RU2419390C1 - Method of forming reflux-free choledochoduodenal anastomosis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to abdominal surgery and is intended for performing choledochoduodenal anstomosis. For this purpose longitudinal choledochotomy is performed, concrements from hepaticocoledoch are removed. Serous membrane of anterior wall of duodenum is cut transversally towards duodenum length. Muscular, submucous and mucous layers are opened by point puncture. In formation of CDA needle with tread is stuck into duodenum wall, passed through muscular, submucous and mucous and brought into duodenum lumen. After that, direction of atraumatic needle is changed into the opposite one. Atraumatic needle is stuck into the point, located between submucous and muscular layers of duodenum, passed from inside outwards and stuck in the point at the distance 2.0-2.5 mm from duodenum edge. After that, from inside outwards atraumatic needle with threat is passed through entire thickness of general bile duct and brought out on its serous membrane, after which threats are crisscrossed and tightened in opposite directions, excess of mucous and submucous duodenum layers, turned outside are stuck inside with formation of reflux-free valve cusps, serous membranes of duodenum and general bile duct are matched to each other. ^ EFFECT: method makes it possible to prevent injury to longitudinal and transversal duodenum muscles, mucous and serous membranes of duodenum and general bile duct, ensure anastomosis tightness and eliminate risk of cholangitis development. ^ 3 dwg, 1 ex

Description

The invention relates to medicine, namely to abdominal surgery, and is intended to perform choledochoduodenostomy, with multiple choledocholithiasis, extended strictures of the terminal department of the common bile duct, uncertainty about the complete removal of calculi from the bile ducts or when performing repeated reconstructive operations on the biliopancreatoduodenal region.

A known method of forming choledochoduodenostomy (CDA) according to Jurash (see Halperin E.I., Dederer Yu.M. Non-standard situations in operations on the liver and biliary tract. - M .: Medicine, 1987. - 336 p.), Which consists in that after opening the common bile duct in the longitudinal direction and the duodenum (duodenum) in the transverse direction at the incision level of the common bile duct, sutures are applied starting from the wall of the duodenum, piercing the needle through all layers of the duodenum from the outside to the inside and then passing it through the wall of the common bile duct from the inside out.

The reasons that impede the achievement of the following technical result when using the known method include the fact that

- when dissecting the wall of the duodenum in the transverse direction, the transverse musculature of the duodenum is damaged, which leads to reflux of the duodenal contents in hepatic choledochus with the subsequent development of cholangitis, with the passage of a peristaltic wave;

- an exact comparison of stitched tissues with serous surfaces is not achieved, since the edges of the duodenal mucosa are turned outward;

- Interposition of the duodenal mucosa between the serous surfaces of the common bile duct and duodenum disrupts the biological integrity of the suture, since the mucous membrane in this case is squeezed by thread and necrotic, which leads to leakage of bile and duodenal contents into the free abdominal cavity, bacterial contamination and enzymatic alteration of tissues, local peritonitis in the CDA zone;

- trauma to the mucosa when trying to screw it in with tweezers and immersion in the seam line at the time of thread tightening leads to necrosis of the edge of the mucosa in the CDA zone, healing of the anastomosis by secondary tension, which subsequently leads to a rapid narrowing of the lumen of the anastomosis and a violation of bile duct.

The closest technical solution in relation to the proposed set of essential features is the method of formation of CDA (see patent for utility model of Ukraine No. 19585, published December 15, 2006), according to which longitudinal choledochotomy is performed directly above the duodenum, stones are removed from the hepatic choledochus in a known manner . In the place of the alleged anastomosis with duodenum, the latter is stitched with kapron thread (No. 3) and pulled up to form a cone. Directly under the thread, the WPC wall is cut off so that a point hole is formed in the WPC. The latter expands with a long curved clamp in the direction perpendicular to the length of the duodenum. Then CDA is formed in two rows of seams.

The reasons that impede the achievement of the technical result indicated below when using this method include the fact that when performing CDA, exact matching of stitched tissues with serous surfaces is not achieved, since the edges of the mucous layer of the duodenum are turned outward. Interposition of the duodenal mucosa between the serous surfaces of the common bile duct and duodenum disrupts the biological integrity of the suture.

The objective of the invention is to provide a method for the formation of areflux choledochoduodenoanastomosis, which provides a technical result consisting in the absence of damage to the longitudinal and transverse muscles of the duodenum, in accurate and reliable comparison with each other of the mucous and serous membranes of the duodenum and common bile duct, ensuring the integrity of the anastomosis and eliminating the risk of development cholangitis, because during the passage of the peristaltic wave, the practically intact wall of the duodenum closes the mouth of the CDA and prevents reflux of the duodenal contents into the hepatic choledochus.

The specified technical result in the method of forming areflux choledochoduodenoanastomosis is achieved by performing longitudinal choledochotomy in the supraduodenal part of the common bile duct, calculi are removed from the hepatic choledochus, stitched with nylon filament of the duodenum in the place of the proposed anastomosis with the latter, they form a pointed hole in the direction of which the extension is bent, the clip is bent to extend it length of duodenum, and form the CDA.

The peculiarity lies in the fact that the serous membrane of the anterior wall of the duodenum is dissected directly between the kapron filaments with the holders transversely to the length of the duodenum, 18-20 mm long, the muscular, submucous and mucous layers are opened with a puncture puncture of 2-3 mm, and an atraumatic needle with a synthetic absorbable suture into the front wall of the duodenum at a distance of 4.0-4.5 mm from the edge from the side of the serous membrane, pass it through the muscle, submucous and mucous layers and bring into the lumen of the duodenum, then the direction of the atraumatic needle They inject on the opposite, atraumatic needle, inject it into a point located between the submucosal and muscle layers of the duodenum, conduct it from the inside out and puncture it at a point at a distance of 2.0-2.5 mm from the edge of the duodenum, then retreat from the edge by 2.5- A 3.0 mm atraumatic needle with a synthetic resorbable suture is passed through the entire thickness of the common bile duct and excreted on its serous membrane, then the synthetic resorbable sutures cross and stretch in opposite directions, while the excess of the mucous and submucosal layers of WPC, splayed outwards, is charged into the forming flaps areflux valve and serous membranes KDP and common bile duct are compared with each other.

The invention is illustrated figure 1-3.

Figure 1 illustrates choledochotomy and duodenotomy:

1 - longitudinal choledochotomy in the supraduodenal part of the common bile duct,

2 - kapron thread holder,

3 - dissection of the serous membrane transversely to the length of the duodenum,

4 - puncture puncture.

Figure 2 illustrates the formation of CDA:

5 - injection of an atraumatic needle into the anterior wall of the duodenum from the edge from the side of the serous membrane,

6 - holding an atraumatic needle with a synthetic absorbable thread through the entire thickness of the common bile duct and removing it on its serous membrane.

Figure 3 illustrates a view of the generated CDA:

7 - leaflet areflux valve,

8 is a comparison of the serous membranes of the duodenum and common bile duct.

The method is as follows.

An audit of the hepatobiliary zone is performed, the gall bladder is removed. A longitudinal choledochotomy of 18-20 mm is performed (Fig. 1, pos. 1) in the supraduodenal part of the common bile duct and calculi are removed from the hepatic choledochus in a known manner. In the place of the alleged anastomosis with duodenum, the latter is stitched with two nylon filaments with holders 2 at a distance of 2.0 cm from each other and the front wall of the duodenum is pulled up. Directly between the nylon filaments of the holders 2, the serous membrane of the anterior wall of the duodenum is dissected transversely to the length of the duodenum with a length of 18-20 mm (Fig. 1, item 3). The muscular, submucosal and mucous layers are opened with a puncture puncture of 2-3 mm (Fig. 1, item 4). The puncture point 4 expands with a long curved clamp in the direction perpendicular to the length of the duodenum to 18-20 mm. Then the CDA is formed. The ductile wall of the duodenum is well adapted to the choledochotomy section. Atraumatic needle with a synthetic absorbable thread with a diameter of 4/0 is injected into the front wall of the duodenum at a distance of 4.0-4.5 mm (figure 2, position 5) from the edge from the side of the serous membrane. Then it is carried out through the muscular, submucosal, mucous layers and is excreted into the lumen of the duodenum. Then the direction of the atraumatic needle changes to the opposite. An atraumatic needle is punctured at a point located between the submucosal and muscle layers of the duodenum, carried out from the inside out and punctured at a point at a distance of 2.0-2.5 mm from the edge of the duodenum. Further, from the inside outward, departing from the edge by 2.5-3.0 mm, an atraumatic needle with a synthetic absorbable thread is drawn through the entire thickness of the common bile duct and displayed on its serous membrane (Fig. 2, item 6). Then the synthetic absorbable sutures cross each other and stretch in opposite directions. The excess mucous and submucous layers of the duodenum, turned outwards, is refilled inward, forming the valves of the areflux valve (Fig. 3, item 7), and the serous membranes of the duodenum and common bile duct are accurately and reliably matched to each other, ensuring the integrity of the anastomosis (Fig. 3 , item 8).

Clinical example.

Patient S., 64 years old, was admitted to the 6th surgical department of the Ulyanovsk City Clinical Hospital for Emergency Medicine on 05.03.2009 at 10 a.m. with the diagnosis: Gallstone disease. Acute cholecystitis. Mechanical jaundice. Upon admission, the patient complained of pain in the right hypochondrium, nausea, bitterness in the mouth, and yellow skin. Sick for 7 days. Gallstone disease for 5 years, has repeatedly undergone conservative treatment in hospitals of the city, previously the patient refused surgical treatment.

