RU2365345C1 - Method of applying cholecystic enterostomosis - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: anastomosis applying is carried out between a gall bladder and a small bowel. Thus an anastomosis is carried out with a body of the gallbladder closer to its neck. A site of a gall bladder wall with an indicator of average arterial pressure in blood vessels of a gall bladder wall APav not less than 28 mm of a mercurial column is chosen for anastomosis applying.

EFFECT: prevention of a cholecystic enteroanastomosis incompetence at the expense of maintenance of optimum haemocirculation in an anastomosis place.

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Description

The invention relates to medicine, namely to surgery, and can be used when performing various surgical interventions, including the imposition of cholecystoyunoanastomosis.

A known method of applying cholecystoyunoanastomosis by anastomosing the jejunum with the bottom of the gallbladder [1]. However, this method has the following disadvantage: imposition of anastomosis between the gallbladder and jejunum is carried out without taking into account the fact that hemocirculatory disorders can occur in some areas of the gallbladder wall that are supposed to be applied to the anastomosis. Hemocirculatory disorders in the wall of the gallbladder can develop as a result of a violation of blood flow along one of the branches (anterior or posterior) of the cystic artery up to its complete absence in one of these vessels. Such hemodynamic disturbances in the gallbladder wall can also occur as a result of intraoperative damage to the anterior branch of the cystic artery due to technical difficulties during the operation to form cholecystojunoanastomosis, as well as the development of thrombosis or thromboembolism of one of the branches of the gallbladder before or after surgery. Anastomosis of the jejunum with a section of the gallbladder wall, the hemodynamics of which are inferior to ensure reliable tissue fusion, can lead to failure of cholecystojunoanastomosis.

The objective of the invention is the creation of a complete cholecystoyunoanastomosis, as well as the prevention of its insolvency in the postoperative period.

The technical result is the provision of optimal hemocirculation at the site of cholecystoyunoanastomosis.

To do this, when applying cholecystoyunoanastomosis, a section of the gallbladder wall is preliminarily selected for anastomosis with the jejunum in the body of the gallbladder closer to its neck with an average blood pressure of at least 28 mm Hg. In this case, the average blood pressure (BP _cf ) is determined by the formula:

HELL _cf = (HELL _s + 2AD _d ) / 3,

where blood pressure _s is systolic blood pressure;

AD _d - diastolic blood pressure.

As a result of experimental studies (in dogs), it was found that blood pressure in the blood vessels of the gallbladder wall decreases from the neck to the bottom [2]. It was also experimentally established that when an anastomosis is applied between the jejunum and the wall of the gallbladder with an average arterial blood pressure lower than 28 mm Hg. hemocirculatory disorders occur, leading subsequently to cholecystoeunoanastomosis failure. Based on the foregoing, it is preferable to choose a wall section with such blood pressure precisely closer to the neck of the gallbladder, because in case of thrombosis or thromboembolism of one of the branches of the gallbladder artery in the postoperative period, the mean arterial pressure of the vessels of the gallbladder wall in the area located in the bottom can drop below 28 mm Hg, and this hemodynamic state will be inferior to ensure reliable tissue fusion .

To measure systolic and diastolic blood pressure of blood vessels in the gallbladder wall, an apparatus was used to measure blood pressure in the vessels of hollow organs according to A.S. 1287840, USSR [3]. The camera chamber was placed in the cavity of the gallbladder through an incision in the bottom of the gallbladder with a size of 0.8-1.0 cm, which was sutured after selecting a section of the wall of the gallbladder for anastomosis.

Performing cholecystoeunoanastomosis closer to the neck of the gallbladder, taking into account the mean arterial pressure in the wall of the gallbladder, avoids the development of cholecystoeunoanastomosis insolvency. This choice allows you to take into account existing hemocirculatory disorders in this area of the gallbladder wall or the likelihood of their development in the postoperative period.

Example 1

Patient A., 59 years old. Received March 24, 06 in the surgical department with complaints of pain in the epigastrium, nausea, vomiting, skin itching, weakness. He considers himself sick for one month, when there were pains in the epigastrium, later nausea and vomiting joined. Yellowness of the skin appeared 10 days ago. Upon admission, the patient is in serious condition. The patient is lethargic, inhibited, inactive. The skin is icteric. The vesicular breathing, no wheezing. Pulse 98 per minute, blood pressure 100/60 mm Hg The tongue is dry, covered with a whitish coating. The abdomen is not swollen, participates in the act of breathing. On palpation, painful in epigastrium. There are no symptoms of peritoneal irritation. Blood test: Hb 106 g / l, er. 3.2 × 10 ¹² / l, c.p. 0.99, l 11.2 × 10 ⁹ / l, p. 30%, s. 52%, lymph. 12%, mon 6%; ESR 36 mm / h. Urinalysis: density 1018 g / l, protein 0.033 g / l, white blood cells 12-13 in the field of view, epithelial cells 1-2 in the field of view. The total bilirubin is 310 μmol / L, the associated bilirubin is 212 μmol / L. According to ultrasound: the gall bladder is stretched, enlarged to 120 × 80 mm, the wall is not changed. Intrahepatic ducts expanded to 6-7 mm. The common bile duct is expanded to 20 mm, there are no calculi. The pancreas is enlarged, compacted, does not contain focal formations, the contours are clear. Dimensions: 56 × 23 × 39 mm. Pancreatic duct is not expanded. Echogenicity of the parenchyma is increased. Diagnosed with Pseudotumor pancreatitis. Obstructive jaundice. After preoperative preparation, March 29, 2006, the following operation was performed: Laparatomy, application of a cholecystoyunoanastomosis with a plug according to Shalimov in the neck of the gallbladder. At the diagnostic stage of the operation, a biopsy was taken in the area of the pancreatic head. The result of rapid histology: pseudotumor pancreatitis. During the operation, the mean arterial pressure of the portion of the gallbladder wall located closer to the neck of the gallbladder selected for anastomosis was calculated using the parameters obtained using an apparatus for measuring blood pressure in the vessels of hollow organs according to A.S. 1287840 of the USSR, and amounted to 77 mm Hg (blood pressure index _s - 105 mmHg. blood pressure _d - 63 mmHg). There were no complications in the postoperative period. The surgical wound healed by first intention. Blood test at discharge (10 days after surgery): Hb 108 g / l; er. 3.7 × 10 ¹² / l; col. pok. 0.88; l 5.6 × 10 ⁹ / L; p. 4%; p. 59%; lymph 27% mon 10%; ESR 27 mm / h. Bilirubin at discharge 24 μmol / L. Examined after 2 months. There are no complaints.

This method is simple, affordable, does not require expensive equipment, and it can be used in any departments of surgery, both specialized and general.

Information sources

1. Shalimov A.A., Domansky B.V., Klimenko G.A., Shalimov S.A. Surgery of the liver and bile ducts. Kiev: HEALTH, 1975, 408 p.

2. Anesthesiology and intensive care / Edited by Gelfand BR / M. Litera, 2006. - 576 p.

3. Fedorov N.F., Nikolaev G.G. Apparatus for measuring blood pressure in the vessels of hollow organs: A.s. 1287840 USSR // Open inventions. - 1987. - No. 5. - S.17-18.

Claims (1)

The method of applying cholecysteunoanastomosis, characterized in that the imposition of anastomosis between the gallbladder and small intestine is performed in the body of the gallbladder closer to its neck, while for applying the anastomosis, select a section of the wall of the gallbladder with an blood pressure index in the blood vessels of the gallbladder wall of at least 28 mmHg.