RU2600925C1 - Method for laparoscopic mini gastric bypass surgery for obesity treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and surgery. Laparoscopic mini gastric bypass surgery is made for obesity treatment without crossing of stomach. From laparoscopic access an element is placed circularly around stomach, which tightly clamps stomach to small upper and big lower segments. Segmenting element is fixed and covered at outer surface of the stomach with seromuscular sutures between walls of small and big segments of stomach. Anastomosis is made between small lower part of stomach and small intestinal loop with transverse dissection of the small intestine wall.

EFFECT: method provides more effective and safe gastric bypass surgery for obesity treatment due to positive gastrointestinal gradient with maximum values of pressure in small segment of the stomach, absence of stomach intersection, reduced surgery time and risk of complications.

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Description

The invention relates to medicine, in particular to bariatric and metabolic surgery.

Known laparoscopic gastric bypass surgery for the treatment of obesity according to the Py method (Roux-en-Y), which involves the creation of an average volume of 15 ml (5 cm long) in the cardiac section of the stomach of the small ventricle (restrictive component), which is anastomosed with the skinny loop turned off by Py the intestine (shunt component) of the required length (up to 150 cm), depending on the body mass index, and creating at the distance from 30 to 50 cm from the ligament of the Traits of the intestinal anastomosis - the fusion site (Y) of the proximal end of the small intestine (biliopancreatic management) with the distal end of the small intestine - Py alimentary lead [Buchwald, Henry / Buchwald′s Atlas of Metabolic & Bariatric Surgical Techniques and Procedures, Philadelphia, Chapter 6 - Laparoscopic Roux-en-Y Gastric Bypass, 2012, P. 114- 141. ISBN: 978-1-4160-3106-2 DOI - http://dx.doi.org/10.1016/B978-1-4160-3106-2.00006-4; URL - http://www.sciencedirect.com/science/article/pii/B9781416031062000064)].

This operation is technically difficult due to the need to form a small ventricle and gastroenteroanastomosis in the cardiac part of the stomach in conditions of excessively developed adipose tissue in the abdominal cavity. In addition, an obligatory component of such operations is the creation of a second anastomosis - an intestinal anastomosis, which increases the likelihood of complications from the sutures of the anastomoses in the form of insolvency, bleeding and stricture formation. A serious drawback of this method is the high risk of developing internal hernias in the newly artificially formed intra-abdominal pockets, which occur in three places: 1) in the place where the intestinal loop through Py passes through the window in the mesentery of the colon; 2) in the zone of jejunal anastomosis; 3) between the mesentery of the jejunum and colon in the Peterson space [Lee WJ, Ser KN, Lee YC, et al .: Laparoscopic Roux-en-Y vs. Mini-gastric bypass for the treatment of morbid obesity: A 10-year experience. Obes Surg 2012; 22: 1827-1834].

The prototype of the invention is a method of performing laparoscopic mini-gastric bypass for the treatment of obesity, introduced by the American surgeon Robert Rutledge [Rutledge R: The mini-gastric bypass: Experience with the first 1,274 cases. Obes Surg 2001; 11: 276-280]. The developed method (mini gastric bypass) has various English names: single-anastomosis gastric bypass; one-anastomosis gastric bypass; omega loop gastric bypass.

This method of laparoscopic mini-gastric bypass surgery for the treatment of obesity in its modern form includes: laparoscopic access; the implementation of the window in the hepatic-gastric ligament of the lesser omentum and the window in the gastro-diaphragmatic ligament in the bottom of the stomach; the introduction through the data of the window of the device separating the cavity of the stomach into a small upper part with a volume of from 30 ml to 50 ml and a large lower part of the stomach; anastomosis of a small part of the stomach with a loop of the small intestine from 200 to 300 cm long from the ligament of Treitz. This operation also consists in the formation of a "small ventricle" and the creation of a gastroenteroanastomosis - the connection of the stomach with the leading loop through which the bile and juice of the pancreas enter, and the leading through which the food is mixed with the incoming enzymes along the leading loop.

