RU2415650C1 - Method of dissecting large and gigantic ulcers of lesser curvature of stomach in patients with high degree of operational risk and device for its realisation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, namely to surgery and can be used for treatment of large and gigantic ulcers with localisation on lesser curvature of stomach in patients with high degree of operational risk. For this purpose section of lesser curvature with complicated ulcer is dissected by means of clamp, consisting of jaws of rigid fixation, to whose distal part parallel to rigid jaws, fixed is pair of elastic jaws, with elastic jaws being directed toward stomach. After that sewing of wound by closed method by application of uninterrupted double-layer suture is performed. After mobilisation of section of lesser curvature beyond ulcer infiltration, reduction of dimensions of ablated fragment by application of purse-string suture on its base, rotation of clamp with dissected fragment at 45° for bringing onto anterior stomach wall and ensuring convenience during suture application.

EFFECT: group of inventions makes it possible to simplify the technique, provide possibility of sewing wound by closed method, ensure mechanical strength of suture, reduce consumption of suture material, improve quality of wound healing, reduce number of complications of inflammatory type.

2 cl, 10 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of gastric ulcer complicated by perforation or bleeding.

Known methods for surgical treatment of large and giant ulcers of lesser curvature of the stomach by resection of the stomach according to the method of Billroth-1, Billroth-2 or tubular resection, the volume of which depends on the location of the ulcer (G.E. Ostroverkhov, Yu.M. Bomash, D.N. Lubotsky, Operative Surgery and Tonographic Anatomy. - Kursk: AP Kursk; Moscow: ZT Litera JSC, 1995-720 pp.), But in patients with a high degree of operational and anesthetic risk these operations are accompanied by high mortality. An alternative method of surgical treatment, which is a method of minimally invasive intervention, is the excision of ulcers (A.I. Chernousov, P.M. Bogonolsky, F.S. Kurbanov. Surgery of peptic ulcer of the stomach and duodenum: A guide for doctors. M: Medicine, 1996 , 256 p.). The technique of open and closed excision and suturing of ulcers was developed for the anterior and posterior walls of the stomach, but it was not used on small curvature of the stomach, especially with ulcers of high localization.

The prototype of the invention is a method for the surgical treatment of gastric ulcers (Yu.P. Novominets et al. 2004 Patent No. 2261666 for the invention “Method for the surgical treatment of complicated gastric ulcers”), but this method does not allow excision of a fragment of the gastric wall more than 4 cm in diameter due to the limited length of the working jaws of the instrument, ulcers of lesser curvature of the stomach were not excised due to their difficult accessibility.

The objective of the invention is a method for the surgical treatment of large and giant ulcers of lesser curvature of the stomach in patients with a high degree of operational risk.

The task is achieved in that after mobilization of the lesser curvature of the stomach in volume, taking into account the existing inflammatory infiltrate and the need for subsequent suturing of the stomach, the ulcer is stitched with a ligature-holder, a purse string suture is made and tied around the wall of the stomach around the ulcer infiltrate, thus reducing the diameter of the base of the excised fragment, imposing in the transverse direction to the lesser curvature of the stomach, the clamp of combined action, the fragment of lesser curvature to be removed is rotated with the clamp 45 ° so that it is brought out of the window in the small omentum to the front wall of the stomach, under the lips of elastic fixation of the clamp, the stomach wall is stitched with a continuous trapezoidal suture with atraumatic synthetic absorbable suture material, a scalpel between the lips of the rigid and elastic fixation of the clamp cross the gastric fragment to be removed from the ulcer . A stomach wall stitched with a trapezoidal suture slides out of the elastic lips of the clamp and the clamp with the excised fragment of the stomach is removed. Continue to impose a small curvature in the excision zone from the back to the front wall of the twisted stitch seam to the depth to the trapezoidal seam with the tightening of each subsequent stitch, achieving final hemostasis. The end of the upholstery and the beginning of the trapezoidal seam are connected. The wall of the stomach, sutured with a two-story continuous suture, is peritonized with nodular serous-muscular sutures.

THE INVENTION IS EXPLAINED BY FIGURES (FIGS. 1-7)

Figure 1 shows the volume of mobilization of the plot of lesser curvature of the stomach, taking into account the projection of ulcerative infiltrate.

Figure 2 shows a stomach ulcer stitched with a ligature. Around the ulcerative infiltrate, the wall of the stomach is stitched with a purse string suture.

