RU2436520C1 - Method of videoassisted sewing of perforative pyloroduodenal ulcers - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to surgery and can be applied for videoassisted sewing of perforative pyloroduodenal ulcers. Cut is made umbically. Laparoscope and instrumental port for aspirator are installed. Cut for manipulator is made in right hypocondrium at 2 cm distance from right costal margin and 4 cm rightward medial line, which is later extended with transformation into transrectal 3-5 cm miniaccess. "Mini-assistant" is installed. Perforation is sutured. Sanitation of subhepatic and subdiaphragmal space on the right is carried out. ^ EFFECT: method makes it possible to improve conditions of visualisation and manipulation, reduce trauma of intervention. ^ 1 ex, 2 dwg

Description

The invention relates to medicine, in particular to endoscopic surgery, and can be used in the treatment of perforated pyloroduodenal 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, suturing of the perforated hole, primary resection of the stomach, vagotomy with suturing of the perforated hole were found (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 severe 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. In this case, 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.

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., Sigal E.I., Odintsov V.V. Endoscopic surgery. - M.: GEOTAR Medicine, 1998. P.259- 270).

The disadvantages of the method

1. An incision for mini-access is performed 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, which increases the trauma of the anterior abdominal wall and worsens the cosmetic effect of the operation.

The objective of the invention is to improve the visualization and manipulation conditions in the area of surgical intervention, reduce the morbidity and severity of postoperative pain, achieve a good cosmetic result by reducing the number of incisions on the anterior abdominal wall and performing one of the incisions in the navel.

The problem is achieved by the method of video-assisted suturing of perforated pyloroduodenal ulcers, including two incisions on the anterior abdominal wall, one of which is performed in the projection of the localization of the ulcer.

An incision is performed umbilically, into which a laparoscope and an instrument suction port are installed. At a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, an incision is made to insert a second instrument port for the manipulator. After abdominal sanitation, the instrumental port in the right hypochondrium is removed, the incision for the instrumental port in the right hypochondrium is expanded with its transformation into a vertical transrectal mini-access of 3-5 cm, the Mini-Assistant apparatus is installed in it, perforation is sutured, subhepatic sanitation is performed and subphrenic space on the right.

Novelty of invention

- Perform an incision umbilically, in which a laparoscope and an instrument suction port are installed. In the projection of the localization of the ulcer at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, an incision is made to insert a second instrument port for the manipulator. This arrangement allows you to improve the conditions for the rehabilitation of all parts of the abdominal cavity. The introduction of a laparoscope and an instrumental port through a single access does not impair the quality of visualization and rehabilitation of the abdominal cavity. The location of the suction and manipulator at an angle of more than 45 degrees allows you to well sanitize all parts of the abdominal cavity.

- In the projection of the localization of the ulcer at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, after removing the instrumental port in the right hypochondrium, the incision is expanded with its transformation into a vertical transrectal mini-access of 3-5 cm, and the apparatus is installed in it “Mini-assistant”, they perform suturing of the perforation, rehabilitation of the subhepatic and subphrenic space on the right. Performing an abdominal wall incision and introducing the instrument port at the mini-access point with its further expansion and transformation into the mini-access leads to a decrease in the number of additional incisions on the abdominal wall and a decrease in the morbidity and good cosmetic effect. 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. This allows you to suture pyloroduodenal perforations larger than 1 cm with severe periulsirogenic infiltration and eliminate other complications of peptic ulcer disease, such as stenosis and bleeding. Using the injection port in the right hypochondrium for mini-access allows reducing the number of incisions on the anterior abdominal wall to two, which reduces trauma to the anterior abdominal wall and leads to a good cosmetic effect.

Thus, the proposed method for video-assisted suturing of perforated pyloroduodenal 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 traditional (laparotomy) and laparoscopic treatment options for perforated pyloroduodenal 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 pyloroduodenal ulcer, an anatomical experiment was conducted on unoperated male and female corpses from 18 to 80 years old. 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 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 figure 1, which shows the location of the incisions during the laparoscopic stage of the operation.

1 - Section for the introduction of the instrument port at a distance of 2 cm from the right costal arch and 4 cm to the right of the median line.

