RU2310401C1 - Method for suturing perforated gastric and duodenal ulcers - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should bring together the edges of perforated foramen; sutures should be applied with omental sector; moreover, one should apply a fragment of reticular allotransplant, its sizes exceeding those of the ulcerous infiltrate; it is important to apply the fragment of reticular allotransplant onto ulcerous defect; with one interrupted suture one should suture in the edges of the ulcerous defect; simultaneously it is necessary to fix the center of reticular allotransplant's fragment. Then the fragment's angles should be fixed with separate interrupted sutures within the limits healthy tissues. After that the fragment's edges should be sutured with uninterrupted suture. From the top of the allotransplant's fragment one should apply a strand of greater omentum to fix it with ligatures by the angles. The innovation enables to save the organ and its physiological lumen that decreases the risk in the development of peritonitis, the progress of ulcerous process at liquidating the defect of gastric or duodenal wall and prevents the development of stenosis in post-surgical period.

EFFECT: higher efficiency.

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Description

The present invention relates to medicine, in particular surgery, and can be used for suturing perforated ulcers of the stomach and duodenum.

There are many known methods of sheltering perforations, which are based on the use of their own tissues (autoplasty). All of them include an incision of the anterior abdominal wall, revision and excretion of an organ with a perforation site in the wound, the imposition of the first row of through nodal sutures to approximate the edges of the ulcer defect, and the subsequent subsequent second row of nodal sutures. Common disadvantages of these methods is the deformation of the lumen of the hollow organ due to invagination of the walls with impaired blood supply, leading to the development of cicatricial ulcerative stenosis of the pyloric-duodenal zone, which requires repeated surgical intervention (1).

Known methods for suturing perforated holes using isolated local tissues as various additions in the form of autoplastic material: tamponade with muscles, followed by suturing according to V. A. Krasivtsev; plastic by sero-muscular flap of the stomach wall L.V. Serebryannikov and V.P. Snezhkova, 1940; plastic with an isolated omentum and muscles - Yu.Kh. Petrova, 1946; plastic with an isolated omentum and parietal peritoneum - N. A. Kulichkov, 1955 and other methods [1]. These methods include the use of the walls of their own and neighboring organs, the omentum, the round ligament of the liver, a piece of the wall of the gallbladder, which cover the holes with subsequent suturing of the edges [2].

However, an isolated omentum or other biological tissue, lacking nutrition, prolong the healing time of the suture and can cause ulcer relapse, followed by penitration and perforation due to the fact that the own tissues do not interfere with the ulcerative process, which also leads to the need for repeated surgery.

Known methods for suturing perforations of hollow organs using an autoplastic material on the feeding leg: hemming an omentum with additional tamponade with gauze - V.A. Opel, 1896; suturing with a mattress seam with plastic omentum - M.A. Kantorovich; plastic reinforced gland on the leg - A.B.Savchik [1, p.231-232]; fixation to the seam line of the omentum on the leg of I.I. Neymark, 1958; hemming around the circumference of a lock of a large omentum on a feeding leg Jordan R., Morrow S., 1988; plastic by serous-muscular flap of the stomach on the vascular pedicle - V.E. Kutukov, 1989 [1, 2, 3].

The disadvantage of these methods is the possibility of peritonitis and also the continuation of the ulcerative process.

As a prototype, the method of suturing the perforated hole with ulcers with an isolated omentum, A.A.Shalimov, V.F.Saenko, including the rapprochement of the edges of the perforated opening with the first row of sutures / without screwing /, then the second row of serous-muscular sutures with the gland section, is selected, hemming it around the circle [1]. This method has all the disadvantages inherent in the above methods, i.e. the possibility of peritonitis, the continuation of the ulcerative process with subsequent penetration and perforation.

The objective of the invention is to provide a method for suturing perforated ulcers of the stomach and duodenum of the pyloroduodenal zone (to expand the arsenal of such methods), which will save the organ and its physiological clearance, prevent the occurrence of peritonitis, the continuation of the ulcer process in the elimination of a defect in the wall of the stomach or intestine, prevent the development of stenosis in the postoperative period.

The problem is solved due to the fact that in the method, which involves bringing the edges of the perforated hole closer together with the first row of sutures, applying a second row of sutures to the insulated gland section, in contrast to the prototype, a mesh allograft flap is used that is larger than the size of the ulcer infiltrate, first with one nodal suture the edges of the ulcer defect are sutured and at the same time the center of the allograft flap is fixed, then the flap angles are fixed at the corners with separate interrupted sutures, after which the flap edges are stitched continuously a seam, and on top of the allograft flap lay a strand of a large omentum, which is fixed with suture threads in the corners.

