RU2529415C2 - Method for performing laparoscopic fundoplication depending on patient's body type - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and can be used to perform a laparascopic fundoplication depending on a patient's body type. A patient's somatotype is determined. If the patient has a macrosomatic type, the laparoscopic fundoplication is performed by inserting five trocars into the abdominal cavity with the first 11 mm trocar inserted 20 cm below a xiphoid process, the second 11 mm trocar inserted along the mid-line 1 cm below the xiphoid process, the third 11 mm trocar inserted along a first axillary line on the left 3 cm below a costal arch, the fourth 5 mm trocar inserted along a midclavicular line on the right 4 cm below the costal arch and the fifth 5 mm trocar inserted on the left from the mid-line 4 cm below the costal arch at the intersection of a line connecting the second and third trocars. If the patient has micro- and mesosomatic types, the first 11 mm trocar is inserted through a navel, the second 11 mm trocar is inserted along the mid-line 1 cm below the xiphoid process, the third 11 mm trocar is inserted along the anterior axillary line on the left at the mid-distance between a lower edge of the costal arch and a spina iliaca anterior superior; the fourth 5 mm trocar is inserted along the midclavicular line on the right 2 cm below the edge of the costal arch; the fifth 5 mm trocar is inserted along the midclavicular line on the left 2 cm below the edge of the costal arch. The fundoplication is performed to form a tension-free fundoplication cuff.

EFFECT: method enables creating an optimum approach, reducing risk of recurrence.

2 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery, can be used in the treatment of patients with hiatal hernia and gastroesophageal reflux disease, by performing laparoscopic surgery with non-tensile fundoplication of the anterior wall of the fundus of the stomach, taking into account the constitutional type of the patient.

Gastroesophageal reflux disease (GERD) and hiatal hernia (HAP) is a chronic relapsing disease caused by spontaneous, regularly repeated reflux of gastric and / or duodenal contents into the esophagus, leading to damage to the lower esophagus.

According to the Gallup Institute (USA) (Gallup Organization National Survey: Heartburn across America. Princetown: The Gallup Organization Inc 1988), cited by G. Jamieson and A. Duranceau (Jamieson G., Duranceau A. Gastroesophageal reflux. Philadelphia: WB Saunders 1988; 65), approximately 44% of Americans have symptoms of heartburn at least once a month, 7% experience it daily, and 18% of these people have to resort to self-medication to eliminate the symptom. Esophagitis is present in approximately 1% of the population (Pimanov I.S. Esophagitis, gastritis and peptic ulcer. N. Novgorod 2000). Among these patients, 20% suffer from severe reflux, causing complications such as Barrett's syndrome (10-15%), ulceration (2-7%), stricture (4-20%), bleeding (2%) (Pimanov I.S. Esophagitis, gastritis and peptic ulcer. N. Novgorod 2000). Regurgitation and night aspiration are found in 40% of patients with gastroesophageal reflux disease and hiatal hernia, heartburn and reflux in 86%, nausea and vomiting in 40% (Pimanov I.S. Esophagitis, gastritis and peptic ulcer. N. Novgorod 2000). 30% of these patients have anemia (Cuschieri A. Hiatal hernia and reflux esophagitis. In: Minimally Invasive Surgery. Eds. J. G. Hunter, J. M. Sackier. McGraw-Hill, Inc. 1993; 87-111). Naturally, with such an epidemiology of GERD and HPOD, the development of methods for conservative and surgical treatment of gastroesophageal reflux is of great practical importance.

The importance of determining the patient's somatotype during laparoscopic surgery to remove hiatal hernia or in the treatment of gastroesophageal reflux disease is explained by the relationship between the internal organs and external landmarks used by the surgeon to determine the points of trocar insertion (navel, costal arch, etc. ) differ in patients with different somatotypes. Due to the fact that the laparoscope and instruments have a certain length, it is necessary to take these features into account when choosing the points of introduction of trocars in order to achieve adequate visualization and the possibility of manipulation in the area of the esophageal-gastric transition.

