RU2431448C2 - Method of surgical management of hiatus hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery. A method involves reconstruction of a His corner and a Gubarev's valve with using a polypropylene tape. The polypropylene tape is delivered behind an oesophagogastric junction. The tape is fixed to an anterior abdominal wall without gastric wall surgery.

EFFECT: method provides higher clinical effectiveness and lower operative injury rate, enabled implementation of both standard, and endoscopic approaches.

2 ex, 5 dwg

Description

The invention relates to medicine, namely to surgery.

In cases of occurrence of sliding hernias of the esophageal opening of the diaphragm, a pathological displacement of the stomach into the chest cavity occurs, the angle between the esophagus and the bottom of the stomach (the angle of His) is altered, the closure function of the esophageal-gastric transition is disrupted. In such cases, the method of choice is a series of rather traumatic and not always effective methods of eliminating the hole (krorrorrafiya), reconstructing the angle (Boerem, Tupe), the closure function (Allison, Nissen, Belei).

Prototypes can be considered:

A known method of fixing the angle of the stomach due to the round ligament of the liver (Rampal), which he spent around the esophagus and additionally the stomach was sutured to the esophagus. A significant drawback was the poor bond strength. Therefore, insolvency often arose; therefore, the technique was not widely used.

A known method of prosthetic plastic hernia of the esophageal opening of the diaphragm (RU 2261663 10.10.2005) by closing the hole in the diaphragm with a sewn polypropylene mesh. However, this method solves basically one problem - reducing the hole and fixing the esophagus in this hole, does not recreate the His angle and the Gubarev valve, is more traumatic, does not exclude damage to the branches of the vaguses, since the installation of the prosthesis requires mobilization of this zone.

The technical result and the purpose of the invention are to reduce the invasiveness of the intervention with increasing efficiency and the possibility of both classical and endoscopic access without using the stomach wall to recreate the angle of His and Gubarev’s valve, to prevent reflux and displacement of organs in the chest by fixing the esophagus transition.

The stated goal is achieved as follows. Enter the abdominal cavity. The esophagus-gastric junction is exposed, the stomach is displaced caudally, the peritoneum is cut to the right and left of the abdominal esophagus, a tunnel is made in a blunt way behind the esophagus and esophageal ligament apparatus. Then in the created tunnel spend polypropylene tape in the form of a rolled polypropylene mesh (figure 1). The ends of the tape are attached to the anterior abdominal wall, thereby holding this anatomical formation from displacement, recreate the violated His angle, Gubarev’s valve and prevent reflux. The technique can be implemented with the use of rear or front krorrorrafiya.

This method differs from the previously proposed classical methods by significant differences:

1. Eliminates a rather traumatic stage of mobilization of the bottom of the stomach.

2. There is no need to mobilize the stomach along the lesser curvature.

3. The angle of His is easily restored.

4. The angle of His is firmly fixed, the Gubarev valve is recreated.

5. The possibility of prolapse of the organ into the chest cavity is excluded.

6. You can neglect the need to close the hole at all costs.

7. Fixation takes place in advance with well-known strong material.

8. The methodology does not exclude additions in the form of krorrorrafiya or other methods.

Clinical examples: Patient S., 38 years old, was admitted to the surgical department of the Central Clinical Hospital named after Zakharyin with symptoms of a hiatal hernia. Radiological and endoscopic diagnosis is confirmed (figure 2). Under general anesthesia, a laparotomy was made through medium access, the liver was laid to the right, a tunnel was made bluntly and sharply behind the esophagus, a 30 cm long polypropylene tape was drawn, the ends of the latter were sewn to the anterior abdominal wall. Examined after surgery: there is no hernia, the closure function is good, there is no pathology on fibrogastroscopy, the Gubarev valve is restored (Fig. 3).

Patient M., 54 years old with cholelithiasis, chronic cholecystitis, was examined before surgery, an additional hiatus hernia was revealed (Fig. 4). Simultaneous laparoscopic operations were performed (October 2008) - laparoscopic cholecystectomy and the second stage moved the stomach with the esophagus from the mediastinum to the abdominal cavity, the abdominal esophagus was separated, the tunnel behind the esophagus was bluntly formed, a polypropylene tape was drawn, the ends are fixed to the anterior abdominal wall. Smooth flow. Control study: there is no hernia, the closure apparatus is functioning, the X-ray angle of His is acute (figure 5). FGS - the device passes freely, the Gubarev valve is restored, there is no reflux.

Claims (1)

A method of surgical treatment of axial hernias of the esophageal opening of the diaphragm and reflux disease, including the restoration of the angle of His and the Gubarev valve using a polypropylene tape, characterized in that they carry out a polypropylene tape behind the esophago-gastric junction and fix it to the anterior abdominal wall without interfering with the stomach wall.

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