RU2613940C1 - Method for formation of duodenal stump - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: invention relates to medicine, namely to surgery. After application of apparatus suture duodenal stump is submerged by means of monofilamentous thread with two needles on ends, tightened with serous-muscular-submucosal suture on caudal semicircle of intestine and tied up with knot above apparatus suture. Cranial semicircle of intestine is sewn with the same thread. Capsule of pancreas is sewn with one of thread ends in cranial direction. Needle with thread is turned and intestine is sewn from caudal side. Capsule of pancreas in caudal direction and wall of intestine from cranial side are sewn with the second needle. Threads are evenly tightened until tight fixation of duodenal stump to pancreas capsule takes place. Threads are tied up.

EFFECT: method makes it possible to provide prevention of postoperative complications, and optimal reparative properties of stump.

2 ex, 10 dwg

Description

The invention relates to medicine, namely to abdominal surgery and oncology, and can be used for surgical treatment of patients who require the formation of a duodenal stump.

It is known that in 21.6-70.4% of cases, the surgeon encounters difficulties in the formation of the duodenal stump, due to the need for its resection due to ulcerative lesions, or close to the pyloric tumor [Grigoryan R.A. Relaparotomy in surgery of the stomach and duodenum [Text] / R.A. Grigoryan. - M.: MIA, 2005 .-- 400 p. ISBN 5-89481-306-9; Navrotsky I.N. Suturing of the duodenal stump [Text] / I.N. Navrotsky. - M .: Medicine, 1972. - 183 p .; Nikitin N.A. “Difficult” duodenal stump in urgent surgery of duodenal ulcer [Text] / N.A. Nikitin // Surgery. - 1990. - No. 9. - S. 103-107; Mouse G.D. Pathophysiological aspects of peptic ulcer surgery. Novosibirsk: Science, Siberian Branch, 1983].

Currently, in the literature you can find a description of about 200 methods of suturing the stump of the duodenum when performing a resection of the stomach and gastrectomy, none of which guarantee 100% protection against the development of insolvency, the abundance of different methods indicates the dissatisfaction of the surgeons with the reliability of the proposed options [Nikitin N. BUT. Insufficiency of sutures of the duodenal stump in urgent surgery of peptic ulcer. - Kirov: Vyatka, 2002 .-- 144 p .; Skripnikov N.S. Closure of the stump of the duodenum with penetrating low ulcer / N.S. Skripnikov, B.F. Lysenko, V.D. Sheiko, R.B. Lysenko // Wedge. surgery. - 1995. - No. 9-10. - S. 15-17; Navrotsky I.N. Suturing the stump of the duodenum / I.N. Navrotsky.- M .: Medicine, 1975 .-- 368 p .; Vinogradov I.A. Diagnosis and treatment of insolvency of sutures of the stump of the duodenum after resection of the stomach // Abstract. Ph.D. St. Petersburg. - 2007. - S. 22].

Despite the continuous improvement of surgical technique, the failure of the stitches of the duodenal stump is observed with a frequency of 2.7-19.4% and a mortality rate of 50-80% [Grigoryan R.A. Relaparotomy in surgery of the stomach and duodenum [Text] / R.A. Grigoryan. - M.: MIA, 2005 .-- 400 p. - ISBN 5-89481-306-9; Mouse G.D. Pathophysiological aspects of peptic ulcer surgery [Text] / G.D. The mouse. - Novosibirsk: Nauka, 1983 .-- 195 p .; Navrotsky I.N. Suturing of the duodenal stump [Text] / I.N. Navrