RU2426504C1 - Method of hepatogastroanastomosis formation in case of choledoch obturation with inoperable tumours of porta - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for hepatogastroanastomosis formation in case of high obturation of hepaticocholedoch with inoperable tumour process of porta. Part of left liver lobe on area 6x4 cm is ablated. Bile duct is stented with catheter. On posterior wall of lesser curvature of stomach "П"-shaped serous-muscular sutures are applied with threads with short term of absorption. Both threads of each suture are passed through entire liver parenchyma layer, indenting 1-1.5 cm from posterior and anterior edges of resection liver surface. Internul uninterrupted suture is applied with thread with long term of absorption between stomach lumen and perimetre of liver resection surface. With threads of each earlier applied "П"-shaped suture serous-muscular sutures are applied on surface of lesser curvature of stomach.

EFFECT: method makes it possible to ensure air-tightness of anastomosis, reduce risk of suture failure.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of obstructive jaundice, which developed during obstruction of the proximal hepatic choledochus with inoperable tumors of the liver gate.

As an analogue, Dololiotti and Folyatti suggest a method for the formation of hepatogastroanastomosis during obstruction of the proximal sections of hepaticoholedoch [1]. The disadvantage of this method is the possibility of eruption of the liver parenchyma during suturing. This drawback may be the cause of the failure of the sutures of hepatogastroanastomosis, the development of limited or diffuse peritonitis.

As an analogue, the Bairov method of forming hepatogastroanastomosis, used in pediatric surgery for atresia of all bile ducts, is proposed [2]. The disadvantage of this method is the possibility of eruption of liver tissue during the formation of both lips of the anastomosis.

The closest in technical essence to the proposed method is Gorbanda method for the formation of hepatogastroanastomosis with high hepatic choledochus obstruction [3].

There are common features of this method with the claimed method:

- a) the resection surface of the liver is sutured into the lumen of the stomach;

- b) apply an additional technical technique to prevent insufficiency of hepatogastroanastomosis sutures (for this, use a lock of a large omentum).

However, when using this method, there still remains the possibility of eruption of the liver parenchyma during suturing, since the pressure of the suture on one side of the liver parenchyma remains. Peritonization of the suture line of the anastomosis with the omentum when it is affected by the metastatic process is not always possible.

The objective of the invention is the development of a method for the formation of hepatogastroanastomosis in the surgical treatment of obstructive jaundice that developed during obstruction of the proximal parts of hepatic choledochus with inoperable tumors of the liver gate, ensuring reliability and technical accessibility of the imposed anastomosis.

The solution of this problem allows to maintain the hermeticity of hepatogastroanastomosis and to provide prophylaxis in terms of possible complications from the anastomosis, primarily in relation to the failure of the sutures and the development of limited or diffuse peritonitis.

This object is achieved by the fact that according to the proposed method of hepatogastroanastomosis, through U-shaped sutures are applied in the following sequence: stomach - liver - stomach, the resection surface of the liver is invaginated into the lumen of the stomach and U-shaped sutures are sequentially tied. In this case, the pressure of the threads is created only on the wall of the stomach, which excludes the eruption of liver tissue and reduces the possibility of the development of anastomotic suture failure. Segmental bile duct (or ducts) is drained by a catheter. Stenting of the bile ducts contributes to a better outflow of bile after tying through U-shaped sutures.

Figure 1-3 presents a General diagram of the operation.

The method is as follows.

