RU2545449C2 - Method of dynamic endovideocontrol of enteric anastomosis consistency in patients with acute abdominal surgical pathology - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, surgery. The enteric anastomosis is formed. Proximally to the anastomosis by 5-6 cm a soft polychlorovinyl tube, used as a fixing "holder" is passed under the intestine. The tube ends are brought onto the anterior abdominal wall through the counterpuncture and fixed. A sleeve for dynamic monitoring is installed through a cut in the paraumbical area. The first control is carried out after 48 hours after operation. The unstrained carboxyperitoneum 7-8 mm Hg is created. A laparoscope is introduced. The anastomosis is pulled by the ends of the "holder"-tube. Control is repeated with 24 hour interval not more than 2 times.

EFFECT: method provides reliable and effective dynamic endovideocontrol of the enteric anastomosis zone, reduces trauma and risk of complications in the postoperative period.

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Description

The invention relates to medicine, namely to methods for dynamic endovideo control of the small intestine anastomosis zone in patients with acute abdominal surgical pathology for their viability in the early postoperative period.

A known method of dynamic laparoscopy (endovideocontrol) of the intestinal anastomosis zone, superimposed on the background of peritonitis in patients with various acute abdominal surgical pathologies (see Sazhin V.P., Fedorov A.V., Sazhin A.V. Endoscopic abdominal surgery. - "GEOTAR -Media. ”- Moscow. - 2010 - 512 p.), Which consists in examining the abdominal cavity using standard relaparoscopy with the creation of carboxyperitoneum (pressure not less than 12-13 mm Hg). This is the closest method to the claimed one, using standard relaparoscopy with intense carboxyperitoneum.

The disadvantage of this method is the need for general anesthesia and the creation of intense carboxyperitoneum (at least 12-13 mm Hg), which in patients, especially the elderly and senile, often leads to significant violations of central hemodynamics, cardiac activity and external respiration function. Also often the area of the small intestinal anastomosis is closed by loops of the small intestine, locks of the greater omentum and loosely solder with them, which greatly complicates its visualization and makes its search long and traumatic.

The proposed method more simply, reliably and effectively solves the problem of dynamic endovideocontrol of the small intestine anastomosis zone in patients with acute abdominal surgical pathology. The technical result obtained in this case is to increase the effectiveness of treatment by reducing the morbidity of the study due to the rapid visualization of the small intestine anastomosis zone, eliminating anesthetic risk, reducing the risk of cardiovascular and pulmonary complications associated with intense carboxyperitoneum.

The proposed method of endovideocontrol is performed in 8-12 minutes, while standard relaparoscopy requires at least 30-40 minutes.

The specified technical result is achieved by the fact that during the first operation after application of the small intestinal anastomosis, through the mesentery of the small intestine in the avascular zone, proximal to the anastomosis by 5-6 cm, transverse to the intestine immediately below its wall, a soft PVC pipe with a diameter of 5 mm is played, which plays a role fixing "holders". Through contrapertures made in the immediate vicinity of the anastomosis, both ends of the tube are brought to the front abdominal wall, while the length of the tube should be sufficient to avoid overloading the small intestine. The ends of the tube on the anterior abdominal wall are fixed with Billroth's styptic clamp. Through a separate incision in the paraumbilical region set sleeve for dynamic observation. The abdominal cavity is sutured. The first relaparoscopy is carried out after 48 hours, while the introduction of promedol 2% -1.0 ml iv is sufficient for pain relief. A nozzle for gas supply and the introduction of a laparoscope is connected to the sleeve for dynamic observation, an unstressed carboxyperitoneum (7-8 mm Hg) is created and a laparoscope with beveled optics (45 °) is inserted. Visualization of the anastomosis is carried out after pulling a portion of the small intestine with an anastomosis from the side of the anterior abdominal wall at the ends of the tube used as a fixing “holder”. This allows you to quickly and less traumatic to assess the viability of the inter-intestinal anastomosis. With the viability of the anastomosis, but the continuing probability of its failure, the study is repeated with an interval of 24 hours no more than two times.