But unlike the Py method, a narrow (from 1.5 cm to 2 cm wide) and longer (10 cm) gastric canal is isolated from the angle of the stomach to the His angle using a stapler along the lesser curvature. Such technical features in some cases prevent the reflux of bile from the small intestine into the stomach. In addition, the mucous membrane of the upper antrum of the stomach that enters the formation zone of the gastroenteroanastomosis after crossing the stomach is anatomically and functionally more resistant to bile exposure. But the main difference from the Py method is the creation of a single anastomosis, which is formed using a linear stapler or a manual suture.

The advantage of this intervention is to simplify the technique of gastric bypass surgery while maintaining almost all the advantages of the prototype [Noun R, Skaff J, Riachi E, et al .: One thousand consecutive mini-gastric bypass: Short - and long-term outcome. Obes Surg 2012; 22: 697-703].

The author obtained excellent bariatric results with excellent metabolic syndrome correction results [Rutledge R, Walsh TR: Continued excellent results with the mini-gastric bypass: Six-year study in 2,410 patients. Obes Surg 2005; 15: 1304-1308].

Significantly reduces the likelihood of complications from the gastrointestinal sutures due to the presence of a single anastomosis and a decrease in potential areas of development of internal hernias only between the mesentery of the jejunum and colon, which can be easily eliminated by suturing between these mesenteries.

But this method, selected as a prototype, has the following disadvantages.

Firstly, for the restrictive effect of the operation when creating the "small ventricle" complete anatomical surgical intersection of part of the stomach is performed, as well as anastomosing it with a loop of the small intestine for the malabsorption effect, they are performed with mechanical suturing and simultaneously cutting devices, which has the risk of complications in the early postoperative period on the part of the mechanical staple seam in the form of insolvency, bleeding, the formation of peptic ulcers, etc.

Secondly, a rigid and not completely closed gastroenteroanastomosis is formed due to the use of foreign material. Moreover, in the distant postoperative period, fibrous tissue forms in the tissues around three rows of staples of the stapler, forming a rigid “spacer ring” of brackets and fibrous tissue. In functional terms, this causes gaping of anastomosis and constant reflux of bile and pancreatic juices from the adducting loop of the small intestine into the lumen of the small upper part of the stomach due to the alignment of the gastrointestinal gradient of intracavitary pressure and this, in turn, can cause a marginal gastric ulcer, peptic ulcer of the anastomosis, and later on stomach cancer.

Thirdly, non-absorbable suture material causes chronic inflammation of the anastomosis - anastomositis, which subsequently leads to scarring and the development of stricture of the anastomosis;

Fourth, the size of the anastomosis is important for the long-term restrictive effect of bariatric surgery and the prevention of dumping syndrome. [Heneghan NM, Yimcharoen P, Brethauer SA, Kroh M, Chand B (2012) Influence of pouch and stoma size on weight loss after gastric bypass. Surg Obes Relat Dis 8: 408-415 .; Catalano MF, Rudic G, Anderson AJ, Chua TY. Weight gain after bariatric surgery as a result of a large gastric stoma: endotherapy with sodium morrhuate may prevent the need for surgical revision. Gastrointest Endosc. 2007; 66 (2): 240-245]. The standardization of the diameter of the gastroenterostomy can be precisely observed when using circular staplers with a diameter of 20 mm, but which, as a rule, are not used in the mini-gastric bypass option due to the need for additional enterotomy. And with manual execution of the anastomosis, it is difficult to precisely fulfill the required minimum permissible, but favorable in terms of restrictive effect, small sizes of the gastroenteroanastomosis. Inevitably accompanied by anastomositis in the early postoperative period with small sizes of anastomosis due to edema leads to obstruction from the stump of the stomach and the risk of divergence of sutures on the stomach. All this forces surgeons to perform anastomosis of a wider size.

Fifth, when performing gastroenteroanastomosis with linear staplers, the anastomosed small intestine is dissected along its axis, damaging the circular muscle fibers over a large length, which also leads to a gaping hole in the small intestine;

Sixth, it is indisputable that the operation requires the use of expensive staplers, which cost from two to three thousand US dollars per operation, which increases the cost and reduces the availability of such operations for the majority of the population.

And seventh, this operation remains relatively complex and lengthy, which increases the likelihood of cardiopulmonary, thromboembolic, and other complications, especially with overdriving, usually accompanied by hypoventilation syndrome.