From the left lobe of the liver at the border of the second and third segments, liver tissue is cut out according to the area on the front surface of the liver measuring 6 × 4 cm. The size of the removed part of the liver can vary depending on the size of the left lobe of the liver. Hemostasis is performed and the bile duct (or ducts) is stented with a catheter in the projection of the resection surface of the liver. U-shaped stitches are placed along the lesser curvature of the stomach. Then both threads of each suture are passed through the liver parenchyma. An injection is performed along the posterior surface of the liver, departing 1-1.5 cm from the edge of the resection plane of the liver, an injection is performed on the front surface of the liver, 1-1.5 cm departing from the edge of the resection plane of the liver (Figure 1). As a suture material, an absorbable suture with a short absorption period (catgut, vicryl rapid, sofil quick) 2/0 should be used. The threads are fixed with separate clips. The stomach is brought to the liver simultaneously with the simultaneous pulling of all the threads by traction of the anterior clips. Open the lumen of the stomach, respectively, the wound surface of the liver. An internal continuous suture is applied with absorbable material with a long absorption period (vikril, VAT) between the lumen of the stomach and the perimeter of the resection surface of the liver (Figure 2). During this step, the bile duct catheter is immersed in the lumen of the stomach. The threads of each previously applied U-shaped suture impose sero-muscular sutures (of the “sled” type) on the front surface of the lesser curvature of the stomach. Moreover, the injection is carried out perpendicularly and stepping back 1 cm from the edge of a continuous suture with a capture of 1 cm of the wall of the stomach (Figure 3). The threads are again fixed on the clamps. Then the seams are tied in turn.

Thus, the proposed method for the formation of hepatogastroanastomosis, due to the formation of anastomosis through U-shaped sutures, eliminates the pressure of the thread on the liver tissue and thereby prevents the eruption of its parenchyma. Internal continuous suture provides additional sealing of the anastomosis. Preliminary stenting of the bile duct with a catheter promotes a better outflow of bile after tying through the U-shaped sutures and the final formation of the anastomosis. Also, through U-shaped sutures are hemostatic due to compression of the liver parenchyma. Both functions of end-to-end U-shaped sutures (hermetic anastomosis and hemostatic function) are necessary in the first 3-4 days after application of the anastomosis [4]. Then, due to the short period of resorption of the threads of the through U-shaped sutures, the pressure on the liver parenchyma passes and the outflow of bile improves.

This method of hepatogastroanastomosis has been successfully applied in the clinic when performing surgical interventions for high hepatic obstruction obstruction by an inoperable tumor process in three patients (liver cancer - 1 patient; pancreatic head cancer with the spread of the process to the hepatoduodenal ligament - 1 patient; antrum cancer stomach with metastases to the lymph nodes of the hepatoduodenal ligament - 1 patient). The method is simple in technical terms and can be used in surgical practice when it is impossible to use minimally invasive techniques for internal drainage of the bile ducts.

Information sources

1. Shalimov A.A., Domansky B.V., Klimenko G.A., Shalimov S.A. Surgery of the liver and bile ducts. - Kiev: Health, 1975 .-- 408 p.

2. Shalimov A.A., Shalimov S.A., Nichitailo M.E., Domansky B.V. Surgery of the liver and biliary tract. - Kiev: Health, 1993. - 512 p.

3. Dederer Yu.M., Krylova N.P. Atlas of liver operations. - M.: Medicine, 1975 .-- 200 p.

4. Chernousov F.A., Guchakov R.V. Reconstruction techniques and methods for the formation of anastomoses after gastrectomy for gastric cancer // Surgery. - 2008. - No. 1 - P.58-61.

Claims (1)

A method for the formation of hepatogastroanastomosis with high hepatic choledochus obstruction by an inoperable tumor process of the liver gate, including the removal of a portion of the left lobe of the liver over an area of 6x4 cm, the formation of an anastomosis between the resection surface of the liver and the lumen of the lesser curvature of the stomach, characterized in that the bile duct is stented with a catheter to the posterior wall of lesser curvature of the stomach impose U-shaped serous-muscular sutures with sutures with a short resorption period, both strands of each suture pass through the entire thickness of the liver parenchyma and, departing 1-1.5 cm from the posterior and anterior edges of the resection surface of the liver, a thread with a long absorption period imposes an internal continuous suture between the lumen of the stomach and the perimeter of the resection surface of the liver, the threads of each previously applied U-shaped suture perpendicular to the line of the continuous suture are serosally applied -muscular sutures on the front surface of the lesser curvature of the stomach, the sutures are sequentially tied.

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