A known method of total fundoplication according to Nissen, including laparotomy and laparoscopic access (Dallemagme B., Weerts JM, Jehaes C. Laparoscopic Nissen fundoplication: preliminary report // Surg. Laparosc. Endosc. - 1991. - Vol.1. No. 1. - P .138-143). The method includes dissecting the esophageal-diaphragmatic ligament under laparoscopic observation, isolating the right and left legs of the diaphragm, performing transchiatal mobilization of the esophagus with its holding, forming a retroesophageal window of sufficient width, after which the posterior flap from the bottom of the stomach is passed through the opening, bring it closer together on the opposite side with the same front flap with fixation of the formed circular fundoplication cuff at the level of the abdominal food yes, the lumen of which is introduced previously thick probe. In a modification of Nissen's Rosetti operation, the fundoplication cuff is made entirely from the anterior wall of the stomach (Rossetti M., Liebermann-Heffert D., Braun RB The “Rossetti” modification of the Nissen fundoplication: technique and results. Dis. Esoph. 1996; 9: 251 -257).

One of the drawbacks of this method of surgery is the frequent and prolonged dysphagia, which necessitates repeated surgery (Hunter JG, Swanstrom L., Waring P. Dysfagia after laparoscopic antireflux surgery: The impact of operative technique // Ann. Of. Surg. . - 1996. - Vol.224, No. 1. - P.51-57.). In essence, the Nissen fundoplication cuff is a compression ring that prevents the esophagus from expanding under the cuff and preliminary introduction for calibration, before suturing the cuff, a thick probe into the lumen of the esophagus does not completely exclude dysphagia. Also, compression of the vagus nerves enclosed in the fundoplication cuff causes pylorospasm in patients. Other disadvantages are that the performance of total fundoplication according to Nissen in this way does not take into account the features of laparoscopic surgery in patients with various somatotypes.

A known method of fundoplication according to Toupet, including laparotomic or laparoscopic access (Puchkov K.V., Filimonov VB "Hernias of the esophageal opening of the diaphragm", Medpraktika - M., Moscow, 2003, pp. 70-71). The essence of the method is that they cut the upper half of the small omentum, partially mobilize the bottom of the stomach, abdominal and lower thoracic esophagus, form a fundoplication cuff with fixation of its upper part to the legs of the diaphragm. To do this, it is necessary to bandage 1-2 short gastric arteries passing in the gastro-splenic ligament. The esophagus is secreted from the surrounding tissues, taken to the holder, wrapped in a fold of the bottom of the stomach 270 degrees, move the back wall of the bottom of the stomach behind the esophagus (180 degrees behind and 90 degrees in front). The disadvantages of this method include the presence of a relapse of gastroesophageal reflux, since the valve function of the formed cuff is insufficient, as well as the cuff displacement relative to the esophageal opening of the diaphragm, since the gastro-diaphragmatic ligament is intersected, and the operation procedure also does not take into account the constitutional features of patients.

A known method of video-assisted fundoplication (patent RU 2291672, publ. 01.20.2007, Bull. No. 2). The method consists in mobilizing the small omentum, entering the stuffing bag, visualizing the right leg of the diaphragm, mobilizing the esophagus by highlighting the middle bundle of the right leg of the diaphragm, preserving the gastro-diaphragmatic ligament as a guideline separating the stomach into the anterior and posterior walls, and isolating the esophagus from the posterior mediastinum, restoring its abdominal position, moving behind the esophagus along the medial bundle of the right leg of the diaphragm, complete the mobilization of the esophagus and the muscle loop around it, I the rear wall of the stomach from the small curvature, under the esophagus, followed by the rear wall behind the stomach and esophagus fundoplikatsionnuyu cuff formed by fixing the front and rear walls of the fundus of the stomach to the esophagus wall throughout.

The disadvantage of this method is the technical complexity of the intervention, the method also does not take into account the constitutional features of the patient.

