RU2547778C1 - Laparoscopic method for false and true pancreatic cyst excision in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: one videoport is inserted 2 cm below a navel along the mid-line. Two instrumental ports are inserted from the right and left along the midclavicular line and below the navel line. The right port is inserted 1-1.5 cm above the left one. A third instrumental port for a Cuschieri retractor is inserted along the anterior axillary line from the left 2-3 cm below the left hypochindrium. A peritoneal sac is opened. A cyst cavity is opened by dissecting longitudinally. A jejunum is transected at 25-30 cm from a duodenojejunal bend. One or more arterial stems are preserved as a pedicle. A proximal section of the intestine is sutured in 'end-to-end' in the distal direction outside the abdominal cavity through a mini-laparotomic approach in the navel segment. A short loop 35-40 cm long is formed. A distal end of the intestine is sutured with a locking one-row suture extending through a window in a mesentery of transverse colon. That is fixed tension-free to the pancreatic cyst. A cystojejunostomosis is created.

EFFECT: method provides reducing injuries and postoperative complications, reduces the time for operation and staying in hospital, ensures the effective drainage of the cyst and high aesthetic effect by the optimal placement of the ports, forms the anastomosis outside the abdominal cavity, and uses small incisions.

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Description

The present invention relates to medicine, namely to laparoscopy of pseudocysts and true pancreatic cysts, and can be used in the surgical treatment of children after injuries of the abdominal cavity, an inflammatory pancreatic disease, which resulted in the development of a pancreatic cyst.

Pancreatic cysts (pancreas) are a relatively rare pathology in childhood that requires surgical treatment. Cystic formations can be congenital and acquired, true or false (pseudocysts). The latter are formed mainly after injuries, inflammatory processes, and also in some cases after surgical interventions on the pancreas.

Indications for this or that type of surgical treatment of pancreatic pseudocyst depend on the timing and thickness of the formation wall. After 3 months or more, the formation of a dense wall most often uses internal drainage methods, one of which is pancreatocystejunostomy on an isolated (disconnected) loop according to Ru.

Of the variety of proposed options for minimally invasive and traditional surgical interventions, 3 groups can be distinguished:

A) external drainage of the cyst, including under ultrasound control (see ed. Certificate of the USSR No. 806006, pat. RF No. 2305567);

B) internal drainage of the cyst - cystodigestive anastomoses (cystogastro-, cystoejuno-, cystoduodeno-, including endoscopic and under ultrasound control) (see US Pat. RF No. 2098145, 2190967, 2231303, 2332178, 2319463);

B) radical removal of the cyst (cystectomy, resection of the pancreas of various sizes) (see US Pat. No. 2392020).

Surgical tactics are chosen based on many factors, taking into account the fact whether there is a message from the main pancreatic duct with a cyst cavity or not, its localization, its volume, topographic location relative to other organs and large vessels are evaluated. Currently, in childhood, the operation of choice is laparoscopic cystoejunostomy.

Radical and draining operations are traumatic and are accompanied by a large number of early postoperative complications, which, according to published data, reach 40-80%.

In recent years, with the advent of new diagnostic equipment (ultrasound, computed tomography, magnetic resonance imaging + MRCP), the frequency of detection of patients with pancreatic cysts, which are a complication of pancreatitis (11-18%) or gland injury, has increased. Spontaneous extraction of pancreatic cysts is possible in 8-20% of cases, and only in the initial periods of formation. Diagnosis of formed pancreatic cysts is an absolute indication for surgical treatment because of the possibility of the development of a large number of complications (75%).

A) With external drainage (marsupialization) of the cyst under ultrasound guidance, an operation is used in combination with endoscopic papillotomy. In a typical method of endoscopic papillotomy, the papillotome is freely inserted into the mouth of the large duodenal papilla and set immediately or after several dissections in the direction of the mouth of the bile duct. The operation is facilitated and significantly accelerated if a modern technique for changing catheters is used with endoscopic retrograde pancreatocholangiography on a papillotome along the conductor.

