RU2330619C2 - Method of provided access to main pancreatic duct head - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: pancreas is separated from superior mesenteric, splenic and portal veins. Pancreas is crossed at isthmus height. Vein is medially shifted from pancreas head. Hamulus is uncovered. Hamulus is pulled upwards and laterally. Glandular parenchyma is dissected with duct wall by lower edge of pancreas head within avascular zone between anterior and posterior lower pancreaticoduodenal vessels.

EFFECT: method enables to maintain blood supply of pancreas head and to provide prevention of postoperative complications.

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Description

The present invention relates to medicine, namely to surgical gastroenterology, and can be used in the surgical treatment of chronic complicated pancreatitis.

One of the problems of modern pancreatology is the problem of surgical treatment of complicated forms of chronic pancreatitis (CP).

CP with a block of the main pancreatic duct (GLP) in the head of the pancreas (pancreas) (virsungolithiasis) and ductal hypertension is often complicated by severe pain, as well as externally and intracretory insufficiency.

This group of patients undergoes resection and drainage operations aimed at reducing pressure in the ducts and, accordingly, relieving pain.

During resecting operations (pancreatoduodenal resection, Beger, Frey), a pathologically altered pancreatic head is removed with the formation of an anastomosis between the pancreatic stump and jejunum.

In draining operations (operations of Puestov, Ligidakis, splitting pancreatojejunostomy [Marvin James, 1967.]) decompression is achieved by the application of pancreatoenteroanastomosis (PEA). Operations of this type are the most common and pathogenetically substantiated method of surgical treatment of CP and its complications, because are organ-preserving in nature (A.A. Shalimov et al. 2000).

In a patent information study, the applicants identified the only source of information disclosing a method of providing access to the main pancreatic duct in the surgical treatment of chronic calculous pancreatitis. The identified source of information (operation Ch. Puestow) was taken as the closest analogue (Danilov MV, Fedorov VD Pancreatic surgery. - M .: Medicine, 1995).

The main stages of the operation proposed by Ch. Puestow, the following. After the implementation of the median laparotomy produce wide access to the pancreas through the gland bag. A mesentery is transected longitudinally across the colon along the lower edge of the gland to the left of the upper mesenteric vessels. The incision is continued to the left, after which the gland is bluntly peeled off from the retroperitoneal fiber without damage to the vessels. Next, the entire pancreato-duodenal complex is mobilized, which greatly facilitates the imposition of longitudinal PEA, after which a puncture (GLP) is performed. Successful puncture is confirmed by intraoperative pancreaticography. Puncture of the duct, as well as the detection of cystic extensions, is greatly facilitated by the use of intraoperative ultrasound (ultrasound). After puncture and pancreatography, they begin to open the duct with a scalpel. When the duct is found and opened, it is taken on the holders, with which the entire thickness of the dissected gland is stitched. A grooved probe is introduced into the GLP and a further opening of the duct is performed on it, trying to make an incision in the middle of it, for more convenient suturing of the anastamosis. The length of the incision may vary and depends on the degree and extent of the lesion of the GLP, all branches and lacunae of the GLP are opened, it is also freed from stones, calc-necrotic masses. The wounds of the gland give a “trough-like” shape, excising the gland parenchyma hanging over the GLP.

The disadvantages of the method:

1. The dissection line of the parenchyma passes in the projection of the branches of the upper anterior pancreatoduodenal artery, which is accompanied by a high degree of risk of their intersection and impaired blood supply to the head.

Tasks:

1. To develop a method for dissecting the main pancreatic duct of the pancreatic head while maintaining blood supply.

2. To reduce the number of early postoperative complications, complications in the distant postoperative period with direct surgical interventions on the pancreatic duct system, such as fibrosis with the further development of stricture of the GLP, internal and external secretory insufficiency.

The essence of the proposal.

A method of providing access to the main pancreatic duct of the pancreatic head, including providing access to the ductal system, is characterized in that in order to maintain blood supply, a gland parenchyma is cut with a duct wall along the lower edge of the pancreatic head in the avascular zone between the anterior and posterior lower pancreatoduodenal vessels.

The method is illustrated by drawings and photographs, where: Fig. 1 and photo 1 - view of the pancreas after crossing it at the level of the isthmus, where p. 1 - duct of the pancreatic head, p. 2 - upper anterior pancreatoduodenal artery, p. 3 - lower edge pancreatic head, covered by the superior mesenteric vein, p. 4 - lower anterior pancreatoduodenal artery, p. 5 - portal vein, p. 6 - duct of the pancreas body; figure 2 and photo 2 is a view of the pancreatoduodenal complex after excretion of the lower edge of the pancreas from under the portal vein, where p. 7 is the lower edge of the gland (prospective dissection line); figure 3 and photo 3 - the beginning of the dissection of the duct and parenchyma of the pancreatic head along the lower edge, where p. 8 - dissected edges of the parenchyma of the lower edge of the pancreas; figure 4 and photo 4 is a view of the head of the pancreas after complete dissection of the duct and parenchyma along the lower edge, where item 9 is the lumen of the segmental ducts.

