RU2341205C2 - Method of formation of esophageal-intestinal anastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: impose four "П"-shaped serous-muscular sutures on the abducent loop of a small bowel. Each suture includes two penetrations on a small bowel following one after another with an interval of 0.5 cm in a cross-section direction. Further having receded from edge of an esophagus on 3 cm, stitch the posterior wall of an esophagus in a cross-section direction and the same ligature stitch a small bowel in the opposite direction, in parallel this ligature is similar to earlier imposed sutures on its wall. The second row of is serous-muscular sutures of a anterior labium of an anastomosis is made "П"-shaped serous-muscular and performed as follows. Make puncture on a resulting loop of a small bowel with capture serously-muscular layer. Further using a serous-muscular suture; grasp an esophagus wall in a cross-section direction above on 0.5 cm of a forward row of an esophageal-intestinal anastomosis. Similarly stitch lower on 0.5 cm a wall of a small bowel and further the wall of a resulting loop below the first puncture on 1.0-1.5 cm. Fasten the suture bridging together homogeneous tissues of a small bowel and strengthening an anastomosis wall. Similarly impose 4-5 seams in total, thereby threading the resulting intestine on an anastomosis, covering an anterior wall of an esophagus and strengthening an anterior labium of an anastomosis.

EFFECT: simplifies technics of an anastomosis and raises reliability of an anastomosis.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of stomach cancer.

To date, the most severe and frequent complication after gastrectomy remains the failure of the sutures of the esophageal-intestinal anastomosis, leading to death in 50-79% of cases.

In order to improve the healing conditions of the anastomosis, many methods have been proposed for performing the esophageal-intestinal anastomosis, aimed at creating optimal conditions for its healing and preventing suture failure.

A known method of forming an esophageal-intestinal anastomosis, including the formation of a double-row / posterior and anterior / expansion suture, holding a thick probe under the control of the fingers, followed by tightening the back, then the front rows of expansion sutures (Surgery, 1988. - No. 4. - P. 69- 71. “Formation of the esophageal-gastric / intestinal / anastomosis using the expanding suture of N. N. Blokhin).

The disadvantage of this method is the difficulty in execution, the uneven immersion of the esophagus in the intestine, which leads to the failure of its sutures.

The closest to the achieved result / prototype / is a method of forming an esophageal-intestinal anastomosis, including the creation of a vertical esophageojejunanastomosis, lateral to the side using a lead loop for covering the joints of the anastomosis (Hilarowitz, 1931), (A.A.Shalimov, S.N. Redkin : “ATLAS of abdominal surgery,” Zdorovya Publishing House, Kiev. 1965 P.125-128).

The disadvantage of this method is the difficulty in execution, many seams, the connection of heterogeneous fabrics.

The technical result of the claimed method is the following: simplification of the method, increasing the reliability of the anastomosis by eliminating the inconsistency of the joints (stitching of homogeneous tissues), creating an antireflux mechanism, and eliminating dumping syndrome.

The technical result is achieved by the fact that:

a) four U-shaped serous-muscular sutures are placed on the outlet loop of the small intestine (each suture includes two injections on the small intestine, following each other at intervals of 0.5 cm, in the transverse direction, then departing from the edge of the esophagus 3 cm, the back wall of the esophagus is stitched in the transverse direction and the same ligature is stitched in the opposite direction, parallel to this thread, the small intestine, similar to the previously applied sutures on its wall), thereby strengthening the back wall of the anastomosis.

b) the second row of serous-muscle sutures of the anterior lip of the anastomosis is performed as follows. U-shaped serous-muscular suture is performed as follows: an injection on the adducting loop of the small intestine, with the capture of the serous-muscular layer, then the sero-muscular suture capture the esophagus wall in the transverse direction higher by 0.5 cm of the anterior row of the esophageal-intestinal anastomosis, similarly the wall of the small intestine is flashed lower by 0.5 cm and then the wall of the adductor loop is 1.0-1.5 cm lower than the first injection - the suture is tied, connecting homogeneous small intestine tissues together and strengthening the anastomosis wall. Similarly, a total of 4-5 sutures are imposed, thereby twisting the leading intestine onto the anastomosis, covering the anterior wall of the esophagus and strengthening the anastomotic anterior lip.

The method is as follows.

The method is illustrated by drawings. Under endotracheal anesthesia, the patient is placed on the operating table, a roller is placed under the back at the level of the xiphoid process. The surgical field is treated according to Grossikh, an upper middle laparotomy is performed, with a belly button around the left and down by 30-40 mm. The wound is expanded with the help of Seagal expanders, the stomach with a large and small omentum is mobilized, the duodenum is flashed with a UO-40 device with the intersection and ligation of the vessels of the stomach and omentums, and cut off from the stomach. The stump is immersed in two half-kits and Z-shaped seams. A Satinsky clamp is applied to the esophagus, the stomach is cut off from the esophagus and removed.

