RU2315567C1 - Method for forming valvular areflux jejunostoma - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: after laparotomy it is necessary to cross small intestine at the distance of about 10-15 cm against Treitz ligament, apply small-intestinal anastomosis "end-to-side" by Rou by forming "free" part of small intestine being 30 cm length. At the distance of 3 cm it is necessary to remove mesentery from proximal part of "free" sector of small intestine. One should apply two lateral sutures-holders onto proximal part of "free" sector, 3-4 cm against the borders of mesentery-free part it is necessary to fulfill longitudinal incision of jejunum being of 2 cm length at contramesenteric surface. The walls of the wound developed should be separated, sutures-holders of mesentery-free sector should be captured followed by its invagination into intestinal lumen. Contramesenteric surface of invaginated part should be sutured with distal edge of enterotomic wound by forming areflux valve due to adjoined edge being loosely hanging into intestinal lumen. The innovation prevents digesta leakage and, also, decreases traumatism of interference and excludes the necessity for reconstructive-restorative interference.

EFFECT: higher efficiency.

1 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery. Despite the modern achievements of surgery and science, the issues of patient ostomy remain relevant today. It is no exception and jujnostoma. Indications for the placement of unnatural openings of the gastrointestinal tract at various levels of its extension are widely debated in modern surgery. Massive damage to the hollow organs of the abdominal cavity, inoperable tumors of the cardiac section of the stomach and other pathological processes of the abdominal cavity, requiring the application of a nutritional fistula to the initial sections of the jejunum (jejunostomy), emphasize the need for continuous improvement of techniques and in the development of new methods for applying enterostom.

The prototype of the overlay reflux valve jujunctomy is the Witzel enterostomy operation. The loop of the small intestine selected for enterostomy is freed from the contents and non-crushing clamps are applied. Opposite the borders in the mesentery, a purse string suture is placed on silk 00. Then, a soft rubber catheter of small diameter with several holes is placed on the skin of the jejunum, while nodal sutures are placed at a distance of 1 cm from each other, capturing a little of the intestinal wall on both sides of the catheter. When these sutures are tied, the catheter will hide in the wall of the small intestine for 6-8 cm. After this, an incision is made in the intestine in the middle of the purse string suture, and the end of the catheter is inserted into the small intestine and threaded into the lumen at the desired distance, after which the purse string suture knotted. The remaining part of the catheter and the purse string suture area are then closed with three to four nodal sutures. A puncture wound is made in the peritoneal wall and a clamp is inserted as a guide for suturing between the small intestine and the peritoneum adjacent to the suture line. It is advisable to make an attachment with a broad base so that the small intestine does not twist and bend. After the first row of sutures is tied, the catheter is removed through a puncture wound so that between the peritoneum and small intestine, the front row of sutures can be placed, which completely seals the catheter area. It is recommended to attach the small intestine to the walls by 5-8 cm so that the small intestine does not turn around around a small fixed point. The intestine must be attached to the peritoneum in the direction of peristalsis. Further, after this, the laparotomy wound is traditionally sutured (R. Zollinger - "Atlas of Surgical Operations" - revised and revised edition - Moscow - 2002 - p. 88).

However, the above method has several disadvantages:

1. The possibility of catheter prolapse;

2. Catheter prolapse precludes further use of enterostomy;

3. Enterzoma according to Witzel is a temporary stoma, which is not very convenient for the patient and surgeon;

4. The above variant of patient stomization requires constant wearing of a catheter, which significantly reduces the quality of his life;

5. Enterzostoma according to Witzel is not tight enough, which means it can cause maceration of the skin, and subsequently a number of other purulent complications.

The authors propose their own method of forming valvular reflux jejunostomy (drawing). A laparotomy is traditionally performed. Further, 10-15 cm from the ligament of Treitz produce a complete intersection of the jejunum. After this, the thin-intestinal anastomosis is applied end to side along the Roux. As a result of this, a “free” section of the jejunum 30 cm long is formed. The proximal section of the “free” segment is freed from the mesentery without disturbing the blood supply to its wall for 3 cm (1). Next, two side seams-holders (2) are imposed on it. After that, departing 3-4 cm from the borders of the mesenteric portion of the “free” segment of the jejunum, a longitudinal section of the jejunum wall is made on the mesenteric surface with a length of 2 cm. Two suture-holders are applied to the edges of the wound wall (3). After that, the walls of the resulting wound are bred using two superimposed suture-holders (3a). Then, through the enterotomic wound, with the help of a clamp, the sutures-holders of the segment freed from the mesentery are captured and it is invaginated into the intestinal lumen to the distal edge of the enterotomic wound (2a). Then, using nodal sutures through all layers of the intestinal wall, the anti-mesenteric surface of the invaginated segment is sutured to the distal edge of the enterotomy wound. Thus, the areflux valve is formed, due to the fit of the freely hanging edge into the intestinal lumen. The operation ends with the formation of enterostomy according to the generally accepted technique. During feeding, the probe is easily inserted into the intestinal lumen to the desired depth, and is removed after feeding. The method proposed by the authors has advantages:

1. The proposed method is less traumatic;

2. The method does not require special equipment and additional equipment and various devices;

3. Simple enough in operational execution, therefore, can be used widely in practical health care;

4. The proposed method prevents leakage of intestinal contents, and therefore, minimally alters the water-electrolyte metabolism in the patient's body;

5. In the absence of the need for food through the enterostomy, the proposed method excludes reconstructive surgery, because with time, the enterostomy closes on its own.

According to the method specified by the authors, 23 people were operated on. Clinical example: case history No. 1951, patient P., 34 years old, was admitted to the clinic with a blunt abdominal injury. In the operation, a rupture of the descending part of the duodenum was diagnosed. A bowel rupture was closed, in order to ensure functional rest of the duodenum, it was decided to additionally apply a valve areflux enterostomy. The postoperative period without complications, early enteral nutrition was performed through superimposed valvular areflux enterostomy. At discharge - the patient is in satisfactory condition, able-bodied. After 27 days, self-closure of the enterostomy was noted.

Based on the foregoing, the proposed method due to the simplicity of its implementation and minimal costs can be widely used in practical health care.

Claims (1)

A method of forming a valve arereflux jejunostomy, including the intersection of the small intestine, characterized in that after traditional laparotomy at a distance of 10-15 cm from the Treytz ligament, a complete intersection of the small intestine is performed and the small intestine anastomosis is applied end to side along the Ru, forming a "free" area of the small intestine 30 cm long, without disturbing the blood supply to its wall, for 3 cm release the proximal portion of the “free” segment of the small intestine from the mesentery and place two lateral sutures on it and then, retreating 3-4 cm from the borders of the mesenteric portion of the “free” segment of the small intestine, make a longitudinal section of the skin of the jejunum 2 cm long on the mesenteric surface, put two suture-holders on the edges of the wound wall and spread the walls of the resulting wound, then with a clamp, the suture-holders of the segment freed from the mesentery are captured and its invagination is carried out into the intestinal lumen to the distal edge of the enterotomy wound, the anti-mesenteric surface of the invagina is flashed with interrupted sutures through all layers of the intestinal wall an area with the distal edge of the enterotomy wound, thus forming an areflux valve due to the fit of the edge freely hanging in the lumen of the intestine.