RU2421157C1 - Method of access to retroperitoneal organs and structures of pancreato-duodenal zone in case of treama of abdomen - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to surgery and can be applied for access to retroperitoneal organs and structures of pancreato-duodenal zone in case of abdominal trauma. Right half of colon is drawn aside medially tightening transitional fold of peritoneum. Transitional fold of peritoneum is dissected parallel and 2 cm more lateral than edge of colon, starting cut from right bend of colon and continuing it to the level of head of blind colon. Cut of peritoneum is continued leftward and cranially on the place of attachment of lower edge of small intestine mesentery to duodeno-jejunale transition. Tissues are separated by "blunt" way in vessel-free zone in such a way that right half of colon and small intestine with feeding vessels were separated from paraortal and paracaval tissue. Dissection of tissues is continued to lower edge of lower-horizontal part of duodenum. Small intestine and right half of colon with feeding vessels are drawn aside cranially. Dissection of tissues posterior to duodenum and posterior surface of pancreas body to the level of its upper edge is performed. Tissues are separated anterior to duodenum until lower pancreato-duodenal arteries and veins are tightened. ^ EFFECT: method makes it possible to improve possibilities of examination of organs, increase access safety. ^ 3 ex, 4 dwg

Description

The invention relates to medicine, namely to surgery, and can be used for a complete and safe revision of retroperitoneal organs and structures of the pancreatic-duodenal zone during a surgical operation.

During operations performed for a closed or open abdominal injury, it is sometimes necessary to examine the organs and structures of the pancreatic-duodenal zone. However, the complex anatomical relationships between the aorta and superior mesenteric artery on the one hand, the duodenum and pancreas on the other, make mobilization of the pancreatic-duodenal complex to the left of the superior mesenteric artery. Therefore, for example, revision of the wound canal in the area of the pancreas body is performed by dissecting it, which leads to additional pancreatic injury, or it is not carried out at all, which is fraught with missed injuries. The duodenum is currently mobilized using the well-known Kocher method (Littmann I. Abdominal Surgery. Publishing House of the Hungarian Academy of Sciences, Budapest, 1970, 576 pp.). However, due to the anatomical features of this zone, this method does not allow to examine the lower horizontal and ascending parts of the duodenum, the posterior surface of the pancreas, superior mesenteric artery and vein, lower pancreatic-duodenal arteries and veins.

The closest analogue is the method described in the article Cattell R.B., Braasch J.W. A technique for the exposure of the third and fourth portions of the duodenum. Surgery, Gynecology & Obstetrics. 1960, Vol. 111, P.378-379. However, this method has disadvantages, namely, it does not allow inspection of the posterior surface of the body of the pancreas, superior mesenteric artery and vein, lower pancreatic-duodenal arteries and veins.

The objective of the proposed method is to develop access to the retroperitoneal organs and structures of the pancreatic-duodenal zone in case of abdominal trauma: the posterior surface of the head and body of the pancreas, the descending, lower horizontal and ascending parts of the duodenum, superior mesenteric artery and vein, lower pancreatic-duodenal vessels paraduodenal retroperitoneal fiber.

The technical result consists in providing safe wide access to the retroperitoneal organs and structures of the pancreatic-duodenal zone during abdominal injury during the operation, which is achieved by:

- separation of tissues in the avascular zone between the main trunk and branches of the superior mesenteric artery, the main trunk and inflows of the superior mesenteric vein on the one hand, the abdominal aorta and the infragepatic department of the inferior vena cava, on the other, which ensures the safety of the superior mesenteric artery and vein;

- the separation of the right half of the colon and small intestine from the retroperitoneal tissue with continued dissection cranially to the lower horizontal part of the duodenum along its front and rear surfaces provides safe wide access to: 1) the entire posterior surface of the descending, lower horizontal and ascending parts of the duodenum; 2) the back surface of the head, body and partially the tail of the pancreas; 3) the superior mesenteric artery and vein, branches of the lower pancreato-duodenal vessels; 4) parapancreatic and paraduodenal fiber.

Performing safe access for revision of organs and structures of the retroperitoneal space during a surgical operation, in turn, allows to suture tears and wounds of the duodenum, posterior surface of the pancreas, lower pancreatic-duodenal arteries and veins, aorta and lower vena cava, open abscesses and phlegmon in this zone of retroperitoneal space.

The method is as follows.

A laparotomy is performed, during which the right half of the colon is maximally retracted medially by pulling on the transitional fold of the peritoneum 1, which is cut in parallel and 1-2 cm lateral to the edge of the colon 2. The incision begins from the right bend of the colon and leads to the level of the cecum dome 3 Then, the peritoneal incision is continued to the left and cranial at the site of attachment of the lower edge of the mesentery of the small intestine 4 to the duodenojejunal junction 5 (Fig. 1).

Further tissue separation is carried out in a “blunt” way in the avascular zone so that the right half of the colon and small intestine with supply vessels are separated from the paraortal and paracaval tissue (Fig. 2: superior mesenteric artery and vein 6, 7, aorta 8 and inferior vena cava 9). Tissue dissection is carried out to the lower edge of the lower horizontal part of the duodenum. The entire thin and right half of the colon with feeding vessels is removed cranially.

Dissection of tissues is performed posteriorly from the duodenum and the posterior surface of the pancreas to the level of its upper edge. This technique allows you to visualize the entire posterior surface of the descending, lower horizontal and ascending parts of the duodenum 10, the posterior surface of the head, body and partially the tail of the pancreas 11 (figure 3). Separation of tissues anteriorly from the duodenum is carried out until the lower pancreatic-duodenal arteries and veins are pulled. This technique makes it possible to examine the superior mesenteric artery and vein 12, branches of the lower pancreatic-duodenal vessels 13 (Fig. 4), parapancreatic and paraduodenal retroperitoneal tissue.

Example 1 (an example demonstrating the operation of the proposed method).

Patient P., 28 years old, was admitted with a stab wound located in the left lumbar region. An audit of the wound revealed that it penetrates into the abdominal cavity. A laparotomy was performed, during which an extensive retroperitoneal hemorrhage was revealed, occupying the root of the mesentery of the colon, spreading to the left lateral canal and left mesenteric sinus. The lower horizontal part of the duodenum and the body of the pancreas are surrounded by bundles of blood. It is not possible to detect the wound channel due to tissue imbibition with blood. It was decided to perform an audit of retroperitoneal organs and structures of the pancreato-duodenal zone according to the proposed method.

The parietal peritoneum is dissected in parallel and 2 cm lateral to the edge of the colon from the right bend of the colon and to the level of the dome of the cecum. The incision of the parietal peritoneum is continued to the left and cranial at the site of attachment of the lower edge of the mesentery of the small intestine and is completed at the duodenojejunal junction.

The right half of the colon and the entire small intestine are separated from the retroperitoneal fiber in a "blunt" way. Tissue dissection was performed in the avascular zone between the right half of the colon, the superior mesenteric artery and a vein on the one hand, the aorta and the inferior vena cava on the other. The small and right half of the colon are allotted cranially.

Then tissue is separated posteriorly and cranially to the lower horizontal part of the duodenum and the body of the pancreas. A wound of the left lumbar muscle with active bleeding from it was detected. Bleeding is stopped by flashing. When examining the posterior surface of the body of the pancreas and the lower horizontal part of the duodenum, no damage was found. The patient was discharged on the twelfth day in satisfactory condition.

Access to the proposed method was carried out in 5 victims. Damage was detected and repaired in all cases. In 2 patients with abdominal injuries who required an audit of retroperitoneal organs and structures of the pancreatic-duodenal zone, the proposed method was not applied, which led to a complicated course of the postoperative period.

Example 2 (an example demonstrating the implementation of a full but dangerous access due to additional tissue injury).

Patient B., 41 years old, was admitted to the Research Institute of Emergency Medicine. N.V. Sklifosovsky. A puncture wound 2 × 1 cm was located in the epigastric region. In connection with signs of intra-abdominal bleeding, the operation was started with laparotomy. During revision of the abdominal cavity organs, a through wound of the stomach and a wound of the pancreas body 1 × 0.5 cm with hemorrhage 6 × 5 cm around were found. In order to revise the aorta and superior mesenteric artery, the pancreatic wound is dilated and divorced by hooks. This allowed to exclude damage to the above vessels. The operation is completed by drainage of the stuffing bag and abdominal cavity.

The course of the postoperative period from 1 day was complicated by the development of traumatic fatty pancreatic necrosis, parapancreatitis. The patient died on the 9th day after surgery from bilateral drain bronchopneumonia.

Example 3 (an example demonstrating the implementation of safe but incomplete access, as a result of such access, no wound was identified, complications developed).

Patient N., 36 years old, was taken to the operating room 1.5 hours after being injured. Upon admission, a diagnosis was made of a penetrating stab wound to the abdomen with multiple wounds and small bowel event. Under anesthesia, a laparotomy was performed, a section of the small intestine with wounds was resected with an end-to-end anastomosis. An audit of the abdominal organs revealed a hematoma in the region of the lower horizontal part of the duodenum with spreading to its descending part. Mobilization of the duodenum according to Kocher was performed, while it was not possible to examine the lower horizontal part of the duodenum. The operation is completed by nasointestinal intubation and drainage of the abdominal cavity. The course of the postoperative period was complicated by the development of retroperitoneal phlegmon. With relaparotomy, which was performed on the 5th day, the cause of retroperitoneal phlegmon was a missed wound of the lower horizontal part of the duodenum.

Claims (1)

A method of access to the retroperitoneal organs and structures of the pancreatic-duodenal zone in case of abdominal injury, characterized in that a laparotomy is performed, during which the right half of the colon is maximally retracted by pulling the transitional fold of the peritoneum, which is cut parallel and 2 cm lateral to the edge of the colon, moreover, the incision begins from the right bend of the colon and leads to the level of the dome of the cecum, then the peritoneal incision is continued to the left and cranial at the site of attachment of the lower edge of the mesentery of the small intestine to duodenojejunal transition, then tissue separation is carried out in a “blunt” way in the avascular zone so that the right half of the colon and small intestine with supply vessels are separated from the paraortal and paracaval tissue, tissue dissection is carried out to the lower edge of the lower horizontal part of the duodenum, thin and right half of the colon with feeding vessels is removed cranially, tissue is dissected posteriorly from the duodenum and the posterior surface of the pancreas to its upper level edges, tissue separation anteriorly from the duodenum is carried out until the lower pancreatic-duodenal arteries and veins are pulled.

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