The objective of the present invention was: to improve the safety of gastric bypass surgery, simplifying and accelerating the operation; increasing the functionality of mini-gastroshunting by creating a gastroenteroanastomosis without preserving suture material in the long-term postoperative period; reducing the cost of surgery and increasing accessibility for the general population due to the possibility of a complete rejection of the use of expensive staplers.

The problem is solved due to the fact that the method of laparoscopic mini-gastric bypass for the treatment of obesity, including: laparoscopic access; the implementation of the window in the hepatic-gastric ligament of the lesser omentum and the window in the gastro-diaphragmatic ligament in the bottom of the stomach; the introduction through the data of the window of the device separating the cavity of the stomach into a small upper part with a volume of from 30 ml to 50 ml and a large lower part of the stomach; Anastomosis of a small part of the stomach with a loop of the small intestine from 200 to 300 cm long from the Treitz ligament differs from the prototype in that the stomach is not cut, and a segmenting element is circulated around the stomach, hermetically compressing the stomach into small and large segments, the segmenting is fixed and covered an element on the outer surface of the stomach with serous-muscular sutures made between the opposite contacting walls of the small and large segment of the stomach.

And they complete the operation with the formation of a highly elastic gastroenteroanastomosis with transverse dissection of the anastomosed wall of the small intestine, while creating a positive gastrointestinal gradient with the highest values of cavity pressure in a small segment of the stomach.

In special cases, the method differs in that they use a segmenting element in the form of an elastic ring - a cuff made of a biological inert material - silicone, another special case is the use of a tape in the form of a non-absorbable mesh as a segmenting element.

Also, in special cases, an adjustable segmenting element is used in the form of a device for adjustable gastric banding. In addition, in special cases, a gastroenteroanastomosis between the small segment of the stomach and the loop of the small intestine is created using a compression anastomotic clip with a length of 15 mm to 20 mm. Another embodiment of the gastroenteroanastomosis between the small segment of the stomach and the loop of the small intestine is the creation of an anastomosis only from completely absorbable or removed from the body material.

When comparing with the prototype, the following essential features characterizing the invention are revealed:

1. For the restrictive component of the operation, the stomach is not dissected;

2. A segmenting element is circulated around the stomach circularly, tightly pinching the stomach into small and large segments;

3. Fix and cover the segmenting element on the outer surface of the stomach with serous-muscular sutures made between the opposite contacting walls of the small and large segment of the stomach;

4. A highly elastic gastroenteroanastomosis is formed with a transverse dissection of the anastomosed wall of the small intestine while preserving most of the circular muscles of the small intestine in the anastomosis;

5. Create a positive gastrointestinal gradient with the highest values of cavity pressure in a small segment of the stomach;

6. In some cases, and for greater accessibility of the operation, when performing the method, an unregulated segmenting element is used in the form of an elastic ring - a cuff made of a biological inert material - silicone, or from a non-absorbable mesh in the form of a tape, or an adjustable segmenting element is used in the form of a device for adjustable banding the stomach;

7. Also, in some cases, the implementation of the method of laparoscopic mini-gastroshunting for the treatment of obesity, gastroenteroanastomosis between the small segment of the stomach and the loop of the small intestine is created using a compression anastomotic clip from 15 mm to 20 mm in length or the anastomosis is created only from a completely absorbable or removed from the body material.

The listed set of features provides a technical result.

The technical result of the invention:

1. The safety of patients is increased by eliminating the need for anatomical surgical intersection of the stomach, which can cause insolvency and the risk of bleeding from the area of mechanical staple (staple) sutures;

2. Simplifies and accelerates the separation of the stomach when creating a "small ventricle";

3. In general, operating time is reduced and the likelihood of complications associated with the immobilized condition of patients and the amount of injected drugs for anesthesia and their harmful effects on the body decreases;

4. The functionality and antireflux capabilities of the operation are increased due to the fact that, due to the small size, high elasticity of the anastomosis, with transverse dissection of the anastomosed wall of the small intestine, the gastrointestinal anastomosis opens only under the action of the tonic contraction of the stomach, but not under the action of weaker peristalsis small intestine. This, in the first place, provides a positive gradient of gastrointestinal pressure.