There is a method of selecting the points of insertion of instruments into the cavity (Schnitko S.N., Strinkevich A.L. Endoscopic surgery. - 1999. - 2. - P.75-76), which consists in the fact that the optical axis of the endoscope should be perpendicular to the plane of intervention at the point of the most critical stage of the operation and the angle between two adjacent tools should tend to a value of 45 degrees, while the main plane of the tools should be located on the line of operation.

However, this method does not take into account the constitutional features of the patient, and also does not determine the optimal installation area of the endoscope, which is calculated as a reference point for measuring the angles and places of the remaining punctures, and castling of instruments, in which mirror visual control may occur, is not predetermined in terms of changes angles after her.

A known method of providing endoscopic access (RU 21885587, publ. 09/10/2002), including the introduction of an endoscope, determining the area of operation under the control of an endoscope, selecting the points of introduction of instrumental trocars and puncture of the cavity wall, characterized in that a square is projected onto the surface of the body, for which a tension is projected a ring of flexible material between the points of introduction of the endoscope and the projection onto the cavity wall of the most critical intervention zone, then stretch it in the middle between these two points with the formation of a square, in at the opposite angles of which the endoscope and the zone of the most critical manipulations are located on one diagonal, and the introduction points of the main instrumental trocars on the other diagonal.

However, this method does not provide for the patient’s physique, and does not take into account the peculiarities of work in the field of the esophagus-gastric transition, but has a generally recommending nature for the relationship of the introduced instruments. In addition, the method involves the presence of special equipment that is not available in most institutions. All of the above does not allow for adequate visualization of the esophageal-gastric transition zone.

The objective of the invention is to improve the results of treatment of patients with hernias of the esophageal diaphragm and gastroesophageal reflux disease, reduce the number of relapses and other complications by performing non-tight fundoplication with the anterior wall of the bottom of the stomach and choosing the optimal laparoscopic access to the zone of the esophagus transition, taking into account the patient's somatotype.

The technical result of the invention is to increase the effectiveness of surgical treatment of hernias of the esophageal diaphragm and gastroesophageal reflux disease in patients of various somatic types, by reducing the frequency of complications in the form of dysphagia and pylorospasm.

The task is achieved by the fact that the somatotype is determined in patients, with the macrosomatic type of the patient, laparoscopic fundoplication is performed when five trocars are introduced into the abdominal cavity, while the first 11 mm trocar is injected 20 cm below the xiphoid process, the second 11 mm trocar is introduced along the midline, 1 cm below the xiphoid process, the third 11 mm trocar is introduced along the anterior axillary line to the left, 3 cm below the costal arch, the fourth 5 mm trocar is introduced along the midclavicular line to the right, 4 cm below the costal arch and the fifth 5 mm tro the car is introduced to the left of the midline, 4 cm below the costal arch, at the intersection with the line connecting the second and third trocars, with micro- and mesosomatic types, the first 11 mm trocar is introduced through the navel, the second 11 mm trocar is inserted along the midline, by 1 cm below the xiphoid process, the third trocar 11 mm is inserted along the anterior axillary line on the left, at the middle of the distance between the lower edge of the costal arch and the anteroposterior iliac spine, the fourth trocar 5 mm is introduced along the midclavicular line to the right, 2 cm below the edge of the costal arch, fifth trocar 5 mm at drive along the midclavicular line to the left, 2 cm below the edge of the costal arch, then perform fundoplication with the formation of a loose fundoplication cuff in such a way that they capture the front wall of the bottom of the stomach behind the esophagus, departing 3-4 cm from the greater curvature, spend to the right behind the esophagus, an amount sufficient to form a tension-free cuff imposes a first suture, without tension between the anterior surface of the fundus of the stomach on the left, the anterior surface of the esophageal-cardiac transition and the wall held behind the esophagus the stomach, suture is tightened with five knots, and then the formation of a continuous suture is continued downward, between the anterior surface of the fundus of the stomach on the left, the anterior surface of the cardia and the wall of the stomach held behind the esophagus, then the continuous suture is continued between the anterior surface of the fundus of the stomach on the left and the stomach wall held behind the esophagus , 5 cm long, with the formation of a full cuff.

