peritoneum, vagina of the rectus muscle, the laparotomy incision is sutured around the tube formed from the stomach.

When the mucous membrane is opened at the end of the tube during surgery, it is sutured to the skin, or it is opened 2-4 days after surgery.

The main disadvantages of this method of forming a constant gastrostomy are significant deformation of the stomach, eruption of purse string sutures and violation of the tightness of the fistula, the formation of a scar process around the fistula and the narrowing of its lumen, the possibility of necrosis of the stoma wall.

Another direction when applying a permanent gastrostomy is the creation of a stalked fistula (Beck-Jinu, 1912), its modifications (V.I. Yukhtin. Gastrostomy. M., 1967). According to this technique, a tube is formed from a flap cut out of the stomach wall in the region of great curvature, which is brought out through the rectus abdominis muscle.

With this technique, the creation of a stoma is a complex surgical intervention, the disadvantages of which are: the inability to use the large curvature of the stomach for subsequent esophagoplasty.

The prototype of the invention is the creation of a permanent gastrostomy from the gastric mucosa according to V.M. Voskresensky (1939). (V.I. Yukhtin. Gastrostomy. M., 1967, p. 68-70).

Gastrostoma according to V.M. Voskresensky.

The section of the abdominal wall is transrectal on the left. In the small and large curvature of the stomach, the sutures of the holder are superimposed at a distance of 5-6 cm from each other. Between the holders, an incision is made of the anterior wall of the stomach 5-6 cm long to the submucosa. The mucous membrane is secreted 3 cm on both sides of the incision, its center is taken on the provisional suture and pulled in the form of a cone 3 cm high. A pulp is formed around the cone from a peeled serous-muscular layer of the gastric wall, which is sutured in two parallel folds 2- 3 seams on each side of the cone.

The stomach is fixed to the anterior abdominal wall with separate interrupted sutures. The abdominal wall is sutured in layers around the cone on the mucous membrane of the stomach with fairly tight closure of the walls of the vagina of the rectus muscle, covering the middle of the cone. The edges of the skin along the sides of the cone are sutured to the front wall of the vagina, creating a funnel-shaped depression. The top of the cone, which is 1 cm above the skin, is hemmed to it with two interrupted sutures that do not penetrate into the lumen of the stomach. The mucous cone is opened after 2-3 days.

The main disadvantages of this fistula: according to the author, suppuration of the surgical wound, cicatricial changes in the mucous membrane of the fistula with a violation of tightness and narrowing of the canal.

The technical result is the formation of a slit-like fistula, which increases the integrity of the stoma and provides proper nutrition, simplification of the method, reducing its invasiveness.

The proposed method is as follows. Access to the stomach is made by a median laparotomy with a 5-7 cm incision between the xiphoid process of the sternum and the navel. An incision of the serous-muscular layer 1-1.5 cm long is made on the body of the anterior wall of the stomach closer to the fundus, the submucous-mucous layer of the stomach is gripped with a Mikulich clamp and secreted by drawing in the form of a cone 1 3-4 cm high. Top and bottom, backing 1 cm from the base of the cone at a distance of 2-2.5 cm from each other, impose, without tying, two seam-holders (figure 1).

The second stage is a left-side transrectal incision under the costal arch 3 cm long, the posterior wall of the vagina of the rectus abdominis 2 is dissected 0.5 cm outwards from the level of dissection of the rectus abdominis. An expander is inserted into the wound, with the help of which the cone of the gastric mucosa is brought out. In order to accelerate vascularization of the removed gastric mucosa and fixation to surrounding tissues, it is treated from the outside with the Alloplant powdery preparation (TU 42-537-88). Previously applied suture-holders, the front wall of the stomach is fixed to the peritoneum 3 and the posterior wall of the vagina of the rectus abdominis muscle at the inner ends of the transrectal incision. The top of the cone is incised and the mucous membrane of the stomach is sutured to the edges of the skin incision 4. This forms a slit-like lip-like fistula 2.5-3 cm wide, conducted through the rectus abdominis muscle and its vagina (Fig.2-3).

