RU2432126C2 - Method for creating pancreatojejunal anastomosis in proximal pancreatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically to surgery. A Wirsung's duct is stented with a catheter. A catheter is cut off at 1-1.5 cm and fixed to a gland. Four to five seromuscular monofilament 4/0 "П"-sutures are applied on a posterior wall of a jejunum at 1.5-2 cm from its border parallel to a lumen. Both filaments of each suture are delivered through a pancreatic parenchyma. A stick-in is placed at 1-1.5 cm from a posterior border of the pancreas, and a stick-out - at 1-1.5 cm from an anterior border of the gland. A inside uninterrupted suture is applied between the jejunal lumen and a resection surface of the pancreas. The filaments of the previous "П"-suture are used to apply seromuscular sutures on an anterior surface of the jejunum perpendicularly at 1 cm from an edge of the uninterrupted suture. A pancreatic stump is invaginated in the the jejunal lumen. The sutures are tied up either till touch, or on points of joined branches of a clamp. Lateral walls of the anastomosis are reinforced with an interrupted suture.

EFFECT: method allows avoiding pancreatic tissue cutting, creating a leak-proof anastomosis, and providing adequate pancreatic secretion outflow.

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Description

The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of pancreatic tumors and chronic pancreatitis.

As an analogue, Binkley proposes a method for the formation of terminological pancreatojejunoanastomosis during proximal pancreas resection [1]. The disadvantage of this method is the possibility of eruption of the pancreatic parenchyma with mattress sutures with a "soft" gland. This drawback may be the cause of the failure of the sutures of pancreatojejunoanastomosis, the development of pancreatic fistula or, less commonly, peritonitis. Another disadvantage of this method is that the isolated stitching of the pancreatic duct into the intestine with a narrow duct (less than 3 mm in diameter) can lead to impaired patency, obstructed drainage of pancreatic secretion and subsequent development of pancreatitis. In addition, with a narrow duct, the walls of which, as a rule, are thinned, isolated stitching of the pancreatic duct into the intestine is a rather technically difficult stage in the formation of the anastomosis.

As an analogue, Peng S.Y. is proposed. et al. a method of forming a terminal pancreatojejunoanastomosis during proximal pancreas resection [2]. The disadvantages of the method are: a) the need to evert and demucose jejunum for 3 cm; b) the need to mobilize the pancreatic stump for 3-4 cm. Such mobilization is accompanied by additional trauma to the gland, since it is necessary to separate the pancreatic parenchyma from the large vessels: splenic arteries and veins. At the same time, small arterial and venous vessels are ligated, going to the parenchyma of the gland from the above vascular trunks. Often, due to the close fit of the splenic vein to the pancreatic parenchyma, this stage increases the risk of bleeding. The specified manipulation, together with the previous eversion and demucosis of the jejunum, lengthens the time of the operation and is technically quite laborious.

Closest to the technical nature of the proposed method is Soupault method of forming termolateral pancreatojejunostomy during resection of the pancreas with one row of sutures from the side of the intestinal lumen [3].

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

- impose through U-shaped sutures in the following sequence: gut - pancreatic parenchyma - gut;

- to strengthen the side walls of the pancreatojejunoanastomosis impose one nodal suture on each side.

However, when applying the known method, it is necessary to perform an additional incision on the opposite wall of the intestine created by the anastomosis. The lumen of the intestine is opened from two sides. All manipulations associated with the formation of end-to-end U-shaped and lateral nodal sutures (suturing and tying) are performed from the side of an additional intestinal incision, which increases the degree of infection of the surgical field. The absence of a catheter in the Wirsung duct can disrupt the outflow of pancreatic secretion due to its possible compression after tying through U-shaped sutures.

The objective of the invention is the development of a method for the formation of pancreatojejunoanastomosis with proximal resection of the pancreas for tumors of the pancreas and chronic pancreatitis, providing reliability and technical accessibility of the superimposed anastomosis.

The solution of this problem allows preserving the hermeticity of pancreatojejunoanastomosis and providing prophylaxis in terms of possible complications from the anastomosis, primarily in relation to inconsistency of sutures and the development of acute pancreatitis of the pancreatic stump.

The task is achieved by the fact that according to the proposed method of the terminal pancreatojejunoanastomosis, end-to-end U-shaped sutures are applied in the following sequence: intestine - pancreas - intestine, the pancreatic stump is invaginated into the jejunum, an internal continuous suture is applied and U-shaped sutures are sequentially tied. In this case, the pressure of the threads is created only on the wall of the intestine, which excludes the eruption of pancreatic tissue and reduces the possibility of the development of anastomotic suture failure. Obligatory stenting of the Wirsung duct with a catheter is a necessary preventive measure in terms of impaired outflow of pancreatic secretion after tying through U-shaped sutures.

Figure 1-5 presents a General diagram of the operation.

The method is as follows. According to the generally accepted method, proximal pancreas resection is performed. A loop of the jejunum prepared for application of the anastomosis is moved to the pancreatic stump. On the resection surface of the pancreatic stump, the Wirsung duct is identified and stented with a catheter. The catheter is inserted into the duct until it stops, then tightened by 1-1.5 cm, cut so that it protrudes 1-1.5 cm beyond the resection plane of the pancreas and is fixed to the gland. Four to five U-shaped serous-muscular sutures with a grip of 1 cm of the intestinal wall and with an interval between sutures of 0.8-1 cm are applied to the posterior wall of the jejunum parallel to its lumen, departing from the edge of the intestine by 1.5-2 cm. As a suture material, it is preferable to use 4/0 monofilament yarn: polypropylene yarn or absorbable yarn with a long absorption period (PDS). Then both threads of each suture are passed through the pancreatic parenchyma. An injection is performed along the posterior surface of the pancreas, 1-1.5 cm indented from the edge of the resection plane of the gland, an injection is performed on the front surface of the pancreas, 1-1.5 cm indented from the edge of the resected pancreatic plane (Figure 1). With dense pancreatic tissue, to facilitate this stage, an intermediate needle puncture is possible in the middle of the resection plane of the pancreas, followed by an injection into the gland tissue in the same place. The threads are fixed with separate clips. The loop of the jejunum is brought to the pancreatic stump synchronously with the simultaneous pulling of all the threads by traction of the clamps anteriorly and to the left. An internal continuous suture is applied with absorbable material (vicryl, PDS) between the lumen of the intestine and the perimeter of the resection surface of the pancreas (Figure 2). During this step, the Wirsung duct catheter is immersed in the jejunum. The threads of each previously applied U-shaped suture impose sero-muscular sutures (of the “sled” type) on the front surface of the jejunum loop. Moreover, the injection is performed perpendicularly and departing 1 cm from the edge of a continuous suture with a capture of 1 cm of the intestinal wall (Figure 3). The threads are again fixed on the clamps. Slowly, with a constant tension of the threads, traction is carried out by the clamps anteriorly and to the left. In parallel with the process of traction for the threads, the pancreatic stump is invaginated until it is completely immersed in the jejunum. Then the seams are alternately tied to touch. To dose the effort, you can tie the threads at the tip of the closed jaw of the clamp (Fig 4). We attach great importance to this detail. With tight suturing due to edema, which after surgery may occur in this area, a decrease in the blood microcirculation in the projection of pancreatojejunanastomosis is possible. The lateral walls of the anastomosis are strengthened by flashing the intestine and pancreatic parenchyma with a nodal suture, one on each side (Figure 5).

Thus, the proposed method for the formation of an invagination terminological pancreatoeunioanastomosis during proximal resection of the pancreas, due to the formation of anastomosis through U-shaped sutures, eliminates the pressure of the thread on the pancreatic parenchyma and thereby prevents the penetration of the gland tissue. It does not require a wide (up to 3-4 cm) mobilization of the pancreatic stump. Internal continuous suture provides additional sealing of the anastomosis. Obligatory preliminary stenting of the Wirsung duct with a catheter is a necessary preventive measure in terms of impaired outflow of pancreatic secretion after tying through U-shaped sutures and the final formation of an anastomosis. All manipulations on the formation of through U-shaped sutures are performed outside the intestinal lumen, which reduces the degree of infection of the surgical field. The proposed method for the formation of an invagination terminological pancreatojejunoanastomosis during proximal resection of the pancreas maintains good prophylactic properties in relation to the development of anastomosis insolvency and the development of acute pancreatitis of the stump of the gland after surgery. Along with high reliability, the proposed anastomosis is technically quite simple.

This method of pancreatojejunoanastomosis has been successfully applied in the clinic when performing pancreatoduodenal resection for a pancreatic tumor in seven patients and chronic pancreatitis in three patients. There were no complications associated with the implementation of pancreatojejunoanastomosis. The method can be used in surgical practice.

Bibliographic list

1. Shalimov A.A. Pancreas Surgery - Moscow: “Medicine”, 1964 - 228 p.

2. Peng S.Y., Wang G.W., Li G.T., Vou Y.P., Liu Y.B., Cai X.J. Binding pancreatojejunostomy - a safe and reliable anastomosis procedure // HPB. - 2004, Volume 6 Number 3. - P.154-160.

3. Onopriev V.I., Korotko G.F., Rogal M.A., Voskanyan S.E. Pancreatoduodenal resection - Krasnodar: 2005 - 135 p.

Claims (1)

A method for the formation of an invagination terminological pancreatojejunoanastomosis during proximal pancreas resection, including the application of through U-shaped sutures in the gut – pancreas – gut sequence, invagination of the pancreatic stump into the jejunum lumen, characterized in that the ducts are inserted into the duct wall of the ducts intestines parallel to its lumen and retreating from the edge of the intestine by 1.5-2 cm, impose four to five U-shaped serous-muscular sutures, both threads of each suture they pass through the entire thickness of the parenchyma of the pancreatic stump at a distance of 1-1.5 cm from the posterior and anterior edges of the pancreatic stump, an internal continuous suture is made between the lumen of the intestine and the perimeter of the resection surface of the pancreas, with the threads of each previously applied U-shaped suture perpendicular to the continuous line sero-muscular sutures are applied to the suture on the anterior surface of the jejunum loop, the pancreatic stump is invaginated into the jejunum lumen, the sutures are sequentially tied to the adjacent eniya or at the tip of closed Branche clamping reinforce the sidewalls nodal anastomosis seam.

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