The drawings show a diagram of the proposed method for performing laparoscopic fundoplication depending on the constitutional type of the patient.

The figure 1 (figure 1) depicts a method of introducing trocars in the macrosomatic type of patient:

1) the first 11 mm trocar is injected 20 cm below the xiphoid process;

2) the second 11 mm trocar is introduced along the midline, 1 cm below the xiphoid process;

3) the third 11 mm trocar is introduced along the anterior axillary line to the left, 3 cm below the costal arch;

4) the fourth 5 mm trocar is introduced along the midclavicular line to the right, 4 cm below the costal arch;

5) the fifth 5 mm trocar is introduced to the left of the midline, 4 cm below the costal arch, at the intersection with the line connecting the second and third trocars.

Figure 2 (figure 2) shows a method of introducing trocars with mesosomatic and microsomatic types of patients:

1) the first 11 mm trocar is introduced through the navel;

2) a second 11 mm trocar is introduced along the midline, 1 cm below the xiphoid process;

3) the third 11 mm trocar is inserted along the anterior axillary line on the left, in the middle of the distance between the lower edge of the costal arch and the anteroposterior iliac spine;

4) the fourth 5 mm is introduced, along the midclavicular line to the right, 2 cm below the edge of the costal arch;

5) a fifth 5 mm trocar is inserted along the midclavicular line on the left, 2 cm below the edge of the costal arch.

The method is as follows.

Before the operation, the patient is determined by the somatic type according to the method of Dorokhov R.N. and Petrukhina V.G. (Dorokhov R.N., Guba V.P., Petrukhin V.G. Methods of early selection and orientation in sports, Smolensk, 1994).

With mesosomatic and microsomatic types of patients under endotracheal anesthesia, in the patient’s position on the back, with the head end raised 15 degrees, a skin incision is made through the navel, 1 cm long. Through it, a Veress needle is inserted into the abdominal cavity with the help of which an electronic insufflator, carbon dioxide is pumped through the connecting silicone tube into the abdominal cavity to a level of 14 mm.Hg., after which, through the same incision, the first trocar is introduced 11 millimeters in diameter, and through it a laparoscope 10 millimeters in diameter etre, 330 millimeters long. When revising the abdominal organs, the degree of expansion of the esophageal opening of the diaphragm is determined, the stomach and other organs of the abdominal cavity are examined. The second trocar 11 mm is inserted along the midline, 1 cm below the xiphoid process, the third trocar 11 mm is inserted along the anterior axillary line on the left, in the middle of the distance between the lower edge of the costal arch and the anterior superior iliac spine, the fourth 5 mm is inserted along the midclavicular line on the right, 2 cm below the edge of the costal arch, the fifth trocar of 5 mm is inserted along the midclavicular line on the left, 2 cm below the edge of the costal arch.

A hepatic retractor is introduced through the fourth trocar, with the help of which the left lobe of the liver rises to improve the visualization of the esophageal opening of the diaphragm.

A soft clamp of 10 mm is introduced through the third trocar, which captures the front surface of the stomach.

Through the second and fifth trocars, soft clamps of 5 mm are introduced into the abdominal cavity, with the help of which the stomach is inserted from the mediastinum into the abdominal cavity.

In the fifth trocar, the clamp is replaced by a hook-type electrode and, using monopolar electrocoagulation, the hepatic-gastric ligament is opened in its upper third, the peritoneum at the edges of the right and left legs of the diaphragm is opened. At the same time, the diaphragmatic-gastric ligament is kept as intact as possible in the region of great curvature and along the posterior wall of the cardiac section of the stomach. The hernial sac is separated from the edges of the esophageal opening of the diaphragm and fiber of the posterior mediastinum. The esophagus is secreted from the surrounding fiber using a flexible retractor such as a gold finger. The right and left vagus nerves are visualized. The right vagus nerve stands out, moves from the area of operation.

In the third trocar, the clamp is replaced by a bending retractor, such as a “gold finger”, which is carried out from left to right behind the esophagus, immediately above the cardia, and, with the help of which, the esophageal-cardiac transition is retracted down and to the left, exposing the lower part of the legs of the diaphragm and the right vagus nerve . The legs of the diaphragm behind the esophagus are sutured with a continuous suture, reducing the esophageal opening of the diaphragm to a size 5-7 mm wider than the diameter of the esophagus, using a needle holder inserted through the fifth trocar, a soft clamp inserted through the second trocar, thread vikril 0, on an atraumatic needle 22 mm long . In this case, the right vagus nerve remains behind the sutures, outside the forming cuff.

A soft clamp inserted through the second trocar and carried behind the esophagus captures the front wall of the bottom of the stomach, departing 3-4 cm from the greater curvature, is carried out to the right behind the esophagus, in an amount sufficient to form the cuff.

Using a needle holder inserted through the fifth trocar, a soft clamp inserted through the second trocar, using Vicryl 0 thread, on the atraumatic needle, 22 mm long, the first suture is applied without tension between the front surface of the fundus of the stomach on the left, the front surface of the esophageal-cardiac transition and held behind esophagus by the wall of the stomach. The suture is tightened by five knots, and then the formation of turns of a continuous suture continues downward, between the anterior surface of the fundus of the stomach on the left, the anterior surface of the cardia and the wall of the stomach held behind the esophagus. Further, a continuous suture continues between the anterior surface of the fundus of the stomach on the left and the stomach wall held behind the esophagus without tension, 5 cm long, with the formation of a full cuff. At the end of the seam, the thread is connected to each other by five nodes. An audit of the area of operation and control of hemostasis. The abdominal cavity in the area of operation is drained by a single silicone tube drawn through the fourth trocar. Wounds from trocars are sutured in layers. Bandages are glued.

A specific feature of laparoscopic fundoplication for the macro-somatic type is that a skin incision for injecting carbon dioxide into the abdominal cavity is made 20 cm below the xiphoid process, after which, through the same incision, the first 11 mm trocar is inserted for the laparoscope, the second 11 mm trocar is also introduced as with meso- and microsomatic types, i.e. 1 cm below the xiphoid process in the midline, the third 11 mm trocar is inserted along the anterior axillary line on the left, 3 cm below the costal arch, the fourth 5 mm trocar is inserted along the midclavicular line on the right, 4 cm below the costal arch, and the fifth 5 mm trocar is inserted to the left of the midline, 4 cm below the costal arch, at the intersection with the line connecting the second and third trocars.

The advantage of this method of introducing trocars is an adequate visualization of the esophageal-gastric transition zone, since in patients with the macrosomatic type of addition, the navel is significantly removed from the xiphoid process and the esophageal-gastric transition zone. At the same time, the standard 10-mm laparoscope is too far from the operation area and cannot provide adequate visualization. The location of the entry point of the first trocar according to our technique is optimal for the ratio of the length of the laparoscope and its distance from the manipulation zone. The shift of the point of introduction of the fifth trocar during the macrosomatic type of patient addition provides the maximum range of movements in the trocar during manipulations with the needle holder, and also allows laporolift with minimal effort in patients with pronounced subcutaneous adipose tissue for the hens installed in the zone of introduction of the fifth trocar. This provides an additional improvement in visualization in this category of patients. Thus, the application of a differentiated approach to the choice of trocar injection points depending on the patient’s somatotype provides optimal laparoscopic access to the esophageal-gastric transition zone in all patients with hiatal hernia and gastroesophageal reflux disease.

The authors in the available scientific and medical and patent literature did not reveal information about the popularity of the proposed method for performing laparoscopic non-tension fundoplication with the anterior wall of the fundus of the stomach, with maximum preservation of the ligamentous apparatus of the stomach, depending on the constitutional type of the patient, which meets the criterion of "novelty."

The authors found that determining the somatotype in patients, performing laparoscopic fundoplication with the macrosomatic type of patient by introducing five trocars into the abdominal cavity, when the first 11 mm trocar is injected 20 cm below the xiphoid process, the second 11 mm trocar is introduced along the midline, 1 cm below the xiphoid process, the third 11 mm trocar is introduced along the anterior axillary line to the left, 3 cm below the costal arch, the fourth 5 mm trocar is introduced along the midclavicular line to the right, 4 cm below the costal arch and the fifth is 5 mm t the oakar is introduced to the left of the midline, 4 cm below the costal arch, at the intersection with the line connecting the second and third trocars, and for the mesoscopic and microsomatic types, when the first 11 mm trocar is inserted through the navel, the second 11 mm trocar is inserted along the midline , 1 cm below the xiphoid process, the third 11 mm trocar is introduced along the anterior axillary line on the left, in the middle of the distance between the lower edge of the costal arch and the anterior superior iliac spine, the fourth 5 mm is introduced, along the midclavicular line on the right, 2 cm below the edge of the costal arch, fifth trocar 5 m m is introduced along the midclavicular line to the left, 2 cm below the edge of the costal arch, and then, after sparing mobilization of the esophagus-gastric junction with the maximum possible preservation of the diaphragmatic-gastric ligament, fundoplication with the formation of a non-tensioned fundoplication cuff in such a way as to capture the front wall of the bottom stomach behind the esophagus, 3-4 cm backward from the large curvature, carried out behind the esophagus to the right, in an amount sufficient to form a tension-free cuff, impose the first suture, without tension between the front surface of the bottom of the stomach to the left, the front surface of the esophagus-cardiac junction and the wall of the stomach held behind the esophagus, the suture is tightened with five knots, and then the formation of turns of a continuous suture down, between the front surface of the bottom of the stomach to the left, the front surface of the cardia and the wall behind the esophagus continues stomach, then a continuous suture is continued between the anterior surface of the fundus of the stomach on the left and the stomach wall held behind the esophagus without tension, 5 cm long, with the formation of a floor cuff, increases the effectiveness of surgical treatment of hernias of the esophageal diaphragm and gastroesophageal reflux disease in patients of various somatic types, reduces the frequency of dysphagia, pylorospasm and relapse. Thus, the claimed invention meets the criterion of "inventive step".

An example of clinical use of the proposed method.

Example 1

Patient P., 52 years old, was admitted to the surgical department of the clinical hospital No. 1 of Rostov-on-Don on March 30, 2007 with complaints of pain, bloating in the stomach after eating, persistent heartburn, periodic bitterness in the mouth, nausea, and regurgitation of food when bending and in horizontal position. Height = 154 cm, weight = 89 kg. Defined macrosomatic body type.

During external examination: the tongue is wet, the stomach is of the correct form, symmetrical, takes part in the act of breathing. On palpation - painless in all departments. Symptom Shchetkina-Blumberg negative. The liver along the edge of the costal arch, active peristalsis, the gases exhaust, the stool is normal. The symptom of striking is negative on both sides, urination is free, painless, diuresis is adequate.

Fibroesophagogastroduodenoscopy (FEGDS): distal esophagitis, cardia outlet insufficiency, signs of HPAP, chronic erosive gastritis.

X-ray of the esophagus and stomach: signs of axial HPOD of the third degree.

Complete blood count (OAK):

Hb g / l Er 10 ¹² / l L 10 ⁹ / n P % FROM % E% Lf% M% 123 4.4 8.2 5 61 one 22 eleven

Glucose 5.3 mmol / L

Coagulogram: normocoagulation.

Blood chemistry

ALT, micromol / l ACT, μmol / L Bilirubin total, μmol / l Bilirubin bound, mcmol / l O. protein, g / l 0.149 0.137 12.6 2.0 70

Therapist: Stage 2 hypertension, degree 2 risk group 3.

Based on the complaints, anamnesis, objective and instrumental examination, the diagnosis was established: Hernia of the esophageal opening of the diaphragm 3 degrees.

Complications: Distal reflux esophagitis.

After preoperative preparation, 04/02/2007, the operation was performed: the first 11 mm trocar was injected 20 cm below the xiphoid process, the second 11 mm trocar was in the midline, 1 cm below the xiphoid process, the third 11 mm trocar was in the front axillary line on the left, 3 cm below the costal arch, the fourth 5 mm trocar is on the midclavicular line to the right, 4 cm below the costal arch and the fifth 5 mm trocar is 4 cm below the costal arch, to the left of the midline, at the intersection with the line connecting the second and third trocars. Fundoplication with the formation of a tension-free fundoplication cuff was performed by capturing the anterior wall of the fundus of the stomach behind the esophagus, departing 3-4 cm from the large curvature, performed to the right behind the esophagus, in an amount sufficient to form a tension-free cuff, the first suture was applied, without tension between the front surface of the bottom stomach on the left, the front surface of the esophagus-cardiac transition and the wall of the stomach held behind the esophagus, the suture was tightened with five nodes, the formation of turns of a continuous suture downward continued between the front surface of the bottom of the stomach on the left, the front surface of the cardia and the wall of the stomach held behind the esophagus, then a continuous suture was continued between the front surface of the bottom of the stomach on the left and the wall of the stomach behind the esophagus, without tension, 5 cm long, with the formation of a full cuff.

The postoperative period was uneventful, without complications. The patient received infusion, antibacterial, symptomatic therapy. Postoperative wounds healed by first intention. After the operation, heartburn and reflux of food eaten were stopped. In satisfactory condition, she was discharged for outpatient treatment at the place of residence. The patient was examined in February 2012. There are no complaints at the time of the examination, the patient does not notice episodes of reflux by food and heartburn during the entire postoperative period. Control FEGDS was performed - no inflammation was detected in the esophagus, the cardia outlet closed tightly, no prolapse was noted.

Example 2

Patient C., aged 59, was admitted to the surgical department of the Clinical Hospital No. 1 of Rostov-on-Don on July 8, 2008 with complaints of pain behind the sternum, heartburn, and regurgitation of food during inclines and in a horizontal position. Height = 178 cm, weight = 71 kg. The mesosomatic body type is determined.

During external examination: the tongue is wet, the stomach is of the correct form, symmetrical, takes part in the act of breathing. On palpation, painless in all departments. Symptom Shchetkina-Blumberg negative. The liver along the edge of the costal arch, active peristalsis, the gases exhaust, the stool is normal. The symptom of striking is negative on both sides, urination is free, painless, diuresis is adequate.

Fibroesophagogastroduodenoscopy 07/09/2008 Distal esophagitis, cardia outlet insufficiency, signs of HPOD, chronic gastroduodenitis.

Fluoroscopy of the esophagus and stomach 07/10/2008: signs of axial HPOD of the third degree.

Oak

Hb g / l Er 10 ¹² / l L 10 ⁹ / n P % FROM % E% Lf% M% 147 5.2 6.8 3 53 four 32 8

Glucose 4.3 mmol / L

Coagulogram from 07/08/2007: normocoagulation. Blood chemistry

ALT, micromol / l ACT, μmol / L Bilirubin total, μmol / l Bilirubin bound, mcmol / l O. protein, g / l 128 119 14.5 3.7 82

Therapist: Stage 3 hypertension, degree 2 risk group 4. Based on the complaints, medical history, objective and instrumental examination, the diagnosis was established: Esophageal hernia of the diaphragm 3 degrees.

Complications: Distal reflux esophagitis.

07/11/2008 operation was performed: the first 11 mm trocar is inserted through the navel, the second 11 mm trocar is inserted along the midline, 1 cm below the xiphoid process, the third 11 mm trocar is inserted along the anterior axillary line on the left, in the middle of the distance between the lower edge of the costal arch and the anteroposterior the iliac spine, the fourth 5 mm is inserted along the midclavicular line to the right, 2 cm below the edge of the costal arch, the fifth trocar 5 mm is inserted along the midclavicular line to the right, 2 cm below the edge of the costal arch, fundoplication with the formation of a non-tensioned fundoplication cuff in replenished by capturing the front wall of the bottom of the stomach behind the esophagus, 3-4 cm backward from the large curvature, carried out behind the esophagus to the right, in an amount sufficient to form a tension-free cuff, put on the first suture, without tension between the front surface of the bottom of the stomach to the left, the front surface of the esophagus cardiac transition and the wall of the stomach held behind the esophagus, the suture was tightened with five nodes, continued the formation of turns of a continuous suture down, between the front surface of the bottom of the stomach to the left, the front surface to ardia and the wall of the stomach held behind the esophagus, then a continuous suture continued between the front surface of the bottom of the stomach on the left and the stomach wall behind the esophagus without tension, 5 cm long, with the formation of a full cuff.

The postoperative period was uneventful, without complications. The patient received infusion, antibacterial, symptomatic therapy.

Postoperative wounds healed by first intention.

After surgery, the patient stopped heartburn, reflux of food eaten.

In satisfactory condition, he was discharged for outpatient treatment at the place of residence. The patient was examined in August 2012. There are no complaints at the time of the examination, the patient does not report episodes of reflux by food and heartburn in the postoperative period. Control FEGDS was performed - no inflammation was detected in the esophagus, the cardia outlet closed tightly, no prolapse was noted.

The proposed method treated 178 patients. The method is easily produced in a hospital setting of medical institutions. Therefore, the present invention meets the criterion of "industrial applicability".

Claims (1)

A method of performing laparoscopic fundoplication depending on the constitutional type of the patient, including the introduction of an endoscope, revision of the abdominal cavity, the installation of trocars, characterized in that the somatotype is determined in patients, with the macrosomatic type of patient, laparoscopic fundoplication is performed when five trocars are introduced into the abdominal cavity, the first 11 mm trocar is injected 20 cm below the xiphoid process, the second 11 mm trocar is injected along the midline, 1 cm below the xiphoid process, the third 11 mm trocar is injected of the middle axillary line to the left, 3 cm below the costal arch, the fourth 5 mm trocar is inserted along the midclavicular line to the right, 4 cm below the costal arch and the fifth 5 mm trocar is introduced to the left of the midline, 4 cm below the costal arch, at the intersection with the line connecting the second and third trocars, for micro- and mesosomatic types, the first 11 mm trocar is inserted through the navel, the second 11 mm trocar is inserted along the midline, 1 cm below the xiphoid process, the third 11 mm trocar is inserted along the anterior axillary line to the left, in the middle of the distance between the bottom edge of the costal arch and anteroposterior iliac spine, the fourth trocar of 5 mm is inserted along the midclavicular line to the right, 2 cm below the edge of the costal arch, the fifth trocar of 5 mm is inserted along the midclavicular line to the left, 2 cm below the edge of the costal arch, then fundoplication is performed with the formation of a non-tension fundoplication the cuffs in such a way that they capture the front wall of the bottom of the stomach behind the esophagus, departing 3-4 cm from the large curvature, hold to the right behind the esophagus, in an amount sufficient to form a tension-free cuff, the suture, without tension between the anterior surface of the fundus of the stomach on the left, the anterior surface of the esophagus-cardiac transition and the wall of the stomach held behind the esophagus, the suture is tightened with five nodes, and then the formation of turns of a continuous suture downward, between the anterior surface of the fundus of the stomach on the left, the anterior surface of the cardia and the behind the esophagus by the wall of the stomach, then a continuous suture is continued between the front surface of the bottom of the stomach on the left and the stomach wall behind the esophagus, without tension, 5 cm long, mation full cuff.

Images