RU2342082C1 - Method of share hepatic ducts plasty - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: intestinal tube generated from the isolated segment of the small bowel on a vascular pinch is used as autotransplant. The wall of intestine is resected on antimesenteric edge and its free edges are sutured. Thus a proximal anastomosis form between the transplant end and the share hepatic duct, and a distal anastomosis - between the opposite transplant end and confluence of share hepatic ducts.

EFFECT: restoration of bile outflow in duodenum, close to natural, beneficial influence on digestion process and its regulation.

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Description

The present invention relates to medicine, namely to surgery, and can be used for the surgical treatment of diseases and injuries of the lobar ducts of the liver.

In recent years, the number of cholecystectomies performed has significantly increased, which is associated, on the one hand, with an increase in the number of patients with cholelithiasis, and with the widespread introduction of minimally invasive gallbladder removal technologies into practice (B.I. Alperovich, 1997; K.Slater et al., 2002). The frequency of damage to the bile duct during traditional cholecystectomy over the past decades has remained relatively constant and averages 0.2% (A.A.Shalimov et al., 1993; M.Raute, 1993; IBBrune, 1994; B.I. Alperovich, 1997), and after LCE, according to the conclusion of most authors, it is slightly higher - 0.5-0.6% (DJDeziel et al., 1993; M.Ihasz et al., 1996; B.I. Alperovich, 1997; BV Jr. MacFadyen et al., 1998; K.Slater et al., 2002). In this regard, the number of patients in need of adequate restoration of the bile ducts is growing.

Most authors report that in a significant percentage of cases (from 20% to 60%), the upper level of duct damage is quite high, these are the so-called high or bifurcation strictures (Raczynska S. et al., 1997; Tretyakov A.A. et al., 1998; Walsh RM et al., 1998; Wudel LJ Jr., et al., 2001; Halperin, E.I. et al., 2003). Isolated lesions of the lobar ducts are less common than 5.3% -8.6% (Ooi L.L., et al., 1999, Halperin E.I. et al., 2003).

The problem of treating strictures and damage to the hepatic ducts is higher than hepaticus bifurcation, i.e. lobar hepatic ducts, it is extremely difficult even at the stage of separation of the ducts and preparing them for anastomosis (Strasberg S.M. et al., 2001; Halperin E.I. et al., 2003). Therefore, the choice of reconstructive design, as a rule, is decided in favor of the simplest option - hepatic enterostomy with the intestine turned off according to Ru.

The development of modern technologies for precision operations techniques and the use of special equipment allow developing and applying restorative interventions even in these difficult situations.

Thus, the development of new methods of plastic ducts of the hepatic ducts is an urgent task of modern surgery.

There is a method of surgical treatment of the hepatic ducts (proposed by A. A. Shlimov et al. "Surgery of the liver and bile ducts." - Kiev, 1975. - P.197-199; cited by E.I. Galperin, N.F. Kuzovlev , S.R.Karagyulyan "Cicatricial strictures of the bile ducts", Moscow, "Medicine", 1982, p. 156).

The bifurcation region is resected with stitching of the internal semicircles of the right and left hepatic ducts. Then, to the formed wide lumen of the newly formed hepatic duct, either the distal segment of the common bile duct or an isolated loop of the jejunum is sutured. If it turns out that one of the lobar ducts is much longer than the other during resection of the bifurcation, a short duct is sutured into the side of the long duct followed by the creation of an anastomosis between the long end of the hepatic duct and the distal segment of the hepatocholedochus (if possible) or the closed loop of the jejunum.

The method has the following disadvantages:

1. During the formation of hepatic enteroanastomosis, bile enters the intestine at a distance of more than 90 cm from the duodenum, where it normally enters a healthy person, and therefore the process of digestion of fats is disturbed, because in the duodenum does not occur the process of emulsification and preparation for digestion by pancreatic enzymes, all this leads to dyspeptic phenomena.