5. The accessibility of gastric bypass for the majority of the population increases and the operation becomes cheaper due to the lack of need for expensive, usually imported, disposable endoscopic staplers and consumable cartridges for it;

6. The use of absorbable suture material or a compression device to create an anastomosis in the form of an anastomotic clip allows you to create an almost seamless anastomosis in the postoperative period, which reduces the likelihood of developing anastomotic stricture;

7. Constant compression of the gastric wall by a segmenting element affects baroreceptors and increases the feeling of satiety of patients suffering from bulimia;

8. In particularly difficult clinical cases, in order to simplify the operation, for example, in co-morphology and pronounced internal obesity, it is possible to use a commercially available adjustable segmenting element, which provides even greater simplification of the operation due to the optional full, as required for an unregulated segmenting element, but only partial, and only for fixing at a certain level, immersing the segmenting element inside the gastric wall invaginated above it;

9. In particularly difficult clinical cases, for example, with a limited working space in the abdominal cavity, the use of a compression anastomotic clip allows you to simplify and standardize the magnitude of the anastomosis between the small ventricle and small intestine, which further reduces the likelihood of reducing the restrictive component of gastric bypass and the development of dumping syndrome.

The proposed method is illustrated by the following drawings:

- In FIG. 1 schematically shows the implementation of the window in the hepatic-gastric ligament of the lesser omentum and the window in the gastro-diaphragmatic ligament in the bottom of the stomach;

- In FIG. 2 shows the position of the segmenting element in the form of an elastic ring - cuff;

- In FIG. 3 shows the completion of the operation with the formation of a "small" ventricle, the shelter of a segmenting element in the folds of the stomach and the creation of a gastroenteroanastomosis.

We give an example of the clinical use of the method. Patient N.A. 35 years old, was admitted to the clinic on March 10, 2015 with complaints of weight gain, joint pain, shortness of breath during physical exertion. Overweight notes since childhood. In the past 11 years, there has been a steady increase in body weight. Maximum weight before surgery 139 kg. In the history of repeated attempts to reduce body weight by diet, medication with xenical, siafor, regularly attended fitness. There was a reduction effect to 15 kg followed by reverse fast weight gain. The body mass index (BMI) with the growth of 168 cm was 49.2 kg / m ² before surgery.

The operation of laparoscopic mini-gastric bypass surgery for the treatment of obesity by the proposed method. To do this, laparoscopic access was performed after performing carboxyperitoneum with a typical installation for gastroshunting of trocars and a hepatic retractor under the xiphoid process.

Using Sonosurg ultrasonic scissors, a window 2 in the hepatic-gastric ligament of the small omentum and a window 3 in the gastro-diaphragmatic ligament in the bottom of the stomach 1 were created along the edge of the stomach 1 (Fig. 1).

Through these windows 2, 3, taking into account pronounced internal obesity, a segmenting element is introduced circularly around the stomach 1 (Fig. 1-2) - a device 4 for the adjustable gastric banding of the Russian company Medsil, which divides the cavity of the stomach 1 into a small (upper) segment 5 volume from 30 ml to 50 ml and a large (lower) segment 6 of the stomach 1 (Fig. 2). After installation in the subcutaneous fat layer in the left hypochondrium and fixing to the aponeurosis of the port of the regulatory system, the maximum liquid was introduced into the port until the gastric lumen 1 was completely closed (not shown in Fig.). Then, a gastric tube was inserted into the cavity of the small segment 5 and this cavity was inflated to check its tightness and the absence of communication with the large segment 6 of the stomach (not shown in Fig.).

