RU2367361C1 - Enteroenteroanastomoses protection approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to surgery, to protection approaches to terminal-terminal enteroenterostomies and colic anastomoses. An omental vascularised graft leg with intraorgan-pulsed along the whole omental graft is dissected. It encircles a suturing line. The omental graft is fixed with seromuscular U-suturing to intestinal wall from both sides along great intramural vessels. Gastrocolic omentum is sutured to intestinal mesentery in nonvascular zone.

EFFECT: method provides anastomosis leakage.

2 ex, 2 dwg

Description

The invention relates to surgery, in particular to methods for the protection of terminal-terminal and colonic anastomoses.

There is a method of protecting terminological thin and colonic anastomoses (see V.A. Gorsky, B.K. Shurkalin, A.P. Faller, I.V. Leononenko, S. S. Medvedev, S. S. Andreev " The problem of reliability of the intestinal suture with peritonitis and intestinal obstruction ”, the journal“ Difficult Patient ”No. 4 - 2005, pp. 10-15), which consists in the protection of the anastomosis of the hollow organs from the failure of the sutures in an isolated area of the greater omentum.

The disadvantage of this method is that an isolated omentum not only does not prevent the occurrence of insufficiency of sutures, but can subsequently undergo complete degeneration and be replaced by coarse fibrous connective tissue, which is fraught with stenosis of the anastomosis.

There is also a known method of ileocoloplasty according to Dorton (Dorton) (see I.M. Matyashin, A.M.Gluzman "Handbook of surgical operations", Kiev, "Health", 1979, p.193), taken as a prototype when with ileocoloplasty the front surface of the anastomosis is sutured to the greater omentum, passing seams through the omentum and the wall of the colon.

The disadvantage of this method is that anastomotic suture inconsistency is possible due to the fact that: 1) the omentum does not cover the back wall of the anastomosis; 2) the blood supply to the omentum may not be sufficient for revascularization of the anastomosis; 3) the area of the greater omentum is hemmed without taking into account the intramural vessels, which can be punctured or ligated, which leads to local ischemia of the anastomosis zone and bleeding in the suture band; 4) with this technique, infringement of the intestinal loops is possible.

The objective of the claimed invention is to increase the efficiency and reliability of the healing of intestinal anastomoses.

The problem is solved due to the fact that in the method of protecting the intestinal anastomoses, including stitching the anastomoses to the greater omentum, the omental graft is cut out on the vascular pedicle with an intraorgan pulse throughout the omental graft, the suture band in the form of a ring is enveloped in the graft, the omental transplant is fixed serous-muscular sutures to the intestinal wall on both sides along the large intramural vessels and the greater omentum are sutured to the mesentery of the intestine in the avascular zone.

Using the claimed invention will improve blood supply to the suture band of the anastomosis and accelerate tissue regeneration by using a large omentum on the vascular pedicle with good hemodynamics, to prevent iatrogenic damage to intramural vessels and their ligation, as well as pinching of intestinal loops. In this case, the omentum is firmly fixed to the suture strip along the entire perimeter of the anastomosis. When using this method, there is no deformation of the anastomosis zone, stenosis of it, tightness and peritonization are ensured, which contributes to stable and rapid tissue regeneration.

The claimed method is illustrated by drawings, which depict: figure 1 - suture strip of the anastomosis in the form of a ring shrouded in an omental graft on a vascular pedicle; figure 2 - the omental graft is fixed with U-shaped serous-muscular sutures to the intestinal wall, a large omentum is hemmed to the mesentery of the intestine.

The claimed method is implemented as follows: after surgical intervention (suturing wounds of the small or large intestine, applying termo-terminal small and large intestinal anastomoses, etc.), sanitizing the abdominal cavity, they cut out a section of the omentum on the vascular pedicle with the best blood supply, measuring the intraorgan pulse (for example , according to Z. M. Sigal (see Segal Z. M. “The phenomenon of the mutual transformation of pulse and continuous blood flow in the intramural arteries.” Proceedings of the Academy of Sciences of the USSR, M., 1982, pp. 795-799)) at three points: at the base tra of the implant, in the middle and in the distal section, wrap the omentum in the suture band of the anastomosis in the form of a ring (Fig. 1) and fix it with U-shaped serous-muscular sutures to the intestinal wall along the intramural vessels on both sides of the omentum, without tightly pulling it to the wall of the operated area guts. In order to avoid infringement of the intestinal loops, a large omentum is hemmed to the mesentery of the intestine in the avascular zone (Fig. 2).

Example 1

Patient I. Diagnosis: penetrating stab wound of the abdominal wall with damage to the small intestine. Hemoperitoneum, peritonitis. Surgery - resection of the small intestine, terminological eunoejunoanastomosis, intraoperative hemodynamic control, peritonization of the suture with a portion of the omentum on the vascular pedicle, suturing of the omentum to the mesentery of the small intestine. Sanitation and drainage of the abdominal cavity.

An audit of the abdominal organs at a distance of 1.0 m from the Treytz ligament revealed a cut wound of the jejunum, crossing more than 2/3 of the diameter of the intestine. A resection of the damaged area with the application of a terminal-terminated eunoejunoanastomosis was performed.

During the operation, during hemodynamic examination, over the cut out section of the greater omentum on the vascular pedicle at its base, in the middle and in the distal section, the amplitude of pulse oscillations was revealed - 5.0 mm, respectively; 3.0 mm vs 2.5 mm. The stuffing graft was fixed with U-shaped serous-muscular sutures to the intestinal wall along the intramural vessels and nerves, covering the suture strip. A large omentum is hemmed to the mesentery of the small intestine.

During the control x-ray examination of the intestine before discharge from the hospital, violations of motor-evacuation functions and deformation of the small intestine in the patient were not detected. When examining the patient after one year, X-ray organic pathology was not detected.

Example 2

Patient D. Diagnosis: gunshot wound to the abdomen with damage to the small intestine, peritonitis. Operation - suturing wounds of the small intestine, intraoperative hemodynamic control, peritonization of the suture strip with a portion of the greater omentum on the vascular pedicle, suturing of the omentum to the mesentery of the small intestine. Sanitation and drainage of the abdominal cavity.

During the audit of the abdominal organs at a distance of 60-70 cm from the Treitz ligament, three jejunum wounds were found in the size of up to 2.0 cm × 1.5 cm. The intestinal wounds were sutured.

During the operation, during hemodynamic examination, over the cut out section of the greater omentum on the vascular pedicle at its base, in the middle and in the distal section, the amplitude of pulse oscillations is determined - 4.0 mm, respectively; 2.5 mm; 2.0 mm The gland graft was fixed with U-shaped serous-muscular sutures around the intestine in the form of a ring covering the sutured wounds. A large omentum is hemmed to the mesentery of the small intestine. The postoperative period was uneventful. The patient was transferred to enteral nutrition on the third day after surgery.

During the control X-ray examination of the intestine before discharge from the hospital, violations of motor-evacuation functions and deformation of the small intestine were not detected in the patient. After one year, an X-ray examination revealed no organic pathology.

Claims (1)

A method of protecting inter-intestinal anastomoses, including stitching anastomoses to the greater omentum, characterized in that the omental graft is cut out on the vascular pedicle with an intraorgan pulse throughout the omental graft, the suture band in the form of a ring is wrapped with the graft, the omental graft is fixed with U-shaped serous to the intestinal wall on both sides along the large intramural vessels and the omentum are sutured to the mesentery of the intestine in the avascular zone.

Images