RU2371107C1 - Surgery technique for oesophageal opening hernia in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, particularly paediatric surgery and can be used in treatment of oesophageal opening hernia in children. A cuff is formed around cardiac oesophagus. The cuff is formed of two folds one of which is made of gastric fundus. The fold 3/4 covers parts of oesophageal circle behind and on each side that is sutured to oesophagus. The second fold is formed of anterior wall of stomach, tightened to contact the first fold and fixed in the middle to oesophagus at level of cardiac oesophagus.

EFFECT: method allows improving functionality ensured by formation of the mobile separated cuff of two different sources that allows both for oesophagus, and stomach tissues extending with the years, and at accidental deglutition of big pieces of food.

1 ex, 2 dwg

Description

The invention relates to medicine, in particular to pediatric surgery, and can be used in the treatment of hiatal hernia in children.

There is a method of surgical treatment of insufficiency of cardiac pulp (reflux esophagitis) (Prince I. Littmann "Peritoneal surgery. Budapest, 1970, pp. 130-131).

This operation involves the creation of a circulatory cuff (360 °) around the cardiac esophagus, formed by a fold that is formed from the posterior wall of the stomach.

The operation is performed with laparotomy, but in recent years, thanks to the improvement of surgical technique, it has been done laparoscopically.

This operation has several disadvantages.

So, for example, according to the statistics of A.F. Chernousov’s cuff hyperfunction (compression) was observed from 2.5 to 4.5%, and “dislocation” of the cuff (slipping) leads to the formation of a diverticulum. All these complications are, to one degree or another, related to the violation of the ratios during the formation of the antireflux cuff (insufficient constriction or too tight suturing). This is especially difficult to predict with a growing body of children.

With this operation, it is necessary to correctly correlate the diameter of the esophagus of the child and the degree of narrowing during the formation of the cuff. These relationships change with age and it is important that the formed antireflux valve works at any age.

A known method of surgical treatment of a hernia of the esophageal opening of the diaphragm in children, including creating a cuff around the cardiac esophagus formed by two folds, one of which is formed from the posterior wall of the stomach (Yu.F. Isakov et al. Guidelines for thoracic surgery in children. M., Medicine, 1978, pp. 280-282).

In this method, the cuff is formed in the form of two folds obtained from the back of the esophagus. In this case, the lower fold covers the esophagus completely, and the upper (duplicate) - partially.

The disadvantage of this method is the lack of sufficient amount of stomach tissue in children to form a duplicate cuff.

In accordance with this, the task was set to increase the functionality of the method by creating a movable disjointed cuff from two different sources, which allows both the esophagus and stomach tissues to expand with age and by accidentally swallowing large pieces of food.

To solve this problem, in a method of surgical treatment of a hernia of the esophageal opening of the diaphragm in children, including the creation of a cuff around the cardiac esophagus of the cuff, consisting of two folds, one of which is formed from the posterior wall of the stomach, it is proposed to form a fold from the back wall of the stomach, which covers 3/4 part of the circumference of the esophagus, and form the second fold from the front wall of the stomach, pull it in contact with the first fold and fix it in the central part at the level of the cardiac section to the esophagus.

Figure 1 shows a diagram of the operation.

Figure 2 - photo of a hernia of the esophageal opening of the diaphragm.

The method is as follows.

Before surgery, a probe is inserted into the lumen of the esophagus, corresponding to the normal diameter of the esophagus at a given age.

The operation according to the proposed method is performed using the upper median laparotomy. The left lobe of the liver and the abdominal segment of the esophagus are mobilized. It should be remembered that the abdominal segment of the esophagus may be in the mediastinum.

Mobilization of the bottom of the stomach from the spleen is performed by ligation of small vessels of the ligament. The esophagus is freed from the transitional folds of the peritoneum. The legs of the diaphragm, which, as a rule, are dilated with a hiatal hernia, are sutured with two ligatures. After moving the esophagus into the abdominal cavity, further manipulations with the esophagus are carried out with its tension.

The bottom of the stomach is sutured to the mobilized part of the esophagus on the left with two or three ligatures. A fold is made from the bottom of the stomach, covering the cardiac section at the back and sides on 3/4 of the circumference, and to prevent the cuff from slipping off, it is hemmed with several ligatures to the esophagus. The sequence of this moment (hemming the bottom of the stomach and cuff with separate sutures) is an important point, especially with large hernias.