Disadvantages: When the cyst is connected with the main pancreatic duct or ducts of the first order, an external pancreatic fistula is formed, which requires closure by surgery.

B) The operation of internal drainage is widely used - cystoeunostomy (a textbook for medical students in 2 volumes “Surgical diseases of children” edited by academician RAMP Yu.F. Isakov in 2006 and the “National Guide to Pediatric Surgery” edited by academician RAMS YF Isakov and Professor AF Dronov released in 2009, MV Danilov, VD Fedorov "Pancreatic Surgery", 1995). Cystejunostomy is the most universal, affordable and safe way of internal drainage of pancreatic pseudocysts. The application of an anastomosis with a small intestine is appropriate for both large and small cysts located extra - or intrapancreatically. The technique of cystejunostomy varies depending on the size and location of the cyst. As an operative access, a wide median laparotomy is performed with hardware correction of the operative access by Seagal expanders. Pancreatic head cysts are accessed through the gland sac by dissecting the gastrointestinal ligament and carefully releasing the anterior surface of the pancreas. After the exact location of the cyst is established, it is opened with a cut along the axis of the pancreas. Sometimes abundant bleeding is stopped by applying nodal and U-shaped sutures. After emptying the cyst and hemostasis, a cystejunoanastomosis is usually applied with single nodular sutures. When this anastomosis is applied, preference is given to the formation of an anastomosis with a jejunum on a disconnected loop according to Ru, give the formation of an anastomosis with a jejunum on a disconnected loop according to Ru, Brown or A.A. Shalimov. The width of the lumen of the anastomosis should be the largest possible diameter.

Disadvantages:

1. Inadequate drainage effect of cystoyunoanastomosis in the first days of the postoperative period, due to swelling of the anastomosis and dynamic paresis of the gastrointestinal tract.

2. The possibility of insufficiency of the anastomosis with the development of peritonitis, suppuration of the cyst cavity, the progression of the initial pancreatic necrosis in the early postoperative period, and in the later stages - premature narrowing and obliteration of the anastomosis and, as a result, relapse of the disease, as well as acute peptic ulcers of the anastomosis zone, often complicated by bleeding.

C) Until recently, the main method of treating pancreatic cysts (pancreas) was surgical, including laparotomy, opening the cyst, creating an anastomosis between the cystic cavity and the external environment (external drainage), or between the cystic cavity and the lumen of a hollow organ, for example, the stomach and intestines ( internal drainage). However, this method of treatment for pancreatic cysts is a complex surgical intervention in the open abdominal cavity. In this case, the development of complications such as bleeding, suppuration of the wound, abscesses of the abdominal cavity, peritonitis is possible.

The disadvantage of resection methods is their technical complexity, trauma, high mortality and persistent disability of patients due to the development of both pancreatic endocrine insufficiency with maldigestia and malabsorption, and the development of diabetes mellitus.

Known methods for external drainage of cysts.

The disadvantage of external drainage of pancreatic cysts is the palliative nature of the operation, the recurrence of cysts and their suppuration, the formation of long-existing external pancreatic fistula, poorly amenable to conservative therapy and often require repeated technically complex, traumatic surgical interventions.

Known methods of cystodigestive anastomoses.

The disadvantage of these methods is the recurrence of cysts due to obliteration of cystodigestive anastomoses, infection of pancreatic cysts with the irritated effect of gastric and duodenal contents on the inner surface of the cyst wall with a risk of erosive bleeding into the cyst cavity, acute peptic ulcers of the anastomosis zone, often complicated by bleeding, violation of physiological regularities pancreatic juice through biliodigestive anastomosis to the stomach or directly to t the small intestine below the duodenojejunal junction.

Among them, the most famous is the method of cystejunostomy on the loop of the jejunum turned off along the Roux or with the inter-intestinal Brownian anastomosis, which is accompanied by a violation of digestion processes, malabsorption and maldigestia, due to the "low" supply of pancreatic juice through the cysteunoanastomosis to the small intestine below the major transition duodenoenojoe active proximal part of the small intestine from passage of pancreatic secretion, frequent relapses of the cyst due to obliteration of the cysteuno nastomoza.