2. Direct connection of the end of one of the hepatic bile ducts to the side of the other is technically very rarely feasible, because often there is a significant extent of diastasis between the ducts.

As the closest analogue, a method for plasty of hepatic choledochus with a tubular small intestine transplant was adopted (patent of the Russian Federation No. 22949434 Onopriev V.I., Markov P.V. // Method for plastic surgery of hepatic choledochus with a small intestinal transplant).

The method is as follows.

A loop of the small intestine is selected at a distance of 40-60 cm from the ligament of Traits. Given the architectonics of the mesenteric vessels according to the estimated boundaries of the intersection of the intestine, dissect the peritoneal mesentery of the small intestine, bandage and cross the vessels of the arcades while maintaining the main blood supply. The intestines are crossed at the chosen boundaries so as to obtain an isolated section 8-10 cm long. The continuity of the small intestine is restored with a precision end-to-end anastomosis with a single-row serous-muscular-submucosal monofilament suture.

Strictly along the anti-mesenteric edge of the cut segment of the small intestine, a section of the intestinal wall is longitudinally excised, leaving flaps 0.5 cm wide from the edges of the mesentery. With severe bleeding from the vessels of the submucosal layer, they are ligated. The free edges of the intestinal wall are sutured together by single-row serous-muscular-submucosal nodal sutures with a monofilament thread. Thus, a thin (with an external diameter of up to 1 cm) tubule is formed from the intestine in the mesentery. A thin perforated drainage tube of such length is carried out through the autograft so that it protrudes 2-3 cm from the ends of the graft. Drainage is necessary in the immediate postoperative period for unhindered bile flow during the subsidence of the inflammatory reaction in the anastomotic zones and in the whole graft.

A window is made in the right part of the mesentery of the transverse colon in the avascular zone. Through it, a prepared transplant is transferred to the subhepatic space, which is placed isoperistaltically relative to the flow of bile from the portal of the liver along the hepatoduodenal ligament and further along the descending branch of the duodenum.

Between the end of the common hepatic duct and the end of the graft, a precision single-row anastomosis is applied with interrupted sutures of absorbable synthetic suture material 5 / 0-6 / 0. In this case, a sero-muscular-submucosal suture is performed on the intestine, at the end of the duct, without trapping the mucous membrane. Through the anastomosis, the end of the “hidden” drainage is advanced into the right or left lobar ducts.

Next, they begin to form an anastomosis with the duodenum. In this case, the graft is placed along the descending branch of the duodenum. Anastomosis is formed at the border of its middle and lower third. Previously, the mesentery of the graft in the avascular zones for the sheets of the peritoneum is fixed with several sutures to the wall of the duodenum. The hole in the wall of the duodenum is made as follows: the serous membrane is dissected over no more than 5 mm, and the mucous membrane is opened with a puncture, because the hole in the intestinal wall is easily extensible, which allows the formation of a reliable anastomosis, the lumen of which will subsequently be easily closed. A precision single-row anastomosis is formed with nodular sero-muscular-submucosal sutures with an absorbable monofilament synthetic suture material 6/0 nodes out. The end of the "hidden" drainage is passed into the lumen of the duodenum. Using 4-6 gray-serous sutures, the anastomotic suture line is immersed in the fold of the duodenal wall, thereby enhancing the areflux properties of the formed anastomosis. Sutures are placed in the intervascular spaces to exclude blood supply disturbances in the anastomosed walls.

Disadvantages: the method was used only for plastic surgery of the common hepatic-bile duct.

Objectives: to ensure unhindered passage of bile from the liver to the duodenum.

The essence of the proposed method lies in the fact that a proximal anastomosis is formed between the end of the graft (formed from an isolated segment of the small intestine on the vascular pedicle by resection of the intestinal wall along the mesenteric edge and stitching of its free edges) and the lobar duct, and the distal anastomosis between the opposite end of the graft and confluence of the shared ducts.

