RU2532360C1 - Method for laparoscopic hepaticojejunostomy accompanying pancreatoduodenal resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used in a laparoscopic hepaticojejunostomy accompanying pancreatoduodenal resection. A pancreatectomy is performed. A side-to-end pancreaticojejunoanastomosis is created on the Roux isolated jejunal loop. The hepaticojejunostomy follows. An intestinal lumen is exposed at 10-15 cm from the created pancreaticojejunoanastomosis; the opening diameter is equal to that of a common hepatic duct. The needle is first pricked in a point of 9 o'clock. After knotting, traction of a free end of the needle is generated to extend a posterior wall of the common hepatic duct. A posterior lip of the anastomosis is created by locking continuous stitching at 0.1-0.3 cm to the level of 3 o'clock. The second knot is formed. An anterior lip of the anastomosis is created by locking continuous stitching at 0.1-0.3 cm. Once reaching the position of 9 o'clock, the free ends of the suture are tied together.

EFFECT: method provides reducing the intraoperative injuries, the length of treatment, and the risk of postoperative ventral hernias by applying the laparoscopic approach involving no injuries of the muscles of the anterior abdominal wall and providing the reliable anastomosis to be created.

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Description

The invention relates to medicine, and more specifically to pancreatic surgery, namely to laparoscopic pancreatojejunostomy with pancreatoduodenal resection.

There is a method of hepatikoejunostomy according to Ru, performed from a wide laparotomic access by forming an intestinal anastomosis according to Ru and biliodigestive anastomosis (1 - Petrovsky B.V. et al. Reconstructive surgery for lesions of extrahepatic bile ducts. - M .: Medicine, 1980. - S. 91-93).

Due to wide access, such an operation is very traumatic, which often leads to postoperative complications and long periods of rehabilitation of patients in the postoperative period.

Closest to the claimed is a method of hepatic jujunostomy according to Ru, including paracostal access in the right hypochondrium, allocation of the stricture zone of hepatic choledochus, the formation of an intestinal anastomosis according to the Ru and biliodigestive anastomosis on the loop of the small intestine turned off by the Ru ("Surgery". / Under the general ed. I. Littmann. Budapest. 1985, p. 323, 327, 628-629). In this method, when using paracostal access (for example, a Kocher incision, the length of which is 15-20 cm), the muscles in the right hypochondrium cross, which is accompanied by damage to 3-4 nerve trunks. Arteries and nerve trunks intersect together with nerves, which leads to muscle degeneration with subsequent disorders of the abdominal function and the emergence of a postoperative ventral hernia (Kalinovskaya AM “Operational access to the biliary tract.” - “Surgery”, 1948. - No. 7. - S.32). A hospital stay after such an operation is usually at least 14 days. This method is adopted as a prototype.

The aim of the present invention is to reduce the treatment time and reduce the risk of postoperative ventral hernias by reducing the invasiveness of the method.

The technical result is achieved by the fact that the pancreas is resected, pancreatojejunoanastomosis is formed end-to-side on the jejunum loop isolated by Ru, hepatojejunotomy is performed, at a distance of 10-15 cm from the formed pancreatojejunoanastomosis, the intestinal lumen is opened, corresponding to the diameter of the common hepatic duct, the injection is carried out for 9 hours, after the formation of the node, traction is created for the free end of the thread to the right shoulder of the patient to straighten the posterior wall of the common hepatic a, by wrapping a continuous seam with a seam step of 0.1-0.3 cm, the anastomosis posterior lip is formed from 9 to 3 hours, where the second node is formed, then a front lip is being formed by a continuous sewing with a seam step of 0.1-0.3 cm anastomosis, upon reaching 9 hours, the free ends of the suture are connected together, and the step of the suture depends on the diameter of the common hepatic duct.

The method is as follows.

The technique for the formation of hepaticoyunoanastomosis with separate stitching of the common hepatic duct into the lateral wall of the jejunum. The first stage of the reconstructive stage is the formation of pancreaticoejunoanastomosis on the loop of the jejunum. The loop of the jejunum after crossing the latter is transferred to the upper floor of the abdominal cavity to the right of the middle colon vessels. Having departed 10-15 cm from pancreatoeunoanastomosis on the same loop of the jejunum, an anastomosis is formed between the common hepatic duct and the jejunum.