Known methods for minimally invasive treatment of cavity fluid formations, involving transdermal drainage under ultrasound control, including visual monitoring of the passage of the needle, conductor, drainage, immediately at the time of intervention, the absence of x-ray exposure of the patient and staff. The disadvantage is the limitation of therapeutic possibilities due to the fact that nearby structures such as bones (ribs) or a gas-filled intestine can limit ultrasound control.

There is also a method of drainage of cavity fluid formations under the control of computed tomography, providing good visual control of the position of the instrument. The disadvantage of this method is the limitation of the set of tools that can be placed in the tomography apparatus during the execution of the control tomographic slice, which reduces treatment options and increases the risk of complications.

Depending on the size and anatomical location of the cavity fluid formation, a drainage technique using a stylet catheter or the Seldinger technique is used. Drainage with a stylet catheter is possible only with superficially located large liquid formations, since it does not provide high accuracy of intervention. The disadvantage of the Seldinger technique is the risk of complications, which consists in the need for staged drainage of the drainage canal with buzhi of increasing diameter, at the time of which the contents of the drained cavity fluid formation can enter the puncture canal and abdominal cavity.

According to summary statistics, postoperative mortality in all types of surgical treatment of pancreatic cysts ranges from 3-11% (Vinogradov V.V., Aripov U.A., Danilov M.V. Pancreatic cysts. - Tashkent: Medicine, 1975. - 132 s; GD Vilyavin, VI Kochiashvili, KK Kaltaev. On the pathogenesis and surgery of pancreatic cysts. - M .: Medicine, 1977. - 192 p.), And the frequency of postoperative complications is 34 -37% (Kurygin A.A., Nechaev E.A., Smirnov A.D. Surgical treatment of pancreatic cysts. - St. Petersburg: Hippocrates, 1996. - 156 from.). Recognizing external drainage of pancreatic cysts as an important and necessary method of treatment, it is necessary to warn against excessive unreasonable expansion of indications for this operation, since one of the shadow sides of external drainage of cysts is considered to be the formation of external pancreatic fistula and relapse of the disease.

Postoperative complications after operations of internal drainage of the cysts can develop in 20% of patients (Milonov OB and Soavt. Assessment of diagnostic methods and surgical treatment of pancreatic cysts // Surgery. - 1985. No. 4. - P.87-95), in general, good results were observed in 77-83% of patients (Frey CF Pancreatic psevdocysts operative strategy // Ann. Surg. - 1978. - Vol.188. - No. 5. - P.652-662, Bradley EL Pancreatic dact pressure in chronic pancreatits // Amer. J. Surg. - 1982. - Vol. 144. - No. 3. P.313-317).

It is believed that internal drainage of the cyst eliminates pain, preserves the flow of pancreatic juice into the gastrointestinal tract, and prevents a further decrease in pancreatic function, which gives a higher percentage of good results.

In addition, the tubular drains used in the known method quickly stop working, as they become clogged with fibrinous plugs, thick pus, casts of the necrotic pancreas, causing secondary infection as a foreign body, suppuration of wounds, contributing to prolonged intoxication, which reduces the effectiveness of treatment.

When carrying out treatment in a known manner, the introduction of a drainage device into the cavity of the stuffing bag is possible only through the trocar, as a result of which kinks in the drainage tube and narrowing of the lumen of the drainage are not excluded, and during manipulations in the abdominal cavity its displacement and kink are not excluded, which also reduces the effectiveness of treatment .

Methods of drainage have the following disadvantages: 1) a small diameter of the anastomosis and drainage tube, which does not allow for adequate sanitation of the cystic cavity; 2) a high probability of obliteration of the anastomosis in the early stages and relapse of pseudocysts; 3) the lack of revision of the cyst cavity and removal of sequesters during surgery; 4) technical difficulties in ensuring reliable hemostasis in case of bleeding during surgery.