Figure 3 shows a fragment of the lesser curvature of the stomach after tightening and tying a purse string suture. The base of the removed fragment took the form of a leg.

Figure 4 shows the superimposition of a combined action clamp on the base of a small curvature fragment, the removal of a fragment from a window in a small omentum to the front wall of the stomach, together with the clamp by rotation of 45 °.

Figure 5 shows the step of flashing a trapezoidal seam under the lips of the elastic fascia of a fragment of small curvature to be removed, and its intersection with a scalpel.

Figure 6 presents the second stage of applying a two-story suture in the form of a twisting from the back to the front surface of the stomach with subsequent binding of the beginning and end of the ligature.

Figure 7 shows the peritonization of a continuous stitching seam with nodular sero-muscular sutures.

The method is carried out as follows.

After laparotomy, intraoperative cytobiopsy, a portion of the lesser curvature of the stomach is mobilized 2 cm proximal and distal to the ulcerative infiltrate (Fig. 1). The wall of the stomach with an ulcer is stitched with a ligature-holder. Around the ulcerative infiltrate, the lesser curvature of the stomach is stitched with a purse string suture (figure 2). The seam is tightened and knotted, reducing the diameter of the base of the removed fragment (figure 3). In the transverse direction to the lesser curvature of the stomach, a combined clamp is applied to the base of the fragment with an elastic fixation jaw towards the stomach. The clamp with a fragment of small curvature rotate 45 ° and out of the window in a small omentum on the front wall of the stomach (figure 4).

Under the elastic fixation lips, the base of the fragment is stitched from the front surface to the back with a continuous trapezoidal seam, the ends of the ligature are fixed in the stretched position. Between the jaws of rigid and elastic fixation of the clamp, the walls of the fragment of small curvature cross with a scalpel (Fig. 5) and remove it together with the clamp. Continue to perform the second stage of a two-story continuous suture in the form of a twisting stitch from the back to the front wall of the stomach, with tightening of each stitch until the final hemostasis is achieved (Fig.6). The beginning and end of the ligatures are connected. After treatment with an antiseptic, the lines of the stitching suture are peritonized with nodular serous-muscular sutures (Fig. 7).

A device for excising large and giant ulcers of lesser curvature of the stomach in a closed way relates to medicine, namely surgical gastroenterology.

It is known to use a gastric clamp having rigid jaws, parallel to which at a distance of 2 mm from each other are two elastic staples that bring together and elastically fix the walls of the stomach, which must be sutured by a closed technique.

However, this design of the jaws of rigid and elastic fixation of the clamp is quite inconvenient, since it is necessary to cross the tissues of the walls of the stomach in a narrow space that is limited on all sides.

The prototype of the device for excising large and giant ulcers of lesser curvature of the stomach is a clamp for clamping the aorta, which has rigid fixation lips located relative to the jaw at an angle of 145 °, which allows you to fix the excised fragment of the stomach well and rotate it by 45 °, but the tool does not carry out additional elastic fixation of the walls of the stomach and does not allow the principle of closed excision and suturing of the organ (Yu.V. Belov. Guide to vascular surgery with an atlas of surgical equipment. - M .: Publishing House lstvo "De Novo", 2000. - c).

EFFECT: possibility of excising and suturing large fragments in any parts of the lesser curvature of the stomach by a closed method using a combined action clamp.

The technical result is ensured by the fact that the proposed device contains jaws, a movement unit, working jaws having a longitudinal notch and a conical outer surface, with the base facing the jaws and connected at an angle of 145 °, characterized in that at the distal ends of the hard working jaws along the outer contour through a bend with a radius of 4 mm parallel to their horizontal plane is fixed by a pair of elastic jaws 2 mm thick located at a distance of 4 mm from rigid jaws and with a gap between elastic jaws of 1 mm, providing schaya more freely excision and suturing of large fragments of the walls of hollow organs.

The device after applying it to the walls of the stomach due to hard sponges fixes the fragment to be removed, and due to two sponges of elastic fixation it provides a comparison of the walls of the stomach remaining after excision, temporary hemostasis in them, isolates the lumen of the stomach from the abdominal cavity, ensures good accessibility of the sutured walls of the stomach for suturing, ease of use, eliminates the need for multiple grabbing of the edges of the wound with tweezers, as is the case with the open suturing method.

THE DEVICE IS EXPLAINED BY FIGURES (Figs. 8-10)

On Fig is a view of the device in isometry.

