RU2506904C1 - Method of surgical treatment of chronic impairment of duodenal patency from mini-access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be applied for surgical treatment of chronic impairment of duodenal patency from mini-access. On the eve of operation 150 ml of heated to 37°C water are introduced to patient into lumen of duodenum through biopsy channel of endoscope in the process of carrying out fibrogastroduodenoscopy at the end of examination by means of Janet syringe. After that, ultrasonic examination, during which location of duodenum is controlled, is carried out. Organ contour is determined and presented on anterior abdominal wall by dots in schematic way. During operation longitudinal up to 5 cm long cut of skin, subcutaneous adipose cellular tissue, aponeurosis is made maximally close to the dots. Universal basic set of instruments of "mini-assistant" series is installed and duodenum is exposed.

EFFECT: method makes it possible to reduce trauma.

1 ex

Description

The invention relates to medicine, namely to abdominal surgery and can be used in the treatment of patients with chronic disorders of duodenal patency.

Chronic disorders of duodenal patency is a clinical symptom complex, characterized by an increase in pressure in the duodenum and difficulty in moving the food chyme, delaying its evacuation to the lower parts of the small intestine.

Duodenal obstruction is diagnosed in 45-100% of patients with diseases of the hepatogastropancreatoduodenal zone (I.N. Mikhaskiv, 1980; G.F. Gowen, 1985). And in 70-90% of cases it has a functional nature (A.V. Fedorov et al., 1992; S.A. Kasumyan, M.A. Alibegov, 1997; Martynov V.L., 2006, LS Colemont, M. Camilleri, 1989). Conservative treatment in not all patients allows success (V.F. Saenko et al., 1985; Yu.A. Nesterenko et al., 1990; C.S. Lee, J.C. Mangla, 1978). The positive result of duodenojejunostomy in such cases is noted by many authors (Yu.M. Pantsyrev et al., 1984; P.M. Postolov, 1986; I.V. Sergeev et al., 1991; V.L. Martynov, 2006; A. K. Grafov, 2006, HJ Mindell, JV Holm, 1996).

The modern development of surgery, the improvement of technical approaches, tools, has led to the development of operations from minimal access. A further search is underway, improving various non-traumatic surgical approaches on the abdominal organs (Zhuravlev V.N., 1998; Stepanov V.N., 2002). New operations, however, must comply with the rules of traditional surgery, which are anatomical accessibility, technical feasibility, physiological permissibility (Zilberman MN, 1978; Pytel Yu.A., 1998). The main goal of minimally invasive surgery is to reduce surgical aggression provided that a complete and radical volume of surgery is performed.

A set of tools and early expanders “mini-assistant” allows you to create and maintain a sufficient “operational space” deep in the tissue from a relatively small incision (4-5 cm) and manipulate it freely.

A known method of treating chronic disorders of duodenal patency, which consists in the fact that after a standard laparotomy, an incision is made of the duodenum along its axis at an equidistant distance from the sphincters of the duodenum. A section of the jejunum is performed transversely of its longitudinal axis at an equidistant distance from the sphincter of the jejunum (Nazarenko P.M., Bilichenko V.B., Bart I.I., Petukhov I.M., Petukhov V.M. Patent No. 2111709).

The main disadvantage of this method is the high morbidity due to damage to the tissues of the anterior abdominal wall with standard laparotomy.

The technical result is a reduction in the invasiveness of the operation.

The technical result is achieved by the fact that on the eve of the operation, the patient, when performing fibrogastroduodenoscopy at the end of the study, injects 150 ml of water heated to 37 ° С into the lumen of the duodenum through the biopsy channel of the endoscope, then an ultrasound examination is performed, in which the location of the duodenum is monitored, and points schematically depict the contour of the organ on the anterior abdominal wall; in surgery, a longitudinal incision of the skin is performed as close to the marked points as possible; skin fat, fascia up to 5 cm, set universal basic set of tools Series "Mini-Assistant" and produce the duodenum.

The method is as follows.

On the eve of surgery, the patient when performing

fibrogastroduodenoscopy at the end of the study, 150 ml of water heated to 37 ° C is injected into the lumen of the duodenum with a Janet syringe through the biopsy channel of the endoscope. An ultrasound examination is then performed, in which the location of the duodenum is monitored, the outline of the organ on the anterior abdominal wall is determined and schematized with dots.

