RU2525732C1 - Method of oesophageal hiatus plasty - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: plasty of the oesophageal hiatus is performed by a wall of the mobilised stomach fundus. The highest points of the stomach fundus, the adjacent portions of the left crus of the diaphragm and the oesophagus wall are sewn with inclusion of the oesophageal-diaphragmatic ligament. Lower portions of the left crus of the diaphragm and the adjoining part of the stomach fundus are sewn. The lower part of the right crus of the diaphragm and the adjoining part of the stomach fundus are sewn. Analogous suture is applied on the upper part of the right crus of the diaphragm.

EFFECT: method provides low-traumatic, precise laparoscopic correction of the oesophageal-gastric junction with the absence of the oesophagus shortening due to wide mobilisation of the cardia, the stomach fundus, and the distal part of the oesophagus, which prevents tightening of tissues in the process of carrying out fundoplication.

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Description

The present invention relates to medicine, namely to surgery, and can be used in surgical practice in the treatment of patients with hiatal hernia.

The problem of treating patients with hiatal hernia and its complications, the main reason for the development of which is the throwing of acidic gastric contents into the esophagus in case of insufficiency of the esophageal-gastric junction, remains one of the most urgent in modern surgical gastroenterology. The number of patients requiring such operations continues to increase, which is primarily due to improved diagnosis and rethinking of the medical position in the treatment of hiatal hernia, reflux esophagitis and its complications.

Since 1991, in the era of the rapid development of endoscopic surgery, they have developed and over time gained widespread recognition of methods for laparoscopic correction of insufficiency of the esophageal-gastric transition. The most commonly used methods are “complete” fundoplication according to Nissen, Nissen-Rosetti, “incomplete” fundoplication according to Belsey, Dor and Toupet [Puchkov K.V., Filimonov VB Hernias of the diaphragm. "Medpraktika-M", M., 2003].

The variety of methods used indicates a lack of satisfaction of surgeons with the results of surgical treatment of this category of patients and the absence of a single, universal technique, the "gold standard" that meets all the requirements.

One type of esophageal aperture plastic surgery using synthetic plastic materials is the operation proposed by J. Angelchik [Angelchik J.P., Cohen R. A new surgical procedure for the treatment of gastroesophageal reflux and hiatal hernia. Surg Gynecol Obstet 1979; 148: 246]. Its essence is the establishment of a ring-shaped silicone prosthesis around the esophagus, dosing the lumen of the esophageal opening of the diaphragm.

The clinical use of this operation revealed the following significant disadvantages: frequent postoperative dysphagia, migration of the prosthesis into the lumen of the gastrointestinal tract, into the abdominal and pleural cavity.

For the closest analogue of the proposed method, the variant of laparoscopic fundoplication with the use of synthetic material for plastic surgery of the esophageal opening of the diaphragm was adopted (OV Galimov et al. Method for the surgical treatment of hernia of the esophageal opening of the diaphragm. Application for invention of July 20, 2006, RF No. 2005103256). The method consists in the following: pneumoperitoneum is applied under intubation anesthesia. Using standard trocar placement points, a video laparoscope and manipulators are inserted. Assess the condition of the cardia, esophageal opening of the diaphragm. A thick tube is inserted into the stomach. The stomach is pulled in a caudal direction and a peritoneum is cut over the abdominal section of the esophagus, and it is mobilized. Bypassing the esophagus, they pass a rubber retainer around it and pull it in a ventrocaudal direction. Then, a synthetic polytetrafluoroethylene (PTFE) implant of size 8 × 8 cm is prepared, a circle with a diameter of 2.5 cm is cut out in the center of the implant, communicating due to the radial cut with the external border. The implant is twisted into a tube to carry it into the abdominal cavity through a 10 mm trocar. The implants are grabbed by the manipulators in the abdominal cavity, flattened and set in such a way that the edges of the incision of the implant encircle the esophagus, as a result of which the esophagus is in the cut out hole of the implant. The edges of the polytetrafluoroethylene mesh cut are sewn in the form of a duplicate, while the right leg of the diaphragm is seized in the seam and the implant is fixed to the diaphragm with individual manual or hardware sutures in an amount of 4-6. After this, the fundoplication cuff is formed by conducting the posterior wall of the bottom of the stomach behind the esophagus, with fixation at the lower point to the medial surface of the esophagus with one or two sutures, 2 cm above the anatomical cardia. Then, above this point for at least 4 cm, the anterior wall of the fundus of the stomach is sutured with 2-3 sutures carried out behind the esophagus by the posterior wall of the fundus of the stomach. This completes the operation.

The disadvantages of the closest analogue include:

- fibrosis of the synthetic implant with the development of a local adhesive process with compression of the esophagus and the occurrence of dysphagia in the postoperative period;

- migration of a synthetic implant into the lumen of the esophagus or stomach or into the abdominal cavity;

- partial or complete intersection or compression of the vagus nerves due to their capture in the circular cuff or with fibrosing of the implant is complicated by postoperative gastrostasis and / or intestinal paresis.

Tasks:

1) improving the safety and accessibility of the method of plasty of the esophageal opening of the diaphragm, preventing damage to the vagal innervation of the stomach;

2) the reconstruction of all the elements that make up the areflux mechanism of the cardia (acute angle of His, Gubarev's valve, abdominal segment of the esophagus);

3) the prevention of relapses in the postoperative period;

4) reducing the time of medical and social rehabilitation.

The essence of the invention lies in the fact that the plastic of the esophageal opening of the diaphragm from laparoscopic access, including mobilization of the fundus of the stomach, abdominal esophagus, fundoplication, characterized in that the plastic of the esophageal opening of the diaphragm is carried out by the wall of the mobilized fundus of the stomach by flashing the highest point of the mobilized fundus of the upper stomach, the left leg of the diaphragm and the wall of the esophagus with the capture of the remains of the esophageal-diaphragmatic ligament, then form the next suture ligament by stitching the bottom portion of the left leg of the diaphragm and the adjacent part of the fundus of the stomach, after which the next suture is formed by stitching the bottom of the right leg of the diaphragm and the part of the bottom of the stomach adjacent to it, then a similar seam is applied to the upper part of the right leg of the diaphragm.

Technical result

The method allows for minor trauma and precision surgical correction of the esophageal-gastric transition in case of HPA and the absence of shortening of the esophagus. The method provides technically accessible wide mobilization of the cardia, fundus, distal esophagus, preventing tissue tension when performing fundoplication, creating a functional areflux cuff, and reliably closing the esophageal opening of the diaphragm. The method provides good results in the postoperative period due to the reliable closure of the esophageal opening of the diaphragm with the bottom of the stomach, which prevents the migration of the fundoplication cuff into the posterior mediastinum and thus prevents the recurrence of HPAI, improves the functional result.

The implementation of the method is shown in Fig. 1-8, where Fig. 1 is the mobilization of the cardiac section and the bottom of the stomach, starting with the intersection of the upper part of the gastro-splenic ligament; Fig. 2 - stage of mobilization (allocation of the bottom of the stomach); Fig. 3 - selection of the left phrenic pedicle; Fig. 4 - mobilization of the stomach along the lesser curvature as a superselective proximal vagotomy; Fig. 5 - the beginning of the formation of the reflux cuff - the suture that restores the angle of His; Fig. 6 - the formation of a seam that captures the lower portion of the left diaphragmatic leg and the adjacent part of the bottom of the stomach; Fig. 7 - suture fixing the right side of the cuff and the upper part of the right leg of the diaphragm; Fig. 8 - fixation of both semicircles of the cuff between each other and to the diaphragm and the creation of a circular areflux structure around the esophagus, where: paragraph 1 - front n.vagus; 2 - isolation and clipping of a short gastric vessel; 3 - branch of the lower diaphragmatic artery; 4 - the bottom of the stomach turned away by a clip; 5 - a section line of the parietal peritoneum; 6 - branch of the posterior gastric artery; 7 - abdominal fat flap allotted to the right and up with the front n.vagus; 8 - abdominal esophagus; 9 - the first transverse gastric artery; 10 - rear n.vagus; 11 - seam-ligament restoring the angle of His; 12 - seam-ligament, capturing the lower portion of the left diaphragmatic leg and the adjacent part of the bottom of the stomach; 13 - a seam fixing the right side of the bottom of the stomach and the lower part of the right leg of the diaphragm; 14 - seam-ligament, fixing the bottom of the stomach and the upper part of the right leg of the diaphragm.