Figure 9 is a General view of the device, a top view.

Figure 10 is a General view of the device, side view.

The device consists of two rigid fixation jaws (1), two elastic fixation lips (2), a motion unit (3) in the form of a dead lock, jaws (4) to ensure the mobility of the fixing and elastic lips and clamp fixation of the jaws in the form of a rack (5) . On the outer surface of the fixing jaws (1), in parallel and at a distance of 4 mm from them, elastic fixing lips (2) are located, the distal ends of the elastic lips are bent at the fixation point to a radius of 4 mm. The clamping jaws are bent relative to the fixing jaws at 145 ° (Figs. 8-10).

THE DEVICE WORKS AS FOLLOWS

The device with rigid fixation sponges is superimposed on a protruded fragment of the gastric wall to be removed with an ulcer with elastic fixation lips in the direction of the remaining part of the stomach. When closing the device and the lock of fixation, hard sponges clamp the part of the gastric wall to be excised with an ulcer, and sponges of elastic fixation bring the remaining walls of the stomach together. Under the lips of elastic fixation, the remaining walls of the organ are flashed with a continuous trapezoidal suture, the stomach is intersected between the lips of the rigid and elastic fixation and the clip with the excised section of the stomach is removed.

EXAMPLE OF EXPERIMENTAL APPLICATION

In order to study the technical feasibility of excising ulcers of lesser curvature of the stomach using a combined clamp and assess the quality of suturing with a two-story continuous stitching and nodular serous-muscular suture, chronic experiments were conducted on 10 dogs. Under calypsol anesthesia, a laparotomy was performed, an electrocoagulator was used to simulate a perforated ulcer of lesser curvature of the stomach. The small omentum was mobilized by the ligature method 2 cm proximal and distal to the ulcer of lesser curvature of the stomach. The perforated hole was stitched with a zig-seam ligature. A purse string suture was placed around the ulcer at a distance of 3 cm. He was pulled and tied. On the base of the stitched mobilized fragment of small curvature in the transverse direction, a combined clamp is applied with elastic fixation lips to the stomach. Under the lips of elastic fixation from the front surface of the stomach to the back, the first stage of a continuous two-story stitching seam in the form of a trapezoid was imposed. Then a fragment of the stomach was crossed between the lips of rigid and elastic fixation and the instrument with a fragment of small curvature was removed. A continuous entwining stitching seam continued to suture the stomach from the back to the front wall, tightening each stitch, tied the beginning and end of the ligature. Then, the line of the stitching suture was peritonized with individual sero-muscular sutures. The seam length was 8.0 ± 0.8 cm; the average duration of excision and suturing of the portion of the lesser curvature of the stomach was 32 ± 0.7 min. To assess the mechanical strength of the sutures, hydropression was performed in an isolated stomach. A purse string suture with a diameter of 1 cm was imposed on the front wall of the stomach. The stomach wall was punctured through the region of application of the purse string suture with a Dufo needle. The seam was pulled around the needle. The stomach in the pyloric sphincter and esophagus was pressed with fingers. A 0.9% sodium chloride solution was injected into the lumen of the stomach under a pressure of 600 mm water column. Suture failure was not noted. After 10 minutes, the fluid was removed and partially evacuated into the intestines. In 5 animals, after 7 days, and in the other five, after 14 days, a relaparotomy was performed and a suture line was excised for morphological examination in order to assess the quality of the regeneration of the stomach wall.

Morphological studies when hematoxylin-eosin stained within 7 days after excision and suturing of the lesser curvature section with a closed method showed that the presence of inflammatory infiltrates is determined in the walls of the stomach, the suture line from the mucosa is covered with granulation tissue.

Morphological studies 14 days after suturing of the site of lesser curvature showed the presence of small inflammatory infiltrates in the walls of the stomach, the entire line of the suture from the mucosa is epithelized.

Thus, experimental animal studies have shown the technical feasibility of minimally invasive organ-sparing interventions for large ulcers of lesser curvature of the stomach in patients with a high degree of operational risk for gastric resection, which to date has been performed as a common surgical intervention.

Excision of a portion of the lesser curvature of the stomach with an ulcer by the method of closed excision, using a combined action clamp, simplifies the procedure for performing the operation, provides good mechanical strength of the suture, provides less invasiveness of manipulations on tissues and less pronounced inflammatory changes in the suture area.