2 - A section in the navel for a laparoscope and an instrument port.

The invention is illustrated in figure 2, which shows the location of the incisions when suturing the perforation from the mini-access followed by final rehabilitation of the abdominal cavity.

3 - Vertical transrectal mini-access in the projection of localization of the ulcer 2 cm below the right costal arch and 4 cm to the right of the midline of the abdomen, made by expanding the incision from the instrumental port.

2 An incision in the navel area for a laparoscope and an instrument port.

The method of video-assisted suturing of pyloroduodenal 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. The incision is performed umbilically, i.e. by making an incision through the navel into which the laparoscope port is installed. Perform an audit of the abdominal cavity. In the absence of contraindications for video-assisted suturing, a second trocar d = 5 mm for suction is established through the performed umbilical access. At a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen at the mini-access point, an incision is made to insert a second instrument port for the manipulator d = 5 mm FIG. 1. The introduction of a laparoscope and an instrumental port through a single access does not impair the quality of visualization and rehabilitation of the abdominal cavity. The location of the suction and manipulator at an angle of more than 45 degrees allows you to well sanitize all parts of the abdominal cavity. The abdominal cavity was drained, fibrin films, food particles with washing the abdominal cavity with a large amount of antiseptics and turning the body in different planes were removed. Remove the instrumental port in the right hypochondrium. In order to reduce the number of additional sections of the abdominal wall and reduce the invasiveness of the operation, as well as improve the cosmetic effect, in the projection of the localization of the ulcer at a distance of 2 cm below the costal arch and 4 cm to the right of the midline of the abdomen, the incision for the instrumental port is expanded with its transformation into vertical transrectal mini-access 3-5 cm, install the apparatus "Mini-assistant" in it Fig.2. The installation of the Mini-Assistant apparatus allows you to visualize well the place of perforation and freely manipulate general surgical instruments in this area. Perforation was sutured by the surgeon's preferred method. From the mini-access, sanitation of the subhepatic and subphrenic spaces on the right was performed and drainage was installed in the subhepatic space on the right if there were indications, which was discharged through a separate incision on the side wall of the abdomen on the right. Mini access was sutured. After suturing the perforated hole, the final multiple sanitation of the abdominal cavity was carried out with an aqueous solution of chlorhexidine in a volume of at least 3-5 liters. 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 supraumbilical access is sutured in layers.

Example

Patient G., 45 years old, was admitted to the surgical department on 03.30.10 at 13.35 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 9 hours, when “dagger” pains appeared in the upper abdomen against the background of well-being. 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 03.30.10 at 15:00 After processing the surgical field, a skin incision in the navel area 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. Through the performed umbilical access, another trocar with a diameter of 5 mm is installed for suction. At a distance of 2 cm from the right costal arch and 4 cm to the right of the midline of the abdomen, a skin incision was made for the second instrument port with a diameter of 5 mm, a manipulator was introduced. Pathological exudate with fibrin, particles of food in all parts of the abdominal cavity was aspirated without difficulty. The port in the right hypochondrium is removed. The skin incision at a distance of 4 cm from the midline and 2 cm below the costal arch is expanded vertically to 4 cm, the abdominal cavity is opened in layers. The “Mini Assistant” apparatus is 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 incision of the anterior abdominal wall after removal of the Mini-Assistant apparatus is sutured in layers. The final rehabilitation of the abdominal cavity was performed under the control of a laparoscope. After removing the tools and ports, the dual access is closed. The duration of the operation is 80 minutes. The postoperative period was favorable, analgesia 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)

The method of video-assisted suturing of perforated pyloroduodenal ulcers, including two incisions on the anterior abdominal wall, one of which is performed in the projection of the localization of the ulcer, characterized in that the incision is performed umbilically, into which the laparoscope and the instrumental port for suction are installed, in the right hypochondrium at a distance of 2 cm from the right costal arch and 4 cm to the right of the midline, an incision is made for the manipulator, which is further expanded with transformation into a transrectal mini-access of 3-5 cm, set Pouring "Mini-assistant", suturing the perforation, performing sanitation of the subhepatic and subphrenic space on the right.

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