Laparoscopic formation of cystogastroanastomosis due to increased intra-abdominal pressure negatively affects the state of central hemodynamics (decreased venous return, decreased cardiac output, increased systemic resistance of blood vessels, etc.), changes in respiratory function (impaired lung excursion, decreased lung tissue extensibility, decreased functional residual lung capacity, hypoventilation, etc.), coagulation system (thrombosis, thromboembolism, etc.).

As a result of a patent search, the following patents were selected for further analysis.

Pat. RF №2190967. A method for endoscopic drainage of pancreatic cysts by creating an endoscopic cystogastro- or cystoduodenoanastomosis, including a preliminary assessment of the location, size, structure of the contents of the cyst, the thickness of the capsule and the presence of areas of its contact with the walls of the stomach or duodenum: puncture of the cyst and expansion of the resulting anastomosis with the help of a papillotoma the fact that at the first fibrogastroduodenoscopy determine the place of formation of the future anastomosis and using an electrode, introduced through the manipulation channel of the endoscope, superficial coagulation of the mucous membrane of the organ is performed until a scab forms on a round or ellipsoid section of the wall with a diameter of up to 20 mm, after 48-78 hours with repeated fibrogastroduodenoscopy, the electrodes are punctured between the walls of the hollow organ and the capsule of the cyst through the deepest section formed ulcerative defect, the puncture channel is expanded to 6-10 mm within the limits of a peptic ulcer of the wall of the stomach or duodenum.

Pat. RF №2305567. A method for percutaneous drainage of cavity fluid formations, including a preliminary assessment of the localization, size, structure of the contents of the cavity fluid formation using the visual inspection method, puncture and drainage of the cavity fluid formation under visual control using a device for percutaneous drainage of cavity formations and a conductor, characterized in that under the control of computed tomography selects the optimal point for puncture, then puncture the cavity fluid image Using a needle with a length of not more than 20 cm and a diameter of no more than 1.66 mm, with a mandrel, after the puncture of the cavity liquid formation, the mandrains are removed from the needle, an ultra-rigid conductor with a flexible end is inserted into the cavity, after which the patient is removed from the aperture of the tomograph, the needle is removed from education, rigidly fixing the conductor, on the tomograph display screen measure the distance from the puncture point on the surface of the patient’s body to the center of the cavity fluid formation, and, rigidly fixing the conductor, a transdermal device is inserted through the conductor Drainage of cavity formations without the mandrel, on the measured distance, then produce the bringing down into the cavity drainage liquid formation, the complex "device for drainage of cavity formations - superrigid metal conductor" removed, drainage is fixed to the skin.

Pat. RF №201202020. A known method of drainage of cavity formations, carried out using a device for percutaneous drainage of cavity formations under ultrasound control, wherein the cavity formation is punctured, the mandrin is removed from the device, a flexible metal conductor is introduced into the cavity, then the forward movement of the drainage through the complex is performed: "device for drainage of cavity formations - a flexible metal conductor "into the lumen of the cavity formation, after which the complex:" device for drainage of cavity ducation - flexible metal conductor "is removed, the drainage is fixed to the skin. Positive in this method is that the intervention itself is carried out quickly, there is no need to use a large number of bougie of increasing diameter, the risk of getting chemically aggressive or infected contents of the drained formation into the abdominal cavity is reduced, the process of moving the drainage into the drained cavity fluid formation is simplified. The disadvantage of this method is the limited treatment options and insufficient safety for the patient when draining cavity fluid formations, manifested in the inability to use this method with limited visualization of the cavity fluid formation using ultrasound, in the inability to implement the drainage method under the control of computed tomography due to the significant length of the instrument (40 cm ), in the inferiority of control over the depth of the puncture and the position of the tip of the instrument ment, the impossibility of the simultaneous introduction of several instruments (needles) followed by selecting optimally located instrument (needle).