The method is as follows.

For clarity, the method is illustrated in figures 1-4, in which:

1 - portal vein;

2 - choledoch;

3 - healed stump of the right lobar hepatic duct;

4 - hepatic artery and its branches;

5 - small intestinal transplant;

6 - mesentery of the graft;

7 - anastomosis between the right lobar hepatic duct and small bowel transplant;

8 - anastomosis between the small intestine transplant and the confluence of the lobar ducts;

9 - the inferior vena cava;

10 - celiac trunk;

11 - the duodenum;

12 - superior mesenteric artery.

Using an ultrasonic scalpel (or apparatus similar to it), the liver parenchyma is resected in the area of its gate, highlighting the main tubular structures (portal vein of Figs. 1-1, the hepatic artery and their branches of Figs. 1-4, the common hepatic duct of Fig. 1 -2, conflux of the hepatic ducts and lobar ducts). The stricture region of the lobar hepatic duct (Figs. 1-3) and its proximal unchanged part (Fig. 1) are distinguished. Cicatricial walls of the lobar duct are resected and the ends are prepared for anastomosis.

After this, they begin to form a transplant from a segment of the small intestine. A loop of the small intestine is selected at a distance of 40-60 cm from the ligament of Traits. Given the architectonics of the vessels of the mesentery according to the estimated boundaries of the intersection of the intestine, dissect the peritoneal sheets of the mesentery of the small intestine (Fig.2-6), bandage and intersect the vessels of the arcades while maintaining the main blood supply. At the selected boundaries, the intestine is crossed so as to obtain an isolated area, the length of which will correspond to a defect in the lobar hepatic duct (4-6 cm) (Figs. 2-5). The continuity of the small intestine is restored with a precision end-to-end anastomosis with a single-row monofilament serous-muscular-submucosal suture.

Strictly along the anti-mesenteric edge of the cut segment of the small intestine, a section of the intestinal wall is longitudinally excised, leaving flaps 0.5 cm wide from the edges of the mesentery. With severe bleeding from the vessels of the submucosal layer, they are ligated. The free edges of the intestinal wall are sutured together by single-row serous-muscular-submucosal interrupted sutures with a monofilament thread. Thus form a thin (external diameter up to 1 cm) tubule from the intestine in the mesentery (Fig.3-5).

A window is made in the right part of the mesentery of the transverse colon in the avascular zone. Through it, a prepared transplant is moved to the subhepatic space.

A thin transhepatic drainage (diameter 3 mm) is installed through the end of the lobar duct of the liver.

Between the proximal end of the graft and the lobar duct of the liver, a precision single-row anastomosis is applied with interrupted sutures, absorbable synthetic suture material (PDS 6/0) (Figs. 4-7). In this case, a suture is performed on the intestine of serous-muscular-submucosal, at the end of the duct - without trapping the mucous membrane. After suturing the posterior wall of the anastomosis, transhepatic drainage is performed through the graft. The end of the drainage, which will be located in the distal part of the hepatic duct and in the graft throughout this area, is perforated with many small holes. Drainage is necessary in the near postoperative period for an unobstructed flow of bile during the subsidence of the inflammatory reaction in the areas of anastomoses and in general in the graft.

After applying the proximal anastomosis, they begin to form an anastomosis with confluence of the lobar ducts. A precision single-row anastomosis is formed by nodular serous-muscular-submucosal sutures, absorbable by a monofilament synthetic suture material (PDS 6/0) with nodes outward (Figs. 4-8). In this case, the end of the transhepatic drainage is passed into the lumen of the common hepatic duct.

Thoroughly cover the graft, subhepatic space with cut strands of the greater omentum, which are fixed. The subhepatic space is drained by double-lumen drainage.

Examples.

