RU2427337C1 - 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. Cuts are performed supraumbilically, in mesogastrium on medial clavicular line on the right, in mesogastrium on medial clavicular line on the left, into which 3 ports are installed. Vertical transrectal miniaccess is performed at the distance 2 cm from costal margin and 4 cm rightward from abdominal midline, apparatus "Miniassisstant" is installed into it. Perforation suturing, sanitation of transversal and subdiaphragmal space on the right are carried out. Drainage is installed into subhepatric space on the right.

EFFECT: method makes it possible to improve conditions of visualisation and manipulation, improve sanitation quality.

1 ex, 1 dwg

Description

The invention relates to medicine, in particular to endoscopic surgery, and can be used in the treatment of perforated gastroduodenal ulcers.

More than 30 methods of treating perforated gastroduodenal ulcers are known, and suturing perforated gastroduodenal ulcers is currently the most common surgical intervention. Of these, they found application: suturing of the perforated hole, primary resection of the stomach, vagotomy with suturing of the perforated hole (L.A. Shalimov, V.D. Saenko. Digestive tract surgery, Zdorovya, Kiev, 1987, p. 567 )

Known methods for suturing perforated duodenal ulcers. When suturing perforated holes, various sutures are used: purse string, mattress, single-row and others (1, part II, Surgery of the stomach and duodenum, p. 153-374).

In the classic version, suturing of perforation of gastroduodenal ulcers is performed from laparotomic access in various modifications. In the era of the development of endoscopic surgery, suturing of perforations became possible in the laparoscopic version. However, not all gastroduodenal perforations can be sutured laparoscopically. Suturing is possible if the disease is not more than 12 hours old, in the absence of widespread peritonitis with paralytic intestinal obstruction, perforation diameter of not more than 1.0 cm, the absence of perforation of an ulcer of the posterior wall of the bulb, the absence of other complications of peptic ulcer (stenosis, bleeding, anterior wall ulcer with transition slight curvature), as well as pronounced periulcerogenic infiltration. In addition, the implementation of the intracorporal node is technically difficult and with little operator experience is fraught with the development of postoperative complications, namely suture failure. The method of video-assisted suturing of gastroduodenal perforation from mini-access has a certain number of advantages. At the same time, it is possible to suture perforations of more than 1 cm, perform suturing with severe perifocal inflammation, as well as correct other complications of peptic ulcer.

A known method of minilaparotomy using an annular articulated retractor M.I. Prudkov, through which one section is made 3-5 cm long in the epigastrium and an annular articulated retractor M.I. Prudkov 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., Sigal E.I., Odintsov V.V. Endoscopic surgery. - M.: GEOTAR Medicine, 1998, p.259-270 )

Its disadvantages:

1. The incision for mini-access is made in the epigastrium, which complicates the manipulation of the pyloroduodenal ulcer.

2. A large number of additional incisions (4) for the rehabilitation of the abdominal cavity.

The well-known "Method of minilaparotomy for perforated gastroduodenal ulcers" suturing perforated ulcers through three mini-accesses according to patent No. 2257163, IPC АВВ 17/00, publ. 07/27/2005. In this method, three mini-accesses are performed in various departments of the abdominal wall with the installation of their own conservatives. In the case of a perforated pyloroduodenal ulcer, the first incision is made, transrectal, in the right hypochondrium below the costal arch by 2 cm, the second incision, pararectal in the left hypochondrium is 2 cm below the costal arch and the third incision is made 2-3 cm below the umbilical ring in the midline . In the case of a perforated gastric ulcer, the first incision is performed below the xiphoid process by 2-3 cm in the midline, the second incision is transrectal in the left hypochondrium, the third incision is in the midline below the umbilical ring and the additional incision is transrectal in the right hypochondrium below the costal arch 2 cm. A retractor with a worm mechanism is used, the retractor is installed in the places of cuts alternately.

Its disadvantages:

1. The use of 3 mini-accesses in suturing perforated gastroduodenal ulcers leads to an increase in the invasiveness of the intervention on the anterior abdominal wall due to the fact that they are 4-5 cm in size.

2. Full visualization is not provided during the rehabilitation of the abdominal cavity, which leads to an increase in the duration of the operation.

The objective of the invention is to improve the conditions for visualization and manipulation in the area of surgical intervention, improving the quality of rehabilitation.

The problem is achieved by the method of video-assisted suturing of perforated gastroduodenal ulcers, including four incisions on the anterior abdominal wall.

The sections are performed supraumbilically, in the mesogastrium - along the midclavicular line on the right, in the mesogastrium - along the midclavicular line on the left, in which 3 ports are installed. At a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, a vertical transrectal mini-approach of 3-5 cm is performed, a tool from the Mini-Assistant kit is installed in it, perforation is sutured, subhepatic and subphrenic space sanitation on the right, and subhepatic drainage is installed space on the right.

The novelty of the invention.

- The sections are performed supraumbilically, in the mesogastrium - along the midclavicular line on the right, in the mesogastrium - along the midclavicular line on the left, in which 3 ports are installed. This arrangement allows you to improve the conditions for the rehabilitation of all parts of the abdominal cavity.