To form, use a thread on an atraumatic needle. The length of the thread is calculated according to the length of the laparoscopic instrument, this is necessary for the formation of two continuous semicircular sutures on the common hepatic duct. First of all, a nodal suture is formed between the common hepatic duct at 9 o’clock and the loop of the jejunum, the lumen of which is opened in advance with an ultrasonic scalpel. The diameter of the hole in the loop of the jejunum depends on the diameter of the common hepatic duct. Thus, the point of the first injection of the first suture is located at a distance of 0.1-0.2 cm from the edge of the resection of the common hepatic duct. Moreover, the injection is carried out from the outside to the inside so that the node is formed outside the anastomosis. The point of the second injection of the first suture is at a distance of 0.1-0.2 cm from the edge of the opening of the small intestine. The direction of the injection, in turn, is opposite to the direction of the first injection of the first seam and is from the inside out. Tying the first suture is carried out due to the formation of a surgical node and two or three single nodes. After the formation of the first knot at 9 o’clock, the formation of the first semicircular continuous seam begins clockwise from nine to three hours. Next, the second assistant constantly carried out the tension of the thread with a soft clamp installed through the laparoscopic port, until the end of the continuous suture on the front wall of the anastomosis and tying the thread. The optimal connection of tissues is achieved due to the indicated fixation and traction of the free end of the thread up and to the right, due to this an angle equal to ninety degrees between the seam line and the direction of the needle is achieved. A continuous blanket seam in increments of 0.1-0.3 cm lasts up to three hours. At this point, a knot is formed with a loop of the thread used. The formation of the second node prevents the narrowing of the ring of hepaticoyunoanastomosis. The direction of the second semicircular seam is opposite to the direction of the first semicircular seam. The formation of the anastomosis anterior wall was a continuation of the posterior wall formation stage. The distance between the injections is 0.1-0.3 cm. It should be noted that no additional fixation of the thread by the assistant after the injection of the next stitch is made, so as not to create excessive load on the wall of the common hepatic duct and the loop wall of the jejunum. At the end of the formation of the front semicircular seam, the free ends of the thread are connected to each other, thereby closing the ring of two semicircular seams.

The method is further explained by examples of its implementation.

Example 1

Patient M., 39 years old, was admitted with a diagnosis of intraductal mucinous neoplasia, according to computed tomography with intravenous contrasting, the diameter of the common hepatic duct is not expanded and is 4 mm.

A loop of the jejunum participating in anastomosis with the pancreatic stump and the common hepatic duct is carried out behind the colon through a preformed window in the mesentery of the colon to the right of the middle colon vessels. After the formation of the termo-lateral invagination pancreatojejunoanastomosis, the formation of hepaticojejunoanastomosis is performed. First, a nodal suture was formed with a thread on an atraumatic needle between the common hepatic duct at 9 o’clock and the loop of the jejunum. The lumen of the jejunum loop was opened with an ultrasonic scalpel until the formation of the first suture. Thus, the point of the first injection of the first suture was located at a distance of 0.1 cm from the edge of the resection of the common hepatic duct. Moreover, the injection was carried out from the outside to the inside, so that the node was formed outside the anastomosis. The point of the second injection of the first suture is at a distance of 0.1 cm from the edge of the opening of the small intestine. The direction of the injection, in turn, was opposite to the direction of the first injection of the first seam and was from the inside out. Tying the first suture was carried out due to the formation of a surgical node and three single nodes. After the formation of the first knot at 9 o’clock, the first semicircular continuous twisting seam was formed with a seam step of 0.1 cm clockwise from nine to three hours. Next, the second assistant constantly carried out the tension of the thread using a soft clamp installed through the laparoscopic port, until the formation of a continuous seam on the front wall of the anastomosis and tying the thread. The angle between the line of the anastomosis and the direction of the atraumatic needle was 90 degrees. A continuous blanket stitch lasts up to three hours. At this point, a knot was formed with a loop of the thread used. The direction of the second semicircular seam was opposite to the direction of the first semicircular seam. The formation of the anastomosis anterior wall was a continuation of the posterior wall formation stage. The distance between the injections is 0.1 cm. There was no additional fixation of the thread by the assistant after the injection of the next stitch, so as not to create an excessive load of the thread on the wall of the common hepatic duct and the wall of the jejunum loop. At the end of the formation of the front semicircular seam, the free ends of the thread are connected to each other, thereby closing the ring of two semicircular seams.

