RU2371108C1 - Fundoplication technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, can be used in cardiospasm, diaphragm opening hernia and gastroesophageal reflux operations. Approach is performed. Lesser omentum is dissected. Gastric fundus, abdominal and inferothoracic oesophagus are partially mobilised. Posterior wall of gastric fundus is moved behind oesophagus. A fundoplication cuff is formed with its upper part fixed to cruses of diaphragm. The fundoplication cuff is additionally fixed to lateral walls of oesophagus with single-step through-out suturing of cruses of diaphragm. The cuff is formed so that oesophagus is uncovered between edges of the cuff at 2-3 cm above cardiac orifice on a circle 140°-160°. Thus lower part of the fundoplication cuff at level of cardiac orifice is fixed to anterior wall of oesophagus from both sides so that oesophagus is uncovered between edges of the cuff on a circle 30°-50°. Then left side of the cuff is extended and fixed to lesser curvature of stomach.

EFFECT: offered technique allows eliminating recurrent pathological gastroesophageal reflux, reducing time of hospital stay, and improving life quality.

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Description

The invention relates to medicine, namely to surgery, can be used in operations for achalasia of the cardia, hiatal hernia and gastroesophageal reflux disease.

A known method of Nissen fundoplication, including laparotomy or laparoscopic access. Dissect the upper half of the small omentum. Partially mobilize the bottom of the stomach, for which it is necessary to bandage 1-2 short gastric arteries passing in the gastro-splenic ligament. The esophagus is secreted from the surrounding tissue and taken to the holder. The bottom of the stomach, like a cuff circularly (360 °), envelops the esophagus. With several sutures that capture the esophagus, the walls of the stomach are fixed around the esophagus. The cuff is formed on a thick gastric tube (K.V. Puchkov, VB Filimonov. “Hernias of the esophageal opening of the diaphragm” Medpraktika-M, Moscow, 2003, pp. 70-71).

The disadvantage of this method is the often occurring dysphagia - up to 17% of patients, which is due to insufficient peristaltic function of the esophagus in combination with relative obstruction. There is a need for multiple bougienage of the esophagus to these patients, and sometimes even repeated surgical treatment. Pylorospasm occurs in 8% of patients; it is caused by compression of the vagus nerves enclosed in the fundoplication cuff.

The closest is the method of bilateral partial fundoplication according to Toupet, including laparotomic or laparoscopic access (K.V. Puchkov, VB Filimonov. "Hernias of the esophageal opening of the diaphragm" Medpraktika-M, Moscow, 2003, pp. 71-72) . The upper half of the small omentum is dissected, partial mobilization of the bottom of the stomach, abdominal and lower thoracic esophagus is performed, the fundoplication cuff is formed with its upper part fixed to the legs of the diaphragm. Why it is necessary to bandage 1-2 short gastric arteries passing in the gastro-splenic ligament, the esophagus is isolated from the surrounding tissues and taken to the holder. The esophagus is wrapped in a fold of the bottom of the stomach by 270 °, the posterior wall of the bottom of the stomach is moved behind the esophagus (180 ° behind and 90 ° in front).

The disadvantage of this method is a large percentage of recurrence of gastroesophageal reflux due to insufficiency of the valve function of the formed cuff, in addition, when performing an operation for achalasia of the esophagus, the mucosal area at the site of the myotome incision remains unclosed, which leads to complications.

The objective of the invention is the elimination of these disadvantages, the reduction of postoperative complications due to the restoration of the physiological function of the cardia. In addition, it is possible to perform surgery for patients with impaired peristaltic function of the esophagus.

To do this, in the method of fundoplication, including access, dissection of the lesser omentum, partial mobilization of the bottom of the stomach, abdominal and lower thoracic esophagus, the movement of the posterior wall of the bottom of the stomach behind the esophagus, the formation of a fundoplication cuff with fixation of its upper part to the legs of the diaphragm, the upper part of the fundoplication cuff is proposed fix to the side walls of the esophagus with simultaneous flashing of the legs of the diaphragm with the formation of a radius between the edges of the cuff 140 ° -160 °. The lower part of the fundoplication cuff at the level of the cardia is fixed to the anterior wall of the esophagus on both sides with a radius between the edges of the cuff of 30 ° -50 °, the left side of the cuff is lengthened and fixed with a small curvature of the stomach.

The fact that the upper part of the cuff is simultaneously fixed to the esophagus and diaphragm prevents cuff migration into the pleural cavity. In addition, fixing the cuff to the esophagus and stomach prevents the telescope from slipping and causing a symptom. Covering the mucous membrane of the esophagus with the wall of the stomach reduces the number of complications, allows you to start earlier nutrition of patients and their early rehabilitation. The formation of an oblique partial cuff helps to reduce the number of postoperative dysphagia and relapse of gastroesophageal reflux. Even with the occurrence of dysphagia, a single bougienage is sufficient.