The method is as follows.

After mobilization of the pancreas, it intersects at the level of the isthmus. To do this, a section of the lower edge of the pancreas above the portal vein is twice stitched with nylon monofilament with a cross section of 0.2 mm with a distance between the sutures of 1 cm and a pitch of 0.5 cm for temporary hemostasis of the lower pancreatic vessels. Ligatures are clamped, bred in opposite directions and pulled, lifting and thereby separating the pancreas from the superior mesenteric vein (VBV). The pancreas tissue is crossed with a scalpel between the tightened ligatures, protecting the vein from being accidentally wounded by a tupfer. By further pulling up and breeding the created holders, the exposed area of the front surface of the VBV is exposed. Then, tunneling is continued with a small working tuffer between the posterior surface of the isthmus of the pancreas and the anterior surface of the superior mesenteric and portal veins along their axis. The freed sections of the pancreas are stitched portionwise in the manner described above, bred in different directions, pulled up with the help of holders and crossed. Thus, stepwise stupidly and sharply produce isolation from adhesions and adhesions of VVV. Next, the posterior surface of the pancreas is separated from the splenic and portal veins, also freeing the last of the cicatricial adhesions. Then the pancreas crosses the isthmus and is divided into two parts (head and tail). Moving the vein with a tupfer from the head medially, the hook-shaped process is exposed and it is pulled up and laterally. In the head, the GLP is revised using a button probe of the appropriate diameter. To maintain blood supply, a gland parenchyma is dissected with a duct wall along the lower edge of the pancreatic head in the avascular zone between the anterior and posterior lower pancreatoduodenal vessels. At the same time, thorough hemostasis is performed with punctured seams deep into the bleeding vessel (nylon monofilament 0.16-0.18 mm).

The method was tested on 15 patients; none of them showed inconsistency of the primary pancreatic suture.

Patient E., 42 years old, medical history No. 163, was admitted to the RCSCH clinic with complaints of epigastric pain, right mesogastric pain radiating to the lower back, and diarrhea up to 5-6 times a day. After a set of diagnostic measures (ultrasound, endoscopic ultrasound, retrograde pancreatocholangiography, computed tomography), the clinical diagnosis was established: "Chronic complicated pancreatitis, continuously recurring course with moderately severe exocrine insufficiency. Virsungolithiasis. Block of the main pancreatic duct. " After appropriate preoperative preparation, the patient underwent surgery in the amount of: "Medial resection of the pancreas with direct virsungolithotomy and the formation of bilateral terminal loop pancreatoenteroanastamosis."

In the head of the pancreas, the GLP was revised using a button probe of the appropriate diameter. To maintain blood supply, a gland parenchyma was dissected with a duct wall along the lower edge of the pancreatic head in the avascular zone between the anterior and posterior lower pancreatoduodenal vessels, thorough hemostasis was performed with precision chipping sutures with nylon monofilament 0.18-0.16 mm in diameter. In the middle third of the duct of the pancreatic head, a calculus with a diameter of 0.9-1.0 cm is determined, the calculus was extracted, the HPA was reconstructed, the probe freely penetrates the duodenum. To restore the integrity of the wall of the duct of the pancreatic head, a primary suture was placed “on the drainage” (two-row single nodal sutures passing through the entire thickness of the parenchyma (absorbable monofilament - PDS 5.0)). Before suturing the duct, a vinyl chloride tube with lateral holes of the corresponding diameter was laid in it to divert the juice from the anastomosis zone.

The postoperative period was uneventful. The patient was discharged on the 10th day. At the follow-up examination after 2 months, the patient does not complain, recovered by 3.5 kg. On the control ultrasound of the abdominal organs - signs of diffuse changes in the pancreas, the state after MRP with BA.

Technical result: due to the preservation of blood supply to the pancreatic head, precision overlay of the primary suture, the developed method of access to the main pancreatic duct of the pancreatic head reduces the number of early postoperative complications, as well as complications in the distant postoperative period, such as fibrosis with further development of stricture of the GLP, intra- and exocrine failure.

Claims (1)

A method of providing access to the main pancreatic duct of the pancreatic head, characterized in that the pancreas is separated from the superior mesenteric, splenic and portal veins, the pancreas is intersected at the level of the isthmus, medially moving the vein from the head of the gland, exposing the hook-shaped process and pulling it up and up after which the parenchyma of the gland with the duct wall is cut along the lower edge of the pancreatic head in the avascular zone between the anterior and posterior lower pancreatoduodenal E vessels.

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