The proposed method is as follows. Surgical intervention begins with carbon dioxide insufflation into the abdominal cavity. The trocars are installed at the points: 1) 10 mm trocar is 1-2 cm above the navel in the midline (inserted first) for 30 "optics; 2) 10 mm trocar in the right hypochondrium along the mid-clavicular line is for insertion retractor and leads of the left lobe of the liver; 3) 10 mm trocar in the left mesogastric region along the midclavicular line 3-4 cm lower and 1-2 cm to the left of the xiphoid process - for the introduction of a soft clamp of the Bebcoccus type; 4) 10 mm trocar in the left hypochondrium along the midclavicular line - for the introduction of the main instruments (dissector, scissors, clip applicator; 5) 10 mm trocar in the left mesogastric region along the anterior axillary line - to insert a Beccoccus clamp and a mini retractor for the esophagus. The operating table is moved to the Fowler position (30-35 degrees), a probe is inserted into the stomach (diameter 14 mm). The left lobe of the liver is removed by the hepatic retractor up and to the right.

The peritoneum is opened along the edge of the esophageal opening of the diaphragm, then the AML and its left leg are skeletonized, crossing the esophageal-diaphragmatic, diaphragmatic-cardial and phrenic-fundal ligaments. The intersection of the esophageal-phrenic ligament is carried out after skeletonization of the left leg of the diaphragm at its left edge (safe area for the anterior-left trunk n.Vagus p.1, 3, Fig. 1). The cardia and the abdominal esophagus are produced together with fiber, ligamentous apparatus, trunks of the vagus nerves and their main branches, which significantly lengthens the abdominal esophagus and facilitates the work on the esophagus-gastric junction. Then, parietal in the proximal direction (p. 5, Fig. 2) mobilize the bottom of the stomach, cross the upper part of the gastro-splenic ligament, clip and cross 1-2 proximal short gastric vessels (p. 2, Fig. 1) - only under this condition the mobilization volume will be sufficient for further use of the bottom of the stomach as a plastic material and the formation of the areflux structure without tension (Fig. 1). The mobilized fundus of the stomach is turned anteriorly and downward, revealing the posterior wall of the fundus of the stomach (Section 4, Figure 2), which provides wide access to the left and right legs of the diaphragm, posterior gastric artery (Section 6, Figure 3), and the posterior (right ) to the trunk of the vagus nerve (item 10, Fig. 5), excluding its damage during dissection of the esophagus from the back. The cardia and the proximal part of the body of the stomach are mobilized from behind, the first posterior transverse vascular branch is crossed (item 6, Fig. 3). The mobilized bottom of the stomach is lowered into place and proceed to dissection of the anterior wall of the cardia and small curvature from top to bottom. A flap is formed from mobilized fiber at the apex of the His angle, separating the apex of the small omentum from the wall of the stomach. Pulling for it, they achieve contouring of the main trunk of the anterior vagus and its branches going to the stomach (Clause 7, Fig. 4).

The neurovascular bundles cross parietally. After crossing the cardiac branches n. vagus mobility of the omentum flap increased. The main trunk of the vagus with a small omentum is freely retracted and the angle of lesser curvature and the esophageal-gastric transition open well.

Over the course of 3-4 cm, the abdominal esophagus is mobilized (paragraph 8, Fig. 4), while the connective tissue jumpers located between the vagus nerves and the esophagus are dissected. The small omentum is phased out and precision denervate and skeletonize the lesser curvature of the stomach to the level of the first and second transverse vascular branches (Clause 9, Fig. 4). In a small omentum, vagus branches and vessels cut off from the wall of the stomach leave (Fig. 4). This completes the mobilization. The mobilized esophagus is pulled up with a retractor. The highest point of the mobilized bottom of the stomach (at the level of the last crossed short gastric vessel) is sutured with a serous-muscular suture with Ethibond 2-0 suture on an atraumatic needle, the wall of the esophagus is sutured at a distance of about 3 cm proximal to the esophageal-gastric junction, with the capture of the remains of the esophageal-diaphragmatic ligaments and the adjacent upper portion of the left leg of the diaphragm (paragraph 11, Fig. 5). The thread is tightened without tension of the fixed tissues, the knots are tied intracorporeally. The first suture implements both restoration of the physiological acute angle of His, and abdomination of the lower esophagus. The esophagus is raised, behind it on the front surface, the posterior wall of the fundus of the stomach is carried out. The next suture is formed 2-2.5 cm lower than the previous one; the lower portion of the left leg of the diaphragm and the adjacent part of the fundus of the stomach are captured into it (item 12, Fig. 6). In the next suture, the right part of the bottom of the stomach and the lower part of the right leg of the diaphragm are captured (item 13, Fig. 7), then a similar seam is applied to the upper part of the right leg of the diaphragm (item 14, Fig. 8). Thus, the plastic of the esophageal opening of the diaphragm is completed, after which the fundoplication cuff is formed.

Clinical example: Patient N-va LB, 50 years old, was admitted to XO No. 4 of MUZ GB No. 2 KMLDO on 09.03.09 with a diagnosis of Axial cardio-fundal non-fixed hiatal hernia. GERD: distal catarrhal reflux esophagitis 1 tbsp. by Savary Miller.

The diagnosis is confirmed by fibroesophagogastroduodenoscopy, polypositional x-ray examination of the esophagus and stomach, 24-hour pH-metry.

Under combined anesthesia, March 13, 2010, an operation was performed: laparoscopic elimination of HPOD, formation of areflux cardia.

The application of pneumoperitoneum and the introduction of trocars. The left triangular ligament of the liver is crossed, the left lobe of the liver is laid up and to the right. Mobilization of the upper part of the gastro-splenic ligament with the isolation, clipping and intersection of two proximal short gastric vessels. The fundus of the fundus and bottom of the stomach was mobilized along a large curvature to the left wall of the esophagus with visualization of the left phrenic leg. The mobilization was performed according to the lesser curvature of the stomach as a superselective proximal vagotomy with the intersection of the proximal transverse vessel. The peritoneal fat flap of the small omentum, containing the anterior vagus nerve, is laid up and to the right. The esophagus is elevated, tissue dissection is performed in the posterior esophageal space, the posterior vagus nerve is visualized and displaced dorsally, the phrenic legs are highlighted. 4 cm of the lower third of the thoracic esophagus was mobilized. Then the highest point of the mobilized fundus of the stomach is 5 cm distal to the left wall of the esophagus along a large curvature, stitched with a serous-muscular suture with a thread - Ethibond 2-0 on an atraumatic needle, with subsequent capture of the left wall of the esophagus 5 cm above the level of the cardia, the remains of the esophagus - diaphragmatic ligament and an adjacent portion of the tendon of the diaphragm - the specified angle restored His angle and the abdominal position of the lower part of the esophagus.

The esophagus is elevated, behind it on the front surface is the posterior wall of the fundus of the stomach. A suture is applied that captures the bottom of the stomach and the lower part of the left leg of the diaphragm.

In the next suture, the right part of the bottom of the stomach and the lower part of the right leg of the diaphragm are captured, then a similar suture is applied to the upper part of the right leg of the diaphragm, thus completing the plastic of the esophageal opening of the diaphragm.

After that, the anterior and posterior walls of the fundus of the stomach are sewn together at proximal points with the capture of the wall of the esophagus and the remnants of the esophageal-diaphragmatic ligament and the right leg of the diaphragm. Distal over 5 cm, the right and left sides of the formed cuff are sewn with the inclusion of the esophagus wall, with an interval of sutures of 1 cm.

The postoperative period was uneventful.

The nasogastric tube was removed by the end of 1 day.

Transferred from the anesthesiology and intensive care unit to the ward of the department on the 2nd day, then enteral nutrition was started through the mouth.

On the 3rd day after the operation, a contrast polypositional x-ray of the esophagus and stomach was performed: a satisfactory cuff function, gastroesophageal reflux was not noted, no streaks of contrast were detected.

The patient was discharged on the 4th day after surgery.

During follow-up examination 6 months after surgery:

Esophagogastroscopy: signs of inflammation of the mucous membrane of the esophagus were not detected, the cardia is closed, signs of gastroesophageal reflux are not noted.

Polypositional fluoroscopy of the esophagus and stomach: satisfactory function of the areflux cuff, no signs of HPA and GER were noted.

At present, the condition is satisfactory, complaints typical of a hiatal hernia and gastroesophageal reflux disease are absent.

Claims (1)

A method for plasty of the esophageal opening of the diaphragm from laparoscopic access, including mobilization of the bottom of the stomach, abdominal esophagus, fundoplication, characterized in that the plastic of the esophageal opening of the diaphragm is carried out by the wall of the mobilized bottom of the stomach by flashing the highest point of the mobilized bottom of the stomach, the adjacent upper portion of the diaphragm of the left leg wall with the capture of the remains of the esophageal-diaphragmatic ligament, then form the next suture ligament by flashing the lower portion of the left leg and diaphragm attached thereto fundic portion of the stomach, after which the next seam formed by sewing a bunch-lower portion of the right leg and the diaphragm attached thereto fundus portion, then a similar seam is applied on top of the right leg of the diaphragm.

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