The drawing shows the methodology of the proposed partial fundoplication. The implementation of the method shown in specific clinical examples.

Example 1

Patient L., born in 1957, (IB No. 413), was admitted to the hospital with complaints of dysphagia, lost 5 kg in the last three months. Sick for about 10 years. The patient has a history of three courses of cardiodilation with a temporary positive effect. An X-ray examination of the patient revealed achalasia of the cardia with megaesophagus. The operation was performed - under general anesthesia, the upper middle laparotomy is performed, and the abdominal cavity is revised. A small omentum was cut from the hepatoduodenal ligament to the cardia. The peritoneum is dissected along the right and left legs of the diaphragm and in the area of the diaphragmatic-esophageal transition. Separate the legs of the diaphragm from the esophagus. Along the right leg bypass the esophagus from the back and take it to the holder. A thick tube is inserted into the stomach. The esophagus is produced downward by the latch and the diaphragmatic and lower thoracic esophagus is mobilized. A myotomy is performed lateral to the left branch of the vagus nerve along the left anterolateral surface of the esophagus, for 6 cm on the esophagus and 2 cm on the stomach to the mucosa. The front wall is fixed with three interrupted sutures with a step of 1 cm to the left edge of the myotome incision. Then, the front wall of the stomach is fixed to the right wall of the myotome incision obliquely along the left branch of the vagus, without taking it into the suture. In this case, the front wall of the stomach closes the mucous membrane. Grab the back wall of the stomach and get behind the esophagus. The posterior wall of the stomach is fixed with three nodular serous sutures with a step of 1 cm vertically to the right side surface of the esophagus. The upper seam fixes the cuff to the right leg of the diaphragm. A cuff about 3 cm high is formed. Between the edges of the anterior and posterior semicircles of the fundoplication cuff, the esophagus wall remains uncovered at the level of the cardia at 30-50 ° of the circumference, at the level of 2-3 cm above the cardia, the esophagus remains uncovered at 160-140 °. The fundoplication cuff can be additionally fixed to the right diaphragm leg with two interrupted sutures. Thus, an oblique incomplete fundoplication cuff is formed with an increase in the degree of envelope of the esophagus and cardia in the distal direction. The abdominal cavity is drained with two drains. From the right hypochondrium to the subhepatic space, from the left hypochondrium under the left dome of the diaphragm. Layer-by-layer suturing of a laparotomy wound. The patient began to eat on the 1st day. On the 5th day he was discharged for outpatient treatment.

Example 2

Patient K., born in 1957, I. B. No. 12978, was admitted to the hospital with complaints of recurrent epigastric pain after eating, vomiting. Sick for about 6 months. When x-ray and endoscopic examinations of the patient revealed paraesophageal hernia. Performed laparoscopic posterior crurography with partial fundoplication according to the method described above. The patient began to eat on the 1st day. On the 5th he was discharged for outpatient treatment.

Example 3

Patient O., born in 1966, I.B. No. 6086, was admitted to the hospital with complaints of heartburn, belching, pain in the epigastrium and behind the sternum. A history of GERD, peptic stricture of the lower thoracic esophagus. I took proton pump blockers for a long time, without effect. During X-ray, endoscopic examinations and according to daily pH-meter data, the patient revealed gastroesophageal reflux disease, peptic stricture of the esophagus. At the first stage, esophageal bougienage was performed. Subsequently, laparoscopic partial fundoplication was performed according to the method described above. The patient began to eat on the 1st day. On the 5th he was discharged for outpatient treatment.

According to the proposed method, 23 patients were operated on. All patients underwent partial fundoplication according to the method described above. Dysphagia and pylorospasm were not observed. All patients began to eat on the first day, were discharged on the 5th day for outpatient treatment. They started to work after 14 days. Relapse of pathological gastroesophageal reflux in no patient was observed for 2 years. Postoperative dysphagia occurred in 1 patient and was stopped by a single bougieurage.

The proposed method allows to reduce the patient’s hospital stay, improves the quality of life.

Claims (1)

A method of fundoplication including access, dissection of the lesser omentum, partial mobilization of the fundus of the stomach, abdominal and lower thoracic esophagus, the movement of the posterior wall of the fundus of the stomach behind the esophagus, the formation of a fundoplication cuff with fixation of its upper part to the legs of the diaphragm, characterized in that the upper part of the fundoplication cuff fixed to the side walls of the esophagus with simultaneous flashing of the legs of the diaphragm, the cuff is formed so that between the edges of the cuff the esophagus remains covered at a level of 2-3 cm above the cardia at 140-160 ° of the circle, while the lower part of the fundoplication cuff at the level of the cardia is fixed to the anterior wall of the esophagus on both sides so that between the edges of the cuff the esophagus remains uncovered at 30-50 ° of the circumference, after which the left side of the cuff is lengthened and fixed with a small curvature of the stomach.

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