- At a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, a vertical transrectal mini-approach of 3-5 cm is performed, a tool from the Mini-Assistant kit is installed in it, perforation is sutured, subhepatic and subphrenic space is sanitized on the right, and drainage is established in the subhepatic space on the right. Empirically, when performing an anatomical experiment, we found that the mini-access should be located exactly in this place, since it provides a good visualization of the operation site, conditions for manipulating general surgical instruments. This allows you to suture gastroduodenal perforations larger than 1 cm with severe periulcirogenic infiltration and eliminate other complications of peptic ulcer disease, such as stenosis and bleeding.

The method allows to obtain a new technical result, which consists in improving the conditions of visualization and manipulation, improving the quality of rehabilitation.

Thus, the proposed method for video-assisted suturing of perforated gastroduodenal ulcers from mini-access is simple in technical design, allows you to expand the range and number of minimally invasive interventions for this pathology, allows you to suture perforations in cases that are difficult to access for laparoscopic suturing and reduce the amount of conversion to traditional laparotomy. All of the above gives the right to apply this method of treatment along with the traditional ones - laparotomy and laparoscopic treatment options perforated gastroduodenal ulcers.

In order to determine the projection of the pyloric pulp onto the anterior abdominal wall and the optimal location of the mini-access for suturing the perforation of the gastroduodenal ulcer, an anatomical experiment was conducted on non-operated 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 version of the mini-access is not very traumatic, since it does not have to cross muscle arrays and neurovascular bundles, and there is also the possibility of expanding access up or down. It is calculated that the vertical transrectal mini-access must be performed 2 cm below the costal arch, departing 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 the surgical action is classic 35.8 degrees, the angle of inclination of the axis of the operational action is 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 cuts:

1. An incision on the anterior abdominal wall in the mesogastrium on the right along the midclavicular line for the instrumental port.

2. Supraumbilical incision for a laparoscope.

3. An incision on the anterior abdominal wall in the mesogastrium on the left along the midclavicular line for the instrumental port.

4. Vertical transrectal mini-access 2 cm below the right costal arch and 4 cm to the right of the midline of the abdomen.

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

The operation is 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 is located between the legs of the patient. Mandatory was the introduction of a gastric tube through which the contents were evacuated from the stomach. To perform the operation, use 3 ports. For a laparoscope, a 10 mm trocar is administered supraumbilically, pneumoperitoneum is applied. The second trocar with a diameter of 5 mm is set in the mesogastrium along the midclavicular line on the right. The last injected trocar with a diameter of 5 mm in the mesogastrium along the midclavicular line on the left. Perform an audit of the abdominal cavity. This arrangement of trocars allows for the rehabilitation of almost all parts of the abdominal cavity without difficulty. Drain the abdominal cavity, remove fibrin films, food particles. Then a vertical transrectal mini-approach of 3-5 cm is performed at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, and the Mini-Assistant apparatus is installed. The installation of the instrument from the Mini-Assistant kit allows you to visualize the place of perforation and to freely manipulate general surgical instruments in this area. The perforation is sutured by the surgeon's preferred method. From the mini-access, sanitation of the subhepatic and subphrenic spaces on the right is performed and drainage is installed in the subhepatic space on the right, which is discharged through a separate incision on the side wall of the abdomen on the right. Mini access is sutured. After suturing the perforated hole, the final multiple sanitation of the abdominal cavity with an aqueous solution of chlorhexidine in a volume of at least 3-5 liters is performed. The loose overlays of fibrin are removed as much as possible. Visual control of the surgical intervention zone is performed, trocars with instruments are removed from the abdominal cavity and layer-by-layer wound closure is performed.

Example.

Patient U., 55 years old, was admitted to the surgical department on 05.26.09 at 23.35 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 6 hours, when against the background of well-being - "dagger" pain in the upper abdomen. 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 05.27.09 at 2 hours 45 minutes. 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 500 ml of turbid 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 a perforated hole 0.4 × 0.6 cm in size, duodenal contents enter. In the mesogastric region along the midclavicular line on the right, a trocar with a diameter of 5 mm is installed for the instrument. In the mesogastric region along the midclavicular line on the left, another trocar with a diameter of 5 mm is installed for the instrument. Pathological exudate with fibrin, particles of food in all parts of the abdominal cavity was aspirated. 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. An additional sanation of the subhepatic and subphrenic spaces on the right was performed from the mini-access. 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 60 minutes. The postoperative period was favorable, anesthesia was carried out by non-narcotic agnalgesics for 3 days, healing by first intention. Discharged on the 7th day after the operation in satisfactory condition.

Claims (1)

The method of video-assisted suturing of perforated gastroduodenal ulcers, including making four cuts on the anterior abdominal wall, characterized in that the cuts are performed supraumbilically, in the mesogastrium along the midclavicular line on the right, in the mesogastrium along the midclavicular line on the left there are 3 ports, 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, they perform a vertical transrectal mini-access of 3-5 cm, install the instrument from the Mini-Assistant kit into it, suturing perforations, sanitation of the subhepatic and subphrenic space on the right, install drainage in the subhepatic space on the right.

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