To form an esophageal-intestinal anastomosis in front of the colon, a long loop of jejunum is fed to the esophagus (40-50 cm from the Tracheal ligament). Four serous-muscular sutures are placed on the outlet loop of the small intestine (each suture includes two injections on the small intestine, following each other with an interval of 0.5 cm, with these sutures the back wall of the esophagus is sutured in the transverse direction, departing from the distal edge 3 cm, and the same ligature is stitched in the opposite direction, parallel to this thread, the small intestine, similar to the previously applied sutures on its wall), thereby strengthening the back wall of the anastomosis (Fig. 1). The esophagus is placed in front of the discharge loop of the intestine and at this level the lumen of the small intestine is opened and the second row is laid through all layers - only 4 sutures. Next, similarly impose the front row of the esophageal-intestinal anastomosis. The second row of serous-muscular sutures of the anterior lip of the anastomosis is performed as follows. U-shaped serous-muscular suture is performed as follows: an injection on the adducting loop of the small intestine, then the wall of the esophagus is captured by the sero-muscular suture 0.5 cm higher than the anterior row of the esophageal-intestinal anastomosis in the transverse direction, similarly, 0.5 cm lower is stitched the wall of the small intestine and then the wall of the lead loop below the first injection by 1.0-1.5 cm - the suture is tied, connecting together homogeneous tissues (walls of the small intestine for better healing) and strengthening the front wall of the anastomosis (figure 2). Similarly, a total of 4-5 sutures are superimposed, thereby twisting the intestine leading to the anastomosis, covering the esophagus and strengthening the anastomotic anterior lip (Fig. 3).

Clinical example:

Patient K., 35 years old, was admitted with complaints of poor appetite, weight loss of up to 8 kg. With fibroesophagoscopy "the esophagus is freely passable, in the body of the stomach the mucous membrane is infiltrated, tuberous, dense. Histological diagnosis: cricoid cancer.

On March 15, 2001, an operation was performed from the laparotomy access with a bypass of the navel left and down. During the audit: the tumor affects the body of the stomach, dense, bumpy. Enlarged regional lymph nodes.

An extended gastrectomy with lymphatic dissection of D-2 was performed, esophagoejunoanastomosis was formed according to the proposed method.

Discharged from the hospital on the 14th day after the operation in satisfactory condition.

Last examination: March 2005. There are no complaints of dysphagia, burning behind the sternum, pain during eating.

With FEGS: the mucous membrane of the esophagus is pink throughout, there are no signs of inflammation, the esophageal-intestinal anastomosis is well passed.

When fluoroscopy: barium suspension passes freely and portionwise enters the discharge intestine, the latter without features. In the Tendelenburg position, there is no leakage of contrast mass into the esophagus.

The claimed method is simple to implement. Provides increased reliability of the anastomosis, by strengthening the posterior wall of the anastomosis - four U-shaped serous-muscular sutures are placed on the outlet loop of the small intestine (each suture includes two injections on the small intestine, following each other with an interval of 0.5 cm, in the transverse direction, then, departing from the edge of the esophagus 3 cm, stitch the posterior wall of the esophagus in the transverse direction and with the same ligature stitch the small intestine in the opposite direction parallel to this thread, similar to the previously applied sutures on its wall), as well as eplyaya second row of the front flaps. A U-shaped serous-muscular suture is performed as follows: an injection on the adducting loop of the small intestine, then the esophagus wall is grasped in the transverse direction by a sero-muscular suture 0.5 cm higher than the anterior row of the esophageal-intestinal anastomosis, similarly, 0.5 cm lower is sutured the wall of the small intestine and then the wall of the lead loop below the first injection by 1.0-1.5 cm, the suture is tied, connecting together homogeneous tissue of the small intestine and strengthening the front wall of the anastomosis. Similarly, a total of 4-5 sutures are imposed, thereby twisting the intestine leading to the anastomosis, connecting homogeneous tissues of the small intestine. This anastomosis will find wide application in the provision of surgical benefits for gastric cancer.

Claims (1)

A method of forming an esophageal-intestinal anastomosis, including the creation of an end-to-side azofageoyunoanastomosis using a lead loop, characterized in that four U-shaped serous-muscular sutures are applied to the discharge loop of the small intestine, each suture includes two injections on the small intestine, following each other after another, with an interval of 0.5 cm in the transverse direction, then, departing from the edge of the esophagus 3 cm, the back wall of the esophagus is stitched in the transverse direction and the small intestine is stitched in the opposite direction with the same ligature, parallel but previously held ligature through its wall, the second row on the posterior wall of the anastomosis is performed by applying 4 nodal sutures through all layers of the esophagus and intestine wall, the first row of the anastomosis anterior wall is performed similarly to the second row of the posterior wall, the second row of serous-muscular sutures of the anastomosis anterior lip is U-shaped serous-muscular suture, which is performed by injecting a needle on the adducting loop of the small intestine with the capture of the serous-muscular layer, then the seropuscular suture capture the wall of the esophagus in the transverse direction SRI 0.5 cm above the front row of the esophageal-intestinal anastomosis, similarly sewn below 0.5 cm gut wall outlet further wall afferent loop below the first puncture at 1.0-1.5 cm; the suture is tied, connecting together homogeneous tissue of the small intestine, and 4-5 sutures are similarly applied, thereby twisting the intestine leading to the anastomosis, connecting homogeneous tissue of the small intestine.

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