Pat. RF №2332178. The method of applying cystoduodenoanastomosis with pseudocysts of the head of the pancreas, including duodenotomy, applying an anastomosis between the lumen of the duodenum and pseudocysts, duodenoraphy, characterized in that to apply the anastomosis, the cysts are punctured with a trocar from the lumen of the twelve circumference of the sleeve of the trocar as follows: the needle is injected at a distance of 5 mm from the trocar from the side of the mucous membrane nadtsatiperstnoy intestine at 90 °, via slot vykoli produce trocar sleeve lumen of the cysts, the trocar sleeve is removed, circumferentially impose additional joints between the wall of the cyst and the wall of the duodenum. The disadvantage of this method is a possible complication in both the early and late postoperative period of such a complication as pancreatitis or suppuration caused by the throwing of intestinal contents into the cavity of the cyst.

Pat. RF №2423925. A method for surgical treatment of post-necrotic pancreatic pseudocysts, including transgastric cystogastrostomy, external-internal drainage of the pancreatic cyst, characterized in that they perform a laparotomy of 4-5 cm in the projection of the cyst, set the Mini-Assistant instrument kit, create an operative field, perform gastrotomy 4 see, puncture the cyst through the posterior wall of the stomach, cross-section through the posterior wall of the stomach and the wall of the cyst for 4 cm, remove the contents of the cyst, sew back ny wall of the stomach and the wall of the cyst, establish drainage through the front wall of the stomach and anastomosis into the cavity of the cyst.

A common disadvantage of the above methods is: multi-stage treatment of a child with cystic pancreatic formation; the difficulty of managing patients with acute pancreatitis; high risk of severe complications requiring complex reconstructive surgery in the pancreatoduodenal zone.

The closest way to laparoscopic removal of the pancreatic cyst is the laparoscopic method of removing false and true pancreatic cysts of the head, body and tail of the pancreas in the disabled loop of the small intestine according to Ru, including the introduction of ports, opening the stuffing box, subsequent opening of the cystic cavity by dissecting longitudinally and anastomosing with disconnected loop of the small intestine drawn through the mesocolon along the Ru outside the abdominal cavity through the minilaparotomic access in the umbilical region (Russian Bulletin of a Pediatric Surgeon AI, anesthesiology and resuscitation, №3, 2012, pp. 30-34). The method was as follows:

Patient K., 12 years old, January 12, 2010 was hospitalized in the surgical department of the Morozov Children's City Clinical Hospital (MDGKB) with suspected acute appendicitis. Within a few days before hospitalization, the girl ate fatty fish, noted severe thirst, and complaints of cramping abdominal pain in the umbilical region appeared. During follow-up, the diagnosis of acute appendicitis was ruled out. A laboratory examination revealed an increase in glucose level - up to 11.24 mmol / l, alpha-amylase in the blood - up to 813 IU / l, urine diastasis - up to 6020 ME / l. Ultrasound examination of the pancreas: the contours are clear, even, dimensions - 17 × 17 × 19 mm, the structure is homogeneous, the echogenicity of the parenchyma is not changed. In connection with the detection of glucoseemia on December 13, 2010, the patient was transferred to MDGKB with a diagnosis of diabetes mellitus, acute pancreatitis. The next day, according to ultrasound data, an increase in the size of the pancreas to 28 × 23 × 27 mm, an increase in echogenicity, heterogeneity of the echostructure with fuzzy contours, which are difficult to differentiate from surrounding tissues, were noted. The patient was given infusion, replacement, symptomatic analgesic therapy. During the consultation by the endocrinologist, a violation of glucose tolerance was detected against the background of the course of acute pancreatitis, there were no indications for insulin administration. Based on clinical and laboratory data, as well as repeated ultrasound and computed tomography, a diagnosis of pancreatic necrosis was established. On December 21, 2010, laparoscopy was performed. During the revision of the abdominal cavity, the mesentery and omentum are sharply swollen, infiltrated, with elements of stearosis, the gall bladder is sharply tense, infiltrated. After dissection of the gastrointestinal ligament, an omental bursa was opened, in the cavity of which a significant amount of turbid effusion with fragments of necrotic tissues was noted, edematous parapancreatic tissue, and the pancreatic parenchyma was not visualized. The cavity of the stuffing bag was washed and drained. Against the background of subsequent infusion, antibacterial therapy, the introduction of sandostatin, Gordox, the patient's condition improved. Sonography and computed tomography revealed signs of the possible formation of pancreatic cysts (in the head and tail of the pancreas, sections of low density that did not accumulate the contrast preparation, 1.5 × 1.8 and 3.7 × 1.8 cm in size, remained). The patient was discharged in satisfactory condition on the 24th day after the operation under the supervision of an endocrinologist with the recommendations of a control ultrasound examination. After 6 months, an ultrasound examination revealed a multi-chamber cyst about 9 × 6 × 4 cm in size, adjacent to the lesser curvature, antrum of the stomach, displacing it anteriorly. Given the location of the cyst and the intraoperative picture with previously performed laparoscopy (between the left lobe of the liver and the antrum of the stomach, the anteroposterior fluid formation with a dense capsule emanating from the omental bursa is revealed - a pseudocyst 10.0 × 8.0 × 6.0 cm in size, located posterior to the stomach), it was decided to perform open surgery; On June 28, 2011, a laparotomy was performed, gastrocystostomy was performed. In the postoperative period, the child had persistent hyperglycemia (8-11 mmol / l), was diagnosed with insulin-dependent diabetes mellitus, and insulin therapy was carried out. Against the background of the treatment, carbohydrate metabolism was compensated. After 3 months, a relapse of the cystic formation of the pancreas was revealed. Computed tomography compared with a previous study showed an increase in the size of the cyst in the area of the head and body of the pancreas. For full drainage of the pancreatic cyst, on November 23, 2011, a laparoscopic pancreatojejunostomy was performed on the disconnected loop of the small intestine according to Ru. After opening the stuffing bag, cicatricial tissue was visualized in the region of the pancreatic head, the cystic cavity was opened, it was dissected longitudinally and anastomosed with the jejunum loop disconnected through the mesocolon along the Roux. A small intestinal anastomosis is applied outside the abdominal cavity through mini-laparotomy access in the umbilical region. The postoperative period was uneventful. The patient was discharged from the clinic on the 14th day after the operation. According to ultrasound data, 3 and 6 months after the operation, cystic formations in the abdominal cavity were not detected, partial restoration of the pancreas structure, absence of pain and dyspeptic disorders were noted, carbohydrate metabolism was compensated against the background of insulin therapy.

The presented observation of the multi-stage treatment of a child with cystic pancreatic formation reflects the complexity of managing patients with acute pancreatitis and the high risk of developing serious complications requiring complex reconstructive surgery in the pancreatoduodenal zone.

The objective of the proposed method of laparoscopic cystejunostomy for children is the elimination of side processes such as adhesions and intestinal obstruction, effective drainage of fluid from the cyst, and reducing the time of the child under anesthesia and in the intensive care unit, high cosmetic result.

This goal can be achieved by using the laparoscopic method for removing false and true pancreatic cysts on the disconnected loop of the small intestine according to Ru, including the introduction of ports, opening the stuffing box, subsequent opening of the cystic cavity by dissecting longitudinally and anastomosis with the loop of the small intestine held through the window in the mesentery of the transverse colon. First, one video port is introduced 2 cm below the navel along the midline, then two instrument ports on the right and left along the midclavicular line and below the umbilical line, with the right port 1-1.5 cm higher than the left and the third instrument port for introducing the Kushieri retractor set along the front axillary line on the left 2-3 cm below the left hypochondrium, anastomosis is applied between the lumen of the small intestine and the pancreatic cyst, cross the small intestine at a distance of 25-30 cm from the duodeno-jejunum bending, keeping in Among the legs, one or more arterial trunks, its proximal segment, are sutured distally “side-by-side” outside the abdominal cavity through a mini-laparotomic access in the umbilical region, forming a short loop 35-40 cm long, and the distal end of the intestine is sutured with a single-row sewing suture, passing through the window in the mesentery of the transverse colon and without tension, they lead to the pancreatic cyst, followed by the formation of cystejunoanastomosis.