The proposed method of endovideocontrol of the small intestine anastomosis zone in patients with acute abdominal surgical pathology (acute intestinal obstruction, restrained hernias, acute vascular bowel disease, etc.) is simple and accessible for use by any endoscopic surgeon of any skill. The method has proven to be highly effective, easy to implement, significantly reducing the complications that occur in the above prototype, and can be successfully used in patients with the goal of early verification of small bowel anastomoses insolvency.

The proposed method of dynamic endovideocontrol of the anastomosis zone was used in 15 patients with acute abdominal surgical pathology, in which, against the background of peritonitis, a section of the small intestine was resected with the application of a small intestinal anastomosis. The first study was performed 48 hours after the operation, while anastomosis failure was verified in 3 (20%) patients. In 2 (13.3%) patients, insolvency was detected upon repeated examination 72 hours after surgery and in 1 (6.7%) patient only after the third examination, 96 hours after surgery. In any case, there were no complications associated with the tube passing through the mesentery of the small intestine, using it as a fixing “holder” and pulling the anastomosis zone for better visualization, creating an unstressed carboxyperitoneum, and introducing a laparoscope into the abdominal cavity. Also, no patient had complications from the cardiovascular and pulmonary systems.

The invention is illustrated by drawings, where

figure 1 - schematically shows the passage through the mesentery of the small intestine of a polyvinyl chloride tube with a diameter of 5 mm proximal to the anastomosis line by 5-6 cm, its removal to the anterior abdominal wall through contraperture and fixation with Billroth clamp, installation of a sleeve for dynamic observation through the anterior abdominal wall.

Figure 2 - shows the pulling of the loop of the small intestine with an anastomosis by the tube, which plays the role of a fixing "holder", visualization of the anastomosis zone using a laparoscope inserted into the abdominal cavity through a sleeve for dynamic observation with a nozzle for gas supply and the introduction of a laparoscope.

The method of endovideocontrol viability of the small intestine anastomosis in patients with acute abdominal surgical pathology is as follows.

During the first operation, after the application of the small intestinal anastomosis, through the mesentery of the small intestine in the avascular zone 1, proximal to the anastomosis 2 by 5-6 cm, immediately below the intestinal wall, a soft PVC tube 3 with a diameter of 5 mm is used, which plays the role of a fixing “holder”. Through contraperture 4, made in the immediate vicinity of the anastomosis, both ends of the tube are brought out to the anterior abdominal wall, where the ends of the tube are fixed with Billroth 5. By means of a separate incision, a sleeve for dynamic observation is installed in the paraumbilical region 6. The first dynamic video monitoring is performed 48 hours after operations, attach a nozzle for gas supply and insertion of a laparoscope 7 to the sleeve for dynamic observation 6, create an unstressed carboxyperitoneum (7-8 mm Hg) and input laparoscope 8 with beveled optics (45 °). Visualization of the anastomosis 2 is carried out after pulling the portion of the small intestine with the anastomosis from the side of the anterior abdominal wall at the ends of the tube 3, used as a fixing “holder”. With the viability of the anastomosis, but the continuing probability of its failure, the study is repeated with an interval of 24 hours no more than two times.

Clinical example 1

As an illustration, we give an example. Patient S., 72 g., Medical history No. 1696, was admitted to the GUZ KB No. 5 on 05.22.12. with a diagnosis of Adhesive disease of the abdominal cavity? Acute intestinal obstruction? Associated: coronary heart disease. Postinfarction cardiosclerosis. Angina pectoris. Functional class 2. COPD. Respiratory failure I. In 2010, median access was performed for perforated gastric ulcer.