Then (in Fig. 3), anastomosis of the small segment 5 of the stomach was performed with 1 loop of the small intestine 7 from 200 cm long, measured from the duodenojejunal ligament of Treitz 8. For this, the adjacent anastomosed section of the small segment 5 of the stomach 1 and small intestine 7 was connected with serous-muscular sutures and the adjacent wall of the small intestine 7 was transversely dissected from the 15 mm length of the mesenteric side, and using a two-row suture with a non-traumatic Vikril 2/0 thread, a manual gastroenteroanastomosis 9 was created. Performing a side-to-side transverse anastomosis created ny valve from the small intestine. At the same time, a positive gastrointestinal gradient with the highest values of cavity pressure in a small segment of the stomach was ensured by the fact that for the development of bile reflux and pancreatic secretions from the lumen of the small intestine into the stomach through the anastomosis, the small intestine developed peristalsis of the intracavitary pressure was not enough due to the more powerful muscle membrane of the stomach and small sizes of elastic closing anastomosis.

Next, the leading 10 and 11 leading sections of the small intestine 7 were squeezed with soft intestinal clamps and re-injected into the cavity of the small segment 5 of the stomach 1 air and the tightness of the gastroenteroanastomosis 9 was monitored. For this, it was immersed in physiological saline previously introduced into the upper floor of the abdominal cavity ( in Fig. not shown). The absence of air bubbles indicated the tightness of the seams.

The next step for fixing the segmenting element - device 4 was covered in free (accessible) parts of the stomach along the outer surface of the stomach with serous-muscular sutures 12 made between the opposite contacting walls of the small 5 and large 6 segments of the stomach 1. This fixing stage was performed only to prevent displacement segmenting element - device 4.

The operation was completed by drainage of the abdominal cavity. Trocars and all instruments were removed. Sutures for trocar wounds were performed. The duration of the operation was 83 minutes, which is 26 minutes less than the standard time when using the prototype.

The postoperative period was uneventful, the patient was discharged on the 7th day. At the control examination after 3 months: weight loss by 24 kg, joint pain and shortness of breath stopped. In general, the quality of life has improved significantly. The patient is completely satisfied with the operation. Endoscopically, during these periods, we did not observe either bile reflux into the stomach or the presence of suture material in the anastomotic zone. The diameter of the anastomosis was approximately 15 mm, and when insufflated with air, the anastomosis easily opened, and when deinsulated air from the stomach, the anastomosis easily closed. Clinically, we also did not reveal signs of dumping syndrome. X-ray fractional fractional passage of contrast from a small segment of the stomach to the small intestine was noted. In a laboratory study, indicators are within normal limits. Observation continues.

Thus, the application of the proposed method has led to increased safety of gastric bypass surgery, simplification and acceleration of the operation; increasing the functionality of mini-gastroshunting by creating a gastroenteroanastomosis without preserving suture material in the postoperative period; reducing the cost of surgery and increasing accessibility for the general population due to the possibility of a complete rejection of the use of expensive, usually imported, staplers.

Claims (6)

1. The method of laparoscopic mini-gastric bypass for the treatment of obesity, including: laparoscopic access; the implementation of the window in the hepatic-gastric ligament of the lesser omentum and the window in the gastro-diaphragmatic ligament in the bottom of the stomach; the introduction through the data of the window of the device separating the cavity of the stomach into a small upper part with a volume of from 30 ml to 50 ml and a large lower part of the stomach; anastomosis of a small part of the stomach with a loop of the small intestine from 200 to 300 cm long from the Treitz ligament, characterized in that the stomach is not cut, and a segmenting element is circulated around the stomach, hermetically squeezing the stomach into small and large segments, the segmenting element is fixed and covered with an outer the surface of the stomach with serous-muscular sutures made between opposite contacting walls of the small and large segments of the stomach, and complete the operation with the formation of a gastroenteroanastomosis with a transverse p dissection of the anastomosed wall of the small intestine. 2. The method according to p. 1, characterized in that they use a segmenting element in the form of an elastic ring-cuff of a biological inert material - silicone. 3. The method according to p. 1, characterized in that they use a segmenting element made of a non-absorbable mesh in the form of a tape. 4. The method according to p. 1, characterized in that they use an adjustable segmenting element in the form of a device for adjustable banding of the stomach. 5. The method according to p. 1, characterized in that the gastroenteroanastomosis between the small segment of the stomach and the loop of the small intestine is created using a compression anastomotic clip with a length of 15 mm to 20 mm. 6. The method according to p. 1, characterized in that the gastroenteroanastomosis between the small part of the stomach and the loop of the small intestine is created only from completely absorbable or removed from the body material.

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