One hemming of the bottom of the stomach to the esophagus in some methods is considered as an independent operation capable of eliminating gastroesophageal reflux as a result of a decrease in the Giss angle (Rosetti, Lortat-Jacobi operations, etc.)

Then a fold is formed from the anterior wall of the stomach and is also separately fixed to the anterior wall of the esophagus, so that both formed folds are in contact with each other, but represent independent formations that are not able to cause compression or pinching of the esophagus during the operation or in the postoperative period, because they increase with the growth of the child, without losing their function.

The operation ends with suturing and leaving the probe in the esophagus for a day.

Similarly, the authors made several such operations with good results.

Example. Extract from source illness number 102, from 05.01.00. Child MA, 14 years old, was admitted to the DRL MONICA with complaints of heartburn, pain in the epigastric region, poor appetite. Sick during the year, was treated in the somat department for chronic gastritis, erosive bulbitis, reactive pancreatitis. A sliding hernia of the esophageal opening of the diaphragm was also diagnosed there.

The child grew and developed in accordance with age. The tongue is coated with white plaque. The abdomen is soft symmetrical, moderately swollen. On palpation, painful in the epigastric region. The liver and spleen are not palpable. No changes in the heart and lungs were detected. A / D 110/75. Pulse 68 in a minute. ECG - deviation of the electric. axis of the heart to the right (normal variant). Ultrasound: the pancreas is slightly increased to 19 mm. EGDS - the esophagus is not changed, a sliding hernia of the esophageal section of the diaphragm, gastritis, pylorus are atonic, erosive duodenitis.

X-ray examination: lungs unchanged. The esophagus passes, the wall is elastic, it is expanded on the trochoscope, yawns, folds of the mucous membrane of the abdominal stomach are determined above the diaphragm. The arch of the stomach is not changed, the folds of the mucosa are thickened. Dz - gastritis, a sliding hernia of the esophageal opening of the diaphragm, with a gaping and mobile cardia.

Blood: HB - 148; Er - 4.7; e - 6; n is 1; s - 45; l - 39; m - 9. ESR - 12. Bilirub. - 14.9 mmol; K - 4.0 mmol; Na - 136 mmol, sugar - 4.9, ALT - 20, ACT - 29. Urine unchanged.

After the treatment: diet, sea buckthorn oil, enzital, pain disappeared.

In connection with a hernia of the esophageal opening of the diaphragm that causes the pain syndrome, antireflux surgery is indicated. Before surgery, a probe was inserted into the stomach.

Under endotracheal anesthesia, an upper middle laparotomy was performed. The left lobe of the liver and the abdominal segment of the esophagus have been mobilized. At the same time, attention was drawn to the fact that the abdominal segment of the esophagus was partially located in the mediastinum. The bottom of the stomach is mobilized from the spleen by flashing the ligament. The legs of the diaphragm are sutured with two ligatures after moving the esophagus into the abdominal cavity. The bottom of the stomach is hemmed to the esophagus by three ligatures. A cuff is made from the fundus of the stomach, covering the cardial section at the back and sides by 3/4, and is sewn to the esophagus. A small fold of the anterior wall of the stomach is also sutured to the anterior wall of the esophagus, so that both formed lips touch each other (Fig. 1).

The operation is completed by suturing a wound in 4 floors. Aseptic dressing. The probe is left in the stomach for a day.

The child was observed after surgery. There were no complaints or signs of reflux esophagitis.

Using this method will increase the effectiveness of treatment by creating a movable, divided cuff, from two different sources, which allows both the esophagus and stomach tissues to expand with age and with the accidental ingestion of large pieces of food.

Claims (1)

A method for surgical treatment of a hernia of the esophageal opening of the diaphragm in children, including creating a cuff around the cardiac esophagus, characterized in that the cuff is made of two folds, while one fold is formed from the bottom of the stomach, covering 3/4 of the esophagus circumference behind and from the sides, and hemmed to the esophagus, and the second fold is formed from the anterior wall of the stomach, the second fold is pulled in contact with the first fold and in the central part is fixed to the esophagus at the level of the cardiac section of the esophagus.

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