She fell ill acutely, 36 hours before admission, when there were cramping abdominal pains, gas and stool ceased to flow away. I did not seek medical help, I took no-shpa myself. The pains did not pass, took on a permanent character, nausea appeared, there was 3-fold vomiting. The ambulance was delivered to the hospital, hospitalized in the surgical department. The diagnosis of acute intestinal obstruction is confirmed radiographically (pneumatosis, Kloiber’s bowls). After 2 hours of preoperative preparation, an emergency laparotomy was performed under endotracheal anesthesia. During the revision of the abdominal cavity, a pronounced adhesion process was detected, at a distance of 80 cm from the ileocecal angle, the loop of the small intestine was 180 ° wrapped and pinched together with the mesentery with a “cord-like” commissure. The leading loop of the small intestine is expanded to 5 cm; A strangled loop of the small intestine 30 cm long, dark cherry in color, the wall is thickened in plaque of fibrin, in a small basin 200 ml of muddy effusion with an unpleasant odor. Performed adhesiolysis. The effusion is drained. The restrained loop of the small intestine is recognized as non-viable, a resection of this part of the small intestine with an anastomosis “side to side” with a 2-row kapron suture was performed. The abdominal cavity is washed with a solution of furacilin. An intestinal probe could not be performed due to a pronounced adhesive process in the upper floors of the abdominal cavity. In the non-vascular site of the mesentery of the small intestine, near its wall, 5 cm proximal to the anastomosis, a soft PVC tube with a diameter of 5 mm was performed, which plays the role of a fixing “holder”. The latter is removed in the right mesagastria through contraception and is fixed by Billroth's hemostatic clamp. In the paraumbilical region, a sleeve for dynamic observation is installed on the left. The abdominal cavity is drained by catching tubes, the median wound is sutured.

In the postoperative period, the patient's condition is severe, stable. The abdomen is not swollen, soft, intestinal murmurs are sporadic. In the gastric tube up to 500 ml of greenish discharge per day. Given that the intestinal anastomosis is superimposed on the background of peritonitis and an altered small intestine, there is a high risk of its insolvency, and therefore, 48 hours after the operation, the patient underwent endovideo monitoring of the zone of the intestinal anastomosis. A solution of promedol 2% -1.0 iv was injected into the patient as an anesthetic, a nozzle for gas supply and a laparoscope was attached to the sleeve for dynamic observation, an unstressed carboxyperitoneum was created (7-8 mm Hg) and a laparoscope was inserted into the abdominal cavity . The loop of the small intestine with the anastomosis is pulled up by the “holding” fixing tube. Anastomosis examined, recognized wealthy. Gas desufflation. Dressings. Diagnostic manipulation took 8 minutes. The patient was transferred to the ward. Dynamic endovideo monitoring was repeated 72 hours and 96 hours after surgery. Anastomosis recognized wealthy. Passage through the intestines has fully recovered. The fixing tube “holder” and the sleeve for dynamic endovideo monitoring are removed. Postoperative wound healing per prima. On the 9th day after the operation, skin sutures were removed. 12 days after surgery, the patient was discharged in satisfactory condition.

Clinical example 2

Patient P., 76 years old, medical history No. 1486, was admitted to the GUZ KB No. 5 02/12/13. with a diagnosis of Acute vascular bowel disease? Hollow organ perforation? Peritonitis. Associated: coronary heart disease. Postinfarction cardiosclerosis. Angina pectoris. Functional class 2. Atrial fibrillation, tachyform. Arterial hypertension 3, risk 4.

He fell ill acutely, 48 hours before admission, when pain in the upper abdomen appeared for no apparent reason, over time, nausea and thrice vomiting joined. I did not seek medical help for another day, only when the pains became intense and spread to the whole stomach, called an ambulance, which was delivered to the hospital, examined by a surgeon, hospitalized in the surgical department. Ultrasound of the abdominal organs was performed, which showed the presence of free fluid in the abdominal cavity. After 2 hours of preoperative preparation, an emergency laparotomy was performed under endotracheal anesthesia. When revising the abdominal cavity in sloping places, about 400 ml of turbid liquid mixed with bile. The parietal peritoneum and loops of the small intestine are hyperemic, with a plaque of single fibrin strands. In the small intestine at a distance of 70 cm from the ligament of Treitz, perforation of its wall with a diameter of 1.0 cm is determined, the cause of which was the food-free bezoar. Above the obstacle, the intestine is enlarged to 3.0 cm;

Diagnosis: Acute obstructive small bowel obstruction (food-free bezoar). Perforation of the small intestine. Common serous-purulent peritonitis. A resection of this section of the small intestine with an end-to-end anastomosis with a 2-row kapron suture was performed. The abdominal cavity is washed with a solution of furacilin. In the non-vascular site of the mesentery of the small intestine, near its wall, 5 cm proximal to the anastomosis, a soft PVC tube with a diameter of 5 mm was performed, which plays the role of a fixing “holder”. The ends of the tube are brought out in the left mesagastrium through contrapertension and are fixed on the anterior abdominal wall by the hemostatic clamp of Billroth. In the paraumbilical region, a sleeve for dynamic observation is installed on the left. The abdominal cavity is drained by catching tubes, the median wound is sutured.