Distinctive features to confirm the conformity of the proposed technical solution with the criteria of "novelty" and "inventive step" are the following:

- the use of a mesh allograft for perforated ulcer defects of the stomach and duodenum for plastic surgery, which is unknown from the prior art for this purpose and allows replacing the defect of the submucosal layer with a mesh that is closest in structure to the physiological structure of the intestinal wall or stomach, preserving the lumen of the hollow organ, and, in addition to Moreover, this technical solution prevents the further development of the ulcerative process;

- the use of one nodal suture for suturing the edges of the ulcer defect and at the same time fixing the center of the mesh allograft flap, which eliminates the ulcer defect and implant the allograft in the place most prone to perforation;

- fixing the corners of the mesh with separate knotted sutures and the further imposition of continuous sutures along the edges of the mesh allows you to reliably and tightly fix the allograft flap within healthy tissues;

- laying on top of the allograft strands of a large omentum with fixing it with two or three suture threads at the corners, which allows you to fully recreate the structure of the organ wall, thereby replacing its serous cover, and delimit it from the abdominal organs.

Using this method will eliminate the defect in the wall of the stomach or intestine by forming a submucosal layer from the connective tissue that grows through the mesh graft, and replacing the serous layer with the omentum, to avoid narrowing the physiological clearance of the organ (this is especially important for the pyloroduodenal zone), which as a result prevents the development of stenosis in the postoperative period and prevents the need for repeated operations. In addition, this method is simple to implement and has reliability.

The invention is characterized by the following images:

1. figure 1 - defect, covered with a flap mesh allograft;

2. figure 2 - defect, with a fixed strand of a large seal.

The method is as follows. After removing the perforated hole in the wound, a flap of 1 mesh allograft is placed on it, which is larger than the size of the ulcerative infiltrate, for reliable fixation within healthy tissues. Then, with the help of one interrupted suture 2 (Fig. 1), the edges of the ulcer defect are sutured and the center of the flap 1 is fixed, after which the corners of the flap 1 are fixed with separate interrupted sutures 3. Then, the flap edges are sutured with a continuous suture (not shown in Fig. 1). On top of the allograft flap 1, a strand 4 of a large omentum is laid (Fig. 2), which is fixed with two or three suture threads 5 at the corners. After rehabilitation and drainage of the abdominal cavity, suturing of the laparotomy wound is performed.

Example. The method was used in an experiment on 25 rats in the experimental group. After removing the perforated hole in the wound, a flap of 1 mesh allograft was placed on it, exceeding the size of the ulcer infiltrate in size, for reliable fixation within healthy tissues. Then the edges of the ulcer defect were sutured with one interrupted suture and the center of the flap was fixed, after which the corners of the flap were fixed with separate interrupted sutures. Then the edges of the flap were stitched with a continuous seam. A strand of a large omentum was placed on top of the allograft flap, which was fixed with two or three suture threads in the corners. After rehabilitation and drainage of the abdominal cavity, the laparotomy wound was sutured. A control group of 25 rats was operated using the double suturing technique.

The experimental results confirmed that in the experimental group, as well as in the control group, ulcer scarring occurred on day 30, i.e. the presence of the grid did not slow down the regenerative processes. In this case, there was no narrowing of the lumen of the hollow organ, because connective tissue, which grows through the mesh allograft throughout, replaced the submucosal layer, acting as a skeleton of the wall, and the lock of the greater omentum formed the mucous layer (serous cover) of the organ, delimiting it from other organs of the abdominal cavity.

Thus, the use of this method will allow you to save the organ with a natural physiological clearance, which will reduce the risk of peritonitis, the continuation of the ulcer process during the elimination of a defect in the wall of the stomach or intestine, prevent the development of stenosis in the postoperative period and avoid repeated operations. The experimental data were histologically confirmed.

Literature

1. A.A.Shalimov, V.F.Saenko "Digestive tract surgery." - Kiev, 1987, p.231.

2. N.A. Maistrenko, K.N. Movchan "Surgical treatment of duodenal ulcers." - St. Petersburg, 2000, p. 39-51.

3. I.M.Matyash, A.M.Gluzman "Directory of surgical operations." - Kiev, 1979, p. 62-111.

Claims (1)

A method of suturing a perforated stomach ulcer or duodenal ulcer, including rapprochement of the edges of the perforated opening, suturing with the gland section, characterized in that a mesh allograft flap is used that is larger than the size of the ulcer infiltrate, a mesh allograft flap is placed on the ulcer first, then the edges of the ulcer defect are sutured and at the same time the center of the mesh allograft flap is fixed, then the corners of the flap are fixed with separate nodal joints you within healthy tissues, after which the edges of the flap are stitched with a continuous suture, and the lock of a large omentum is placed on top of the mesh allograft flap, followed by fixation with suture threads at the corners.

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