During surgery, a longitudinal incision of the skin, subcutaneous fatty tissue, and aponeurosis up to 5 cm long is performed as close to the marked points as possible. A universal basic set of instruments of the “mini-assistant” series is installed. The visceral sheet of the peritoneum is cut through an arc-shaped incision along the external contour of the duodenum from the root of the mesocolon to the root of the mesentery of the small intestine. Allocate the descending, lower horizontal part of the duodenum. A section of the jejunum, spaced 14–16 cm from the Treitz ligament, is brought to the lower bend of the duodenum. Sphincter zones are visualized in the lower horizontal part (or the initial segment of the ascending part) of the duodenum on the one hand, and in the middle section of the descending part (in the zone the location of the large duodenal nipple), on the other, and the jejunum. A longitudinal-transverse anastomosis is placed between these sphincters and sphincters of the jejunum, its line on the jejunum is preliminarily determined so that it is located transversely to the longitudinal axis and is equidistant from the edges of the sphincter zones of the jejunum. Then, determine the line of the anastomosis on the front surface of the lower bend of the duodenum so that it is parallel to the longitudinal axis and spaced from the edges of the sphincter zones at an equal distance, and from the edge of the head of the pancreas by 1.5-2 cm. A longitudinal-transverse duodeno-anastomosis 1.5 cm wide is formed double-row seam.

Clinical example No. 1

Patient T., 54 years old, was admitted to the surgical department of City Clinical Hospital No. 4 of Kursk on October 18, 2011 with complaints of pain in the upper abdomen, nausea, and vomiting mixed with bile. From the anamnesis it was found that she was ill for about 16 years, 3 years ago a laparoscopic cholecystectomy was performed for acute calculous cholecystitis. Surveyed. Diagnosis: Condition after laparoscopic cholecystectomy. Functional chronic violation of duodenal patency, Art. decompensation. On October 20, 2011, the patient underwent surgery: a longitudinal-transverse duodenoeunioanastomosis was imposed from the mini-access. Under endotracheal anesthesia, departing from the xiphoid process of 4 cm, a longitudinal incision of the skin, subcutaneous fatty tissue, and aponeurosis 5 cm long was made in the midline of the abdomen. A universal basic tool kit of the mini-assistant series was installed. The visceral sheet of the peritoneum along the outer contour of the duodenum from the root of the mesocolon to the root of the mesentery of the small intestine is dissected by an arc-shaped incision. The descending, lower horizontal parts of the duodenum are highlighted. The width of the descending part is 4.8 cm; the ratio of the width of the descending part to the width of the ascending part is 1.7. A section of the jejunum, spaced from the Treitz ligament at a distance of 14-16 cm, is brought to the lower bend of the duodenum. Sphincter zones were determined in the lower horizontal part of the duodenum on the one hand, and in the middle section of the descending part, on the other, and the jejunum. Between these sphincters and sphincters of the jejunum, a longitudinal-transverse longitudinal-transverse duodenojejunoanastomosis with a width of 1.5 cm is double-stitched.

The postoperative period was uneventful. In the postoperative period, she received antibiotics, analgesics, antispasmodics, prokinetics, the drug urrsdeoxycholic acid (ursofalk), fraxiparin in standard doses. After 10 days, was discharged in satisfactory condition. Examined after 5 months. With fluoroscopy, evacuation of contrast from the stomach is portion-rhythmic for 25 minutes, performed in the unexpanded sections of the duodenum, then through duodenojejunostomy to the jejunum and partially to the distal parts of the duodenum. The function of duodenojejunostomy is satisfactory.

Thus, the improvement of the results of surgical treatment of chronic duodenal patency disorders can be achieved by reducing surgical aggression provided that a complete and radical amount of surgery is performed using the universal basic tool kit of the mini-assistant series.

Claims (1)

A method for surgical treatment of chronic duodenal obstruction from the mini-access, including laparotomy, the imposition of a longitudinal-transverse duodenojejunoanastomosis, characterized in that on the eve of the operation, the patient, when performing fibrogastroduodenoscopy, at the end of the study, with a Janet’s syringe through a biopsy channel 150 ml is inserted into the duodenal ulcer through a biopsy channel of 150 ° water, then an ultrasound is performed, in which the location of the duodenum is controlled, and a schematic but the dots depict the contour of the organ on the anterior abdominal wall; in operations as close to the marked points as possible, a longitudinal incision is made of the skin, subcutaneous fat, aponeurosis up to 5 cm long; establish a universal basic tool kit of the “mini-assistant” series and isolate the duodenum.