RU2427336C1 - Method of video-assisted suturing of perforated gastroduodenal ulcers - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to surgery and can be applied for video-assisted suturing of perforated gastroduodenal ulcers. Access for videolaparoscopy and sanitation of abdominal cavity is performed in form of one cut in supraumbilical region with introduction through it of two or three ports for laparoscope and instruments. Access for suturing perforated hole by vertical transrectal 3-5 cm long miniaccess is carried out at the distance of 2 cm below coastal margin and 4 cm rightward from abdominal midline, into which apparatus "Miniassisstant" is installed. ^ EFFECT: method makes it possible to reduce trauma, reduce risk of post-operation hernia formation. ^ 1 ex, 1 dwg

Description

The invention relates to medicine, namely to emergency abdominal surgery, and is intended to perform functionally safe and organ-saving operations in the treatment of perforated gastroduodenal ulcers.

A known method of laparotomy for perforated gastroduodenal ulcers, including the upper median incision 20-25 cm long. Ostroverkhov G.E., Lubotsky D.E., Bomash Yu.M. Course of operative surgery and topographic anatomy. - M.: Medicine, 1964.

The reasons that impede the achievement of the technical result indicated below when using the known method include large tissue trauma, late activation of patients, frequent occurrence of postoperative hernias.

Known laparoscopic method for the treatment of perforated gastroduodenal ulcers, including incisions with a length of 1-1.5 cm at four points, Fedorov I.V., Sigal E.I., Odintsov V.V. Endoscopic surgery. - M .: GEOTAR Medicine, 1998.

The disadvantages of the method include: the use of expensive equipment, the repair of complex and rapidly wearing tools with electrical insulation and micromechanics, as well as optical and electronic distortions of the final image in color and size.

The closest method to the claimed invention in terms of features is the mini-laparotomy method using the M.I. Prudkov annular articulated retractor, according to which one 3-5 cm incision is made in the epigastrium and M.I. Prudkov's annular articulated conservator is installed in the wound with retractors. In addition, laparoscopy is performed with incisions 1-1.5 cm long from four accesses. Fedorov I.V., Segal E.I., Odintsov V.V. Endoscopic surgery. - M .: GEOTAR Medicine, 1998.

The disadvantages of the method are a large number of additional incisions on the anterior abdominal wall, at least 4, 1.5 cm in size, which increases the trauma of the anterior abdominal wall and worsens the cosmetic effect of the operation.

The objective of the invention is the creation of a video-assisted method of suturing perforated gastroduodenal ulcers with less trauma to the anterior abdominal wall, reducing the occurrence of postoperative hernias, the possibility of early activation of patients, a good cosmetic result.

The problem is achieved by the method of video-assisted suturing of perforated gastroduodenal ulcers, including access for video laparoscopy and sanitation of the abdominal cavity, as well as access for suturing the perforated hole.

Access for video laparoscopy and sanitation of the abdominal cavity is performed as a single incision in the supraumbilical region with the introduction of two or three ports for a laparoscope and instruments through it. Access for suturing the perforated hole is performed by means of vertical transrectal mini-access 3-5 cm long at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, in which the instrument from the Mini-Assistant kit is installed.

The novelty of the invention.

- Access for video laparoscopy and sanitation of the abdominal cavity is performed as a single incision in the supraumbilical area with the introduction of two or three ports for the laparoscope and instruments through it. Performing a single access allows to reduce the number of incisions on the anterior abdominal wall for introducing instrument ports, which leads to a good cosmetic effect. The location of the single access in the navel allows adequate, without difficulty, sanitize all parts of the abdominal cavity. The location of the instruments at an acute angle to each other when they are introduced through mono-access does not impair the quality of sanitation of the abdominal cavity.

- The access for suturing the perforated hole is performed by means of vertical transrectal mini-access 3-5 cm long at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, in which the instrument from the Mini-Assistant kit is installed. Empirically, when performing an anatomical experiment, we found that the mini-access should be located in this place, as it provides a good visualization of the operation site, the conditions for manipulating general surgical instruments. Mini-access is less traumatic, since you do not have to cross muscle arrays and neurovascular bundles, and there is also the possibility of expanding access up or down.

Thus, the proposed method of video-assisted suturing of perforated gatsroduodealny ulcers from mono- and mini-access is simple in technical design, allows you to expand the range and number of minimally invasive interventions for this pathology. The method allows to reduce trauma to the anterior abdominal wall, has a good cosmetic effect. The technical result of the invention is to reduce trauma to the anterior abdominal wall, reduce the risk of postoperative hernias, the possibility of early activation of patients, improve the cosmetic result.

In order to determine the projection of the pylorichen pulp onto the middle abdominal wall and the optimal location of the mini-access for suturing the perforation of the gastroduodenal ulcer, an anatomical experiment was conducted on unoperated, non-fixed corpses of male and female sexes aged 18 to 80 years. During the experiment, it was found that the most optimal is a vertical transrectal mini-access 3-5 cm long. This mini-access option is less traumatic, since you do not have to cross muscle arrays and neurovascular bundles, and there is also the possibility of expanding access up or way down. It is calculated that vertical transrectal mini-access must be performed 2 cm below the costal arch, retreating 4 cm from the midline to the right. At the same time, the average depth of the wound was 6.93 cm, the angle of operation was classic 35.8 degrees, the angle of inclination of the axis of the operation was 80.6 degrees, which corresponds to the classical criteria for surgical access. The accessibility zone and the created operating space made it possible to freely visualize the pyloric pulp and the duodenal bulb. There were good working conditions in the area of the duodenal bulb and the use of general surgical technique.