The invention is illustrated in Fig. 1, where 1 is the proximal end of the jejunum, 2 is the distal end of the jejunum, 3 is a side-to-side enteroanastomosis, 4 is a window in the mesentery of the transverse colon.

The method is as follows:

Example 1. Laparoscopic cystoejunostomy

Three 5 mm and one 10 mm trocar were injected under endotracheal anesthesia. The video port was inserted 2 cm below the navel in the midline. We used 2 instrument ports, which are located on the right and left in the midclavicular line and slightly below the navel, and the right trocar should be positioned slightly higher than the left to avoid their crossing. The third instrumental port for introducing the Kushieri retractor was installed along the anterior axillary line on the left, 2-3 cm below the left hypochondrium.

Access to the cyst of the pancreas was through the gastrointestinal ligament using monopolar coagulation.

In the region of the head of the pancreas a cyst was determined, measuring 4 * 5 cm, the latter was partially isolated and subsequently opened throughout.

The most favorable place for crossing the small intestine is at a distance of 25-30 cm from the duodeno-jejunal bend (Treitz ligament). At this point, the arteries of the jejunum run parallel to the curved surface of the one-story arcades. Therefore, it is not difficult to obtain a segment of the intestine of the required length, preserving one or more arterial trunks as a leg. After crossing the jejunum, its proximal segment (Figure 1-1) is sutured into the distal small intestine using a side-by-side method (Figure 1-3). The creation of this anastomosis is performed outside the abdominal cavity, while additional incisions are not performed, because to remove the loop of the small intestine, a ten-millimeter incision is used in the place where the video port was previously installed, thereby not causing additional surgical trauma, after the application of the thin-intestinal anastomosis, the latter is plunged back into the abdominal cavity, thereby forming a so-called short loop 35-40 cm long The distal end of the intestine (Figure 1-2) is sutured with a twisted single-row suture (monofilament thread 4/0), passed through the window in the mesentery of the transverse colon (Figure 1-4) and without any tension chickens to the cyst of the pancreas, followed by the formation of cystoyunoanastomosis.

Conclusion: As a result of this operation from laparoscopic access, effective drainage of fluid from the cyst is achieved by suturing the proximal segment of the small intestine distally side-by-side outside the abdominal cavity through a mini-laparotomic access in the umbilical region, an excellent cosmetic result due to small incisions 5 mm each, the patient’s stay in the hospital is reduced, the average patient’s stay in the postoperative period is 7-10 days, while during the operation on the prototype 20 days. Almost never there is such a complication as adhesive and / or dynamic intestinal obstruction. The application of one of the anastomoses outside the abdominal cavity reduces the operation time by an average of 25-30 minutes (while the child is under anesthesia), additional incisions are not performed, because to remove the loop of the small intestine, a ten-millimeter incision is used in the place where the video port was previously installed, thereby not causing additional surgical injury.

Claims (1)

Laparoscopic method for removing false and true pancreatic cysts on the disconnected loop of the small intestine according to Ru, including the introduction of ports, opening the stuffing box, subsequent opening of the cystic cavity by dissecting longitudinally and anastomosis with the loop of the small intestine disconnected through the window in the mesentery of the transverse colon characterized in that at first one video port is introduced 2 cm below the navel along the midline, then two instrument ports on the right and left along the midclavicular line and below the umbilical of the right line, the right port 1-1.5 cm above the left and the third instrument port for introducing the Kushieri retractor is installed along the front axillary line on the left 2-3 cm below the left hypochondrium, the anastomosis is applied between the lumen of the small intestine and the pancreatic cyst, they cross the small intestine at a distance of 25-30 cm from the duodeno-jejunal bend, preserving one or more arterial trunks as a leg, its proximal segment is sutured distally "side-by-side" outside the abdominal cavity through mini-laparotomic access umbilical region, forming a short loop with a length of 35-40 cm, and the distal end of the intestine is sutured with a single-row seaming seam, passing through the window in the mesentery of the transverse colon and without tension is brought to the pancreatic cyst, followed by the formation of cysteunoanastomosis.

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