Immediately after the fistula is applied, a special soft flat probe is introduced into the stomach and test feeding with semi-liquid food is performed.

Dog experiments (8) showed that the integrity of the stoma remains during the entire observation period (up to 10 months).

Radiography of the stomach, performed two weeks after the operation, did not reveal deformation of the stomach.

Excretion of the stoma through a separate transrectal approach contributed to a better functioning of the valve mechanism of the fistula in comparison with excretion of the stoma through the surgical approach, reduced the development of cicatricial and adhesions around the fistulous passage. This allowed the gastrostomy to be closed extraperitoneally and facilitated the separation of the stomach from the anterior abdominal wall with a view to its further use in esophagoplasty.

Figure 1 shows the formation of a cone from the gastric mucosa.

Figure 2 is a view of the formed fistula in a horizontal section.

Figure 3 is the same on the sagittal section.

The width of the stoma (2.5 cm) made it possible to introduce a flat film probe into the stomach without irritating the mucous membrane of the canal and to fully feed the gruel-like food.

Thus, the experimental data showed that in comparison with the known methods for creating a permanent gastrostomy, the proposed method has the following advantages:

- the method is technically simple and easy to reproduce,

- creates reliable sealing of the fistula for a long time,

- there is no deformation of the stomach,

- creates the possibility of less traumatic closure of the stoma extraperitoneally,

- created conditions for gentle introduction of the probe during feeding,

- less pronounced adhesions and cicatricial processes around the channel of the fistula.

The proposed method is illustrated by the following example.

On a dog weighing 20 kg under intravenous anesthesia, a mid-upper laparotomy is made with a 5 cm section between the xiphoid process and the navel. The stomach is pulled up to the surgical wound and the serous-muscular layer is cut in the middle of the body of the anterior wall, the mucous membrane of the stomach is gripped with a Mikulich clamp and secreted in the form of a cone 2.5 cm high.

Above and below the base of the cone at a distance of 2.5 cm from each other, two half-mesh serous-muscular sutures are applied without knotting with Dacron thread No. 5.

An additional transrectal abdominal access 3 cm long is made under the costal arch on the left. The branches of the Kellian mirror are introduced into the wound. Sutures, previously applied at the base of the cone, the front wall of the stomach is fixed to the peritoneum and posterior wall of the vagina of the rectus abdominis muscle at the inner ends of the incision, expanding the branches of the Kellian mirror, the cone of the gastric mucosa is carried out through the laparotomy incision. The top of the cone is incised and the gastric mucosa is sutured with interrupted sutures to the skin of the incision.

The median laparotomic access is sutured in layers tightly. The duration of the operation is 15 minutes.

Immediately after the operation, a special soft probe is introduced through the fistula into the stomach and test feeding of 5% semolina 100 g is performed. In the future, feeding the animal through the fistula is carried out naturally during the entire observation period.

X-ray of the stomach, performed two weeks after the operation, with liquid barium, introduced by the probe through the gastrostomy, did not reveal the deformation of the stomach.

1.5 months after the application of the gastrostomy, the fistula is operatively closed extraperitoneally under local anesthesia with a 0.5% novocaine solution. The duration of the operation is 10 minutes.

During the entire observation period, gastric contents were not released through the stoma, the skin around the fistula remained dry, which indicates a good tightness of the proposed gastrostomy.

Claims (1)

A method of creating a permanent gastrostomy, including the allocation of the submucosal-mucous layer of the anterior wall of the stomach in the form of a cone 3-4 cm high, characterized in that the cone is formed by stretching the mucous membrane through the incision of the serous-muscular layer along the axis of the stomach in the body region, removing it through transrectal the incision is 3 cm long, while the front wall of the stomach at the base of the cone is fixed to the peritoneum and posterior wall of the vagina of the rectus abdominis muscle at the internal ends of the access with two sutures, the selected tip of the cone is incised and mucus fifth membrane of the stomach sutured to the edges of the skin incision, forming a slit-like fistula.

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