On examination: the general condition of the patient is severe. The skin is moist, icteric. The pulse is satisfactory filling and voltage of 86 beats per minute. Blood pressure 110/80 mm Hg

The tongue is dry, coated with a yellow coating. The abdomen is of the correct form, not swollen, symmetrical, does not participate evenly in the act of breathing, the right half lags behind. On palpation, soft and painful in the right hypochondrium. An enlarged, tense, painful gall bladder is palpated. Symptoms of Ortner, Grekov, Murphy are positive. Symptom Shchetkina-Blumberg negative. Ultrasound of the abdominal cavity was performed, the gallbladder was 100 × 60 mm in size, and the wall was 2 mm long. It contained many calculi with a diameter of 2 to 5 mm. The choledoch 20 mm wide contains many stones with a diameter of 2 mm. Diagnosed with gallstone disease. Acute cholecystitis. Choledocholithiasis. Biliary pancreatitis. Obstructive jaundice.

A comprehensive conservative pathogenetic therapy was carried out for 5 days in order to stabilize the state and reduce endogenous intoxication, surgical treatment was carried out on 10.03.2009.

Operation: 03/10/2009 9 hours 15 minutes - 10 hours 35 minutes Minilaparotomy was performed by transrectal incision in the right hypochondrium, 5.0 cm long. A universal frame retractor was installed. Gall bladder measuring 90 × 50 mm, edematous, hyperemic. Produced cholecystectomy in a known manner. Holedoch 20 mm wide. A longitudinal choledochotomy of 18 mm was performed in the supraduodenal part of the common bile duct, calculi were removed from the hepatic choledochus in a known manner. In the place of the alleged anastomosis with duodenum, the latter is stitched with two nylon filaments with holders at a distance of 2 cm from each other (No. 3) and the anterior wall of the duodenum is pulled up, the serous membrane is dissected directly between the threads transversely to the duodenum length of 18 mm, the muscular, submucous and mucous layers opened with a puncture puncture of 3 mm, the latter expanded by a long curved clamp in the direction perpendicular to the length of the duodenum to 18 mm. The formation of CDA. An atraumatic needle with a synthetic absorbable thread with a diameter of 4/0 is injected into the wall of the duodenum at a distance of 4 mm from the edge from the side of the serous membrane, passed through the muscular, submucous, mucous layers and brought into the lumen of the duodenum, then the direction of the atraumatic needle is reversed, the atraumatic needle is pierced to the point located between the submucosal and muscle layers of the duodenum, it is drawn from the inside out and punctured at a point 2.5 mm from the edge of the duodenum, then from the inside outwards 2.5 mm atraumatic needle retreating from the edge A synthetic absorbable thread is drawn through the entire thickness of the common bile duct and brought out on its serous membrane, then the synthetic absorbable sutures cross and stretch in opposite directions, while the excess of the mucous and submucosal layers of the duodenum, turned outward, is threaded inward, forming the valves of the areflux valve.

Sanitation and drainage of the abdominal cavity. Stitches on the wound.

Diagnosis: Gallstone disease. Acute cholecystitis. Choledocholithiasis. Biliary pancreatitis. Obstructive jaundice.

The postoperative period was uneventful, smooth, the patient received complex pathogenetic therapy.

Pathological examination. Catarrhal cholecystitis.

The wound of the anterior abdominal wall healed by primary intention. In satisfactory condition, March 17, 2009, the patient was discharged from the hospital under the supervision of a surgeon in the clinic at the place of residence. Inspected November 20, 2009. Condition is good. No complaints.

Thus, the proposed method allows to exclude damage to the longitudinal, transverse muscles of the duodenum, mucous and serous membranes of the duodenum and common bile duct are accurately and reliably compared with each other, ensuring the tightness of the anastomosis. With the passage of the peristaltic wave, the almost intact wall of the duodenum closes the mouth of the CDA and prevents the reflux of the duodenal contents into hepatic choledochus, thus eliminating the risk of cholangitis.

Claims (1)

The method of forming areflux choledochoduodenostomy (CDA), including longitudinal choledochotomy in the supraduodenal part of the common bile duct, removing calculi from the hepatic choledoch, stitching with a capron thread of the duodenum (duodenum) at the site of the anterior long-pointed anastomosis, the formation of which is pointed KDP and the formation of CDA, characterized in that the serous membrane of the anterior wall of the KDP is dissected directly between with nylon filaments with holders transverse to the length of the duodenum, 18–20 mm long, the muscular, submucous and mucous layers are opened with a puncture puncture of 2–3 mm; when forming a CDA, an atraumatic needle with a synthetic absorbable thread is pierced into the anterior wall of the duodenum at a distance of 4.0–4 5 mm from the edge from the side of the serous membrane, pass it through the muscle, submucosal and mucous layers and bring into the lumen of the duodenum, then the direction of the atraumatic needle is changed to the opposite, the atraumatic needle is punctured at a point located between the submucosa and the mouse with the end layers of the duodenum, they are carried out from the inside out and punctured at a point at a distance of 2.0-2.5 mm from the edge of the duodenum, then from the inside outwards, 2.5-3.0 mm departing from the edge, an atraumatic needle with a synthetic absorbable thread is drawn through the entire thickness common bile duct and excreted on its serous membrane, then synthetic absorbable sutures cross and pull in opposite directions, while the excess of the mucous and submucosal layers of the duodenum, turned outward, tuck inward, forming the valves of the areflux valve, and serous span of duodenum and the common bile duct are compared with each other.

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