Example 2

Patient Z., 39 years old, was admitted with a diagnosis of postcholecystectomy syndrome, the intersection of the common hepatic duct, the condition after percutaneous transhepatic cholangiostomy. According to cholangiography, the diameter of the common hepatic duct in its distal part is 4 mm.

By dissection of adhesions after a previous laparoscopic cholecystectomy and isolation of the common hepatic duct, the formation of hepaticoejunoanastomosis begins. First, a nodal suture was formed with a thread on an atraumatic needle between the common hepatic duct at 9 o’clock and the loop of the jejunum. The lumen of the jejunum loop was opened with an ultrasonic scalpel until the formation of the first suture. Thus, the point of the first injection of the first suture was located at a distance of 0.1 cm from the edge of the resection of the common hepatic duct. Moreover, the injection was carried out from the outside to the inside, so that the node was formed outside the anastomosis. The point of the second injection of the first suture is at a distance of 0.1 cm from the edge of the opening of the small intestine. The direction of the injection, in turn, was opposite to the direction of the first injection of the first seam and was from the inside out. Tying the first suture was carried out due to the formation of a surgical node and three single nodes. After the first knot was formed at 9 o’clock, the first semicircular continuous seam was formed with a seam pitch of 0.3 cm clockwise from nine to three hours. Next, the second assistant constantly carried out the tension of the thread using a soft clamp installed through the laparoscopic port, until the formation of a continuous seam on the front wall of the anastomosis and tying the thread. The angle between the line of the anastomosis and the direction of the atraumatic needle was 90 degrees. A continuous blanket stitch lasts up to three hours. At this point, a knot was formed with a loop of the thread used. The direction of the second semicircular seam with a seam pitch of 0.3 cm was opposite to the direction of the first semicircular seam. The formation of the anastomosis anterior wall was a continuation of the posterior wall formation stage. The distance between the injections is 0.2 cm. There was no additional fixation of the thread by the assistant after the injection of the next stitch, so as not to create an excessive load of the thread on the wall of the common hepatic duct and the wall of the jejunum loop. At the end of the formation of the front semicircular seam, the free ends of the thread are connected to each other, thereby closing the ring of two semicircular seams.

The duration of the operation is 4.5 hours. The postoperative period was satisfactory, without complications. On the 6th day - control cholangiography: the anastomosis is freely passable, there are no streaks of contrast medium.

6 months after the operation, he returned to his previous professional career. With magnetic resonance cholangiography performed after 1 year, the intrahepatic ducts are not dilated, the anastomotic zone is without features. The patient's condition is satisfactory, no complaints.

Thus, the proposed method allows surgery to be performed laparoscopically without damaging the muscles of the anterior abdominal wall, which reduces the morbidity and reduces the patient's stay in the hospital, prevents the occurrence of postoperative complications and has a good cosmetic effect.

Using the proposed method, 16 operations were performed laparoscopically for Wirsung strictures and common bile duct. Subsequent follow-up observation of recurrence of stricture was not.

Claims (1)

The method of laparoscopic hepatikojejunostomy for pancreatoduodenal resection, including resection and anastomosis, characterized in that the pancreas is resected, pancreatojejunoanastomosis is formed end-to-side on the loop of jejunum isolated on Roux, and hepatojejunostomy is performed at a distance of 10 opening of the lumen of the intestine, corresponding to the diameter of the common hepatic duct, the first injection is carried out at 9 o’clock, after the formation of the node create a tract for the free end of the thread to the patient’s right shoulder to straighten the posterior wall of the common hepatic duct, an anastomotic posterior lip is formed by a continuous suture with a suture step of 0.1-0.3 cm to a level of 3 hours, where the second node is formed, then a continuous suture with with a seam step of 0.1-0.3 cm, the anastomosis front lip is formed; upon reaching 9 hours, the free ends of the thread are connected together.