Patient B., 68 years old. Admitted with iatrogenic damage to the right lobar hepatic duct during cholecystectomy

07/03/05 g the patient was operated on. Under general anesthesia with mechanical ventilation, an expanded upper middle laparotomy was performed with excision of the old postoperative scar and hardware correction of access by the Seagal retractor. In the area of the portal of the liver, more on the right, a pronounced scar-sclerotic process. There is a small old bile duct under the hepatoduodenal ligament in the area of the liver gate. The peritoneum of the hepatoduodenal ligament was dissected and its elements were distinguished. Using an ultrasonic scalpel, the parenchyma was resected in the area of the liver gate with exposure of the main tubular structures. An isolated damage to the intrahepatic part of the right lobar duct was found. The duct is stitched and doped with a nylon ligature 3 cm proximal to the bifurcation (Fig. 1). Proximal and distal to the site of damage there is a pronounced cicatricial-sclerotic transformation of the duct. The anterior wall of the right lobar portal vein is picked up in the suture; there is its stenosis. The left lobar duct, the left bifurcation wall, hepatic choledochus are intact. A resection of the intrahepatic part of the right lobar hepatic duct was performed up to bifurcation of the lobar ducts, while the mouth of the bile duct was resected to 1 segment of the liver. An edge resection of the anterior wall of the right branch of the portal branch with its autoplasty was performed.

It was decided to perform plastic surgery of the right lobar hepatic duct with a tubular graft from a segment of the small intestine. At a distance of 40 cm from the ligament of Traits, a loop of the small intestine was selected. A plot up to 5 cm long is isolated on the vascular pedicle. The intestinal wall was dissected along the mesenteric edge of the cut graft and a tube 10 mm in diameter was formed from it. The continuity of the small intestine restored anastomosis end to end. The graft was moved through a window on the right side of the mesocolon into the subhepatic space and placed isoperestally with respect to the bile flow.

A thin transhepatic drainage is installed through the right lobar duct. Between the proximal end of the graft and the right lobar hepatic duct, a precision single-row anastomosis is formed by interrupted sutures, absorbable by the PDS 6/0 monofilament suture. The perforated end of the transhepatic drainage is guided through the graft.

An anastomosis is then formed between the distal end of the graft and the confluence of the lobar ducts. Before suturing the anterior wall of the anastomosis, the end of the transhepatic drainage was carried out in hepaticoholedoch. The mesentery of the graft is placed along the hepatoduodenal ligament, where in the avascular zones for the peritoneum sheets are fixed with several sutures to it. Separate locks of the greater omentum carefully identify the transplant, the area of the portal of the liver, and the entire subhepatic space. Installed drainage in the pelvis and subhepatic space. The abdominal wall is sutured in layers tightly. Stitches for subcutaneous tissue and skin.

The postoperative period was uneventful. Biliary drainage by transhepatic drainage by 12 days decreased from 400 to 100 ml per day. The patient was discharged. During the follow-up examination after 1 month, he feels good. When performing control fistulography, the gall tree of the right lobe of the liver is contrasted and the contrast freely penetrates through the graft into the hepaticoholedoch and further into the duodenum. There is a clear peristalsis of the graft. Transhepatic drainage removed.

When examined after 6, 12 and 18 months, the patient has no complaints. Biochemical markers of cholestasis are within normal limits. Clinical and U3-signs of cholangitis are absent.

The technical result. Using the method allows to restore the outflow of bile into the duodenum along a path that repeats the natural one, which has a beneficial effect on the digestion and its regulation. Thus, the application of the method leads to a reliable recovery of patients, returning them to a full life.

Claims (1)

The method of plasty of the hepatic ducts of the liver, including the use of an intestinal tube as an autograft formed from an isolated segment of the small intestine on the vascular pedicle by resecting the intestinal wall along the mesenteric edge and stitching its free edges, characterized in that the proximal anastomosis is formed between the end of the graft and the hepatic duct and distal anastomosis - between the opposite end of the graft and the confluence of the lobar ducts of the liver.

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