The invention is illustrated in the drawing, which shows the location of the access:

1 - mono-access for the introduction of a laparoscope and instruments

2 - mini access for suturing perforations.

The proposed method of video-assisted suturing of gastroduodenal perforation from mini-access is as follows.

The operation was performed under combined endotracheal anesthesia. The position of the patient on the operating table is on the back with the lower leg and head end raised by 10-15 °. After applying pneumoperitoneum, it is advisable to turn the table 5-10 ° to the left. The operating surgeon was located to the left of the patient. Mandatory was the introduction of a gastric tube through which the contents of the stomach were evacuated. To perform the video laparoscopic stage of the operation, a single access was used, which was performed by cutting a skin 1.5 cm long supraumbilically along the midline of the abdomen. A pneumoperitoneum was placed through the incision and a laparoscope trocar was inserted. The abdominal cavity was revised. In the absence of contraindications to video-assisted suturing of perforations, a second trocar with a diameter of 5 mm for suction and an additional trocar with a diameter of 5 mm for the manipulator were introduced through the same incision. Sanitation of the abdominal cavity was performed. The location of the tools at an acute angle to each other does not impair the quality of rehabilitation. The introduction of instruments through supraumbilical mono-access and the use of the tilt of the operating table in different directions allows adequately sanitizing all parts of the abdominal cavity. Then a vertical transrectal mini-approach of 3-5 cm was performed in the perforation projection, 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, a tool from the Mini-Assistant kit was installed in it. Perforation was sutured by the surgeon's preferred method. From the mini-access, the subhepatic and subphrenic space on the right was sanitized and the drainage was installed in the subhepatic space on the right. Mini access was sutured. After suturing the perforated hole, the final multiple sanitation of the abdominal cavity with an aqueous solution of chlorhexidine in the amount of at least 3-5 liters was performed with the patient tilted in different directions for complete aspiration of the fluid. The loose overlays of fibrin were maximally removed. The operation was completed according to indications by additional drainage of the small pelvis by tubular drainage. Visual control of the surgical intervention zone was performed, trocars with instruments were removed from the abdominal cavity, and supraumbilical single access was sutured.

Example.

Patient Z. 21 years old, IB No. 1920, was admitted to the surgical department on 02/18/10 at 12.25 with a diagnosis of perforated ulcer. Upon admission, the patient complained of “dagger” pain throughout the abdomen, nausea, dry mouth, and vomiting once. Sick for 2 hours, when against the background of well-being, "dagger" pain in the upper abdomen. Suffers from peptic ulcer for five years. On examination, the patient's condition is serious. The skin is pale gray. Blood pressure 110/80 mm Hg, pulse 90 beats per minute, satisfactory filling. The tongue is wet, clean. The abdomen is regular in shape, symmetrical, and does not participate in the act of breathing. On palpation, the abdomen is tense and painful in all departments. Symptom Shchetkina-Blumberg positive in all parts of the abdomen. On the survey radiograph of the abdominal cavity, free gas was detected under the left dome of the diaphragm. Operation 02/18/10 at 2:35 p.m. After processing the surgical field supraumbilical midline, a skin incision 1 cm long. Pneumoperitoneum is standardly applied. A trocar with a diameter of 10 mm was installed through an incision in the abdominal cavity for a laparoscope. In the abdominal cavity in the upper abdomen, up to 200 ml of cloudy effusion mixed with bile and fibrin. Loops of the small, large intestine are not swollen, viable. Single films of fibrin on the diaphragmatic surface of the liver, stomach. The stomach is of normal size. On the front wall of the duodenal bulb there is an ulcerative infiltrate up to 1.5 cm in diameter, in the center of which a perforated opening 0.4 × 0.6 cm in size, duodenal contents enter. Two additional ports were introduced through the supraumbilical incision for suction and manipulator. Pathological exudate with fibrin, particles of food in all parts of the abdominal cavity with sanitation with antiseptics was aspirated, using the slopes of the operating table in different directions. To the right in the epigastric region at a distance of 4 cm from the midline and 2 cm below the costal arch, a layered section of the anterior abdominal wall 4 cm long was made. A tool from the Mini-Assistant kit was installed in the wound. Perforation in the projection of the duodenal bulb is freely visualized. The perforated hole is sutured with a single-row interrupted suture. From mini-access, an additional sanation of the subhepatic and subphrenic spaces on the right was performed. The section of the anterior abdominal wall after removing the instrument from the Mini-Assistant kit is sutured in layers. The final rehabilitation of the abdominal cavity was performed under the control of a laparoscope using laparoscopic instruments. After removing the instruments and ports, the wounds are sutured. The duration of the operation is 45 minutes. The postoperative period was favorable, anesthesia was carried out by non-narcotic analgesics for 3 days, healing by primary intention. Discharged on the 7th day after the operation in satisfactory condition.

Claims (1)

A method for video-assisted suturing of perforated gastroduodenal ulcers, including access for video laparoscopy and abdominal sanitation, as well as access for suturing a perforated hole, characterized in that access for video laparoscopy and abdominal sanitation is performed as a single incision in the supraumbilical region with two or three ports for a laparoscope and instruments, access for suturing the perforated hole is performed by means of vertical transrectal mini-access with a length of 3-5 m at a distance of 2 cm below the costal arch and 4 cm to the right of the middle line of the abdomen, which is mounted in the tool kit of the "Mini-assistant".

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