In the postoperative period, the patient's condition is severe, stable. The abdomen is not swollen, painful along the postoperative wound, soft, single intestinal murmurs. In the gastric tube up to 600 ml of greenish discharge per day. Given that the intestinal anastomosis is superimposed on the background of serous-purulent peritonitis and an altered small intestine, there is a high risk of its insolvency, and therefore, 48 hours after the operation, the patient underwent endovideo monitoring of the intestinal anastomosis zone. A solution of promedol 2% -1.0 iv was injected into the patient as anesthesia, a nozzle for gas supply and a laparoscope was attached to the sleeve for dynamic observation, an unstressed carboxyperitoneum was created (7-8 mm Hg) and a laparoscope was inserted into the abdominal cavity . The loop of the small intestine with the anastomosis is pulled up by the “holding” fixing tube. Anastomosis examined, recognized wealthy. Gas desufflation. Dressings. Diagnostic manipulation took 10 minutes. Dynamic endovideo monitoring was repeated after 24 hours. Also, a nozzle for gas supply and the introduction of a laparoscope was attached to the sleeve for dynamic observation, an unstressed carboxyperitoneum (7-8 mm Hg) was created, and a laparoscope was inserted into the abdominal cavity. In the abdominal cavity, a small amount of turbid fluid mixed with bile. The loop of the small intestine with the anastomosis is pulled up by the “holding” fixing tube. Anastomosis was examined, leakage of intestinal contents between the sutures was detected, anastomosis failure was diagnosed. Under endotracheal anesthesia, relaparotomy and small bowel resection were performed. The abdominal cavity is washed with antiseptics. Retreating from the anastomosis line by 6 cm, a fixing tube “holder” is again inserted through the mesentery under the intestinal wall, and its ends are brought out to the front abdominal wall through the previous counter-hole and fixed to the skin with Billroth's clamp. The middle wound is sutured. Dynamic endovideo monitoring was repeated after 48 and 72 hours after resection, the anastomosis is consistent. Passage through the intestines has fully recovered. The fixing tube “holder” and the sleeve for dynamic observation are removed. Postoperative wound healing per prima, sutures removed. On the 14th day after the second operation, the patient was discharged in satisfactory condition.

Claims (1)

The method of dynamic endovideocontrol of the viability of the small intestinal anastomosis in patients with acute abdominal surgical pathology involves performing standard relaparoscopy with the creation of intense carboxyperitoneum with a pressure of at least 12-13 mm Hg, characterized in that during the first operation after application of the small intestine anastomosis, mesentery of the small intestine in the avascular zone, proximal to the anastomosis by 5-6 cm, transverse to the intestine of the rhinestone under its wall, conduct a soft PVC pipe diameter 5 mm, which plays the role of a fixing “holder”, then through the contraperture made in the immediate vicinity of the anastomosis, both ends of the tube are brought to the anterior abdominal wall, where the ends of the tube are fixed with Billroth’s hemostatic clamp, then a sleeve is installed in a paraumbilical region for dynamic observation, the first dynamic endovideo monitoring is performed 48 hours after the operation, a nozzle for gas supply and the introduction of a laparoscope is attached to the sleeve for dynamic observation zdayut lax karboksiperitoneum 7-8 mm Hg and a laparoscope with a beveled optics 45 ° is introduced, anastomosis is visualized after pulling a portion of the small intestine with an anastomosis from the side of the anterior abdominal wall at the ends of the tube used as a fixing “holder”, while the anastomosis is viable, but the probability of its failure remains, the study is repeated with an interval of 24 hours no more than two times.

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