CLINICAL APPLICATION EXAMPLE

Patient B., 39 years old, medical history No. 16428, was admitted to the clinic of the Department of General Surgery of KSMU on December 5, 2007 about a giant ulcer of lesser curvature of the stomach complicated by bleeding of the second degree. Received on the third day after the onset of bleeding. Ulcerative history 4 years. Previously, the ulcer was localized in the duodenum. In 2006, aortic valve replacement was performed. Is a disabled person of the second group. Upon receipt of vomiting "coffee grounds", melena, collapse. After the infusion, hemostatic therapy, the pulse is 100-110 beats. in 1 min, blood pressure 120/70 mm Hg Performed emergency FGDS. An ulcer of the middle third of the body of the stomach was revealed on the lesser curvature, covered with a bundle of blood. 11 hours after admission to the hospital, deterioration, loss of consciousness. Emergency FGDS. Endoscopic picture F2B. Endohemostasis is ineffective. Red blood cells 2.1 × 10 ¹² / l, Hb - 72 g / l.

December 6, 2007, emergency laparotomy. The small intestine is filled with blood. In the middle third of the lesser curvature of the stomach, an ulcerative infiltrate with a diameter of 4.5 cm was detected. A small omentum was mobilized in the area of ulcerative infiltrate proximally and distally from the infiltrate by 2 cm. The ulcer was stitched with a ligature-holder. A purse string suture was imposed and tightened around the ulcerative infiltrate. On the base of a fragment of lesser curvature with an ulcer in the transverse direction, a clamp of combined action is applied with elastic lips in the direction of lesser curvature. The clamp is rotated 45 ° towards the front wall of the stomach. Under the elastic lips of the clamp, a fixed fragment of the lesser curvature of the stomach is stitched with a trapezoidal suture using an atraumatic needle polysorb 3/0. The ends of the thread are fixed with a Billroth clip. The walls of the stomach in the clamp are intersected between the rigid and elastic lips, the clamp with the excised fragment of the stomach is removed. The trapezoidal suture is sealed and the double-stitched suture is continued in the form of a twisted stitching seam from the back to the front wall of the stomach, not reaching a depth of up to the trapezoidal suture. Each stitch of the suture was delayed, reaching the degree of final hemostasis from the edges of the walls of the stomach, the beginning and end of the two-story suture are connected.

After treatment with an antiseptic, a two-story stitching seam is peritonized with individual nodular serous-muscular sutures. According to this technique, 5 patients were operated on. Two patients with ulcerative bleeding and three with perforated gastric ulcers. There were no complications associated with circulatory disorders in the stomach or failure of sutures.

Experimental animal studies and the use of the method for excising large and giant ulcers of lesser curvature of the stomach in patients with a high degree of operational risk using a new device for performing the operation simplified the technique of surgical intervention to remove the lesion of the ulcer substrate by closed excision, provided increased mechanical strength of the suture, and reduced consumption suture material, improved the quality of wound healing.

Claims (2)

1. The method of excision of large and giant ulcers of lesser curvature of the stomach in patients with a high degree of operational risk by the method of closed excision, characterized in that they mobilize the area of the lesser omentum in the projection of the ulcer infiltrate 2 cm proximal and distal to it, a purse string suture is made and tied around the infiltrate, significantly reducing the diameter of the base of the fragment, a clamp consisting of iron lips is applied to the formed leg of the fragment of small curvature in the transverse direction to the small curvature in the transverse direction fixed fixation, to the distal part of which is fixed parallel to the rigid lips by a pair of elastic lips, the elastic lips being directed towards the stomach, the stomach fragment fixed in the clamp is removed from the window in the small omentum by rotating it 45 ° around the lesser curvature with an atraumatic absorbable synthetic suture material stitch the walls of the stomach under the elastic lips with a trapezoidal suture, cross between the lips of hard and elastic fixation, the mobilized fragment of the lesser curvature of the stomach and remove it o together with the clamp, continue to lay the two-story seam in the opposite direction in the form of a twisted stitch seam to a depth less than the depth of the trapezoidal seam with tightening of each stitch and tying the beginning and end of the two-story seam. 2. The device is a clamp for clamping the aorta, consisting of rigid fixation jaws located at an angle of 145 ° relative to the branches, characterized in that a pair of elastic jaws of 2 mm thickness are fixed to the distal part of the rigid jaws along the outer contour through a bend of 4 mm radius at a distance of 4 mm and parallel to rigid jaws with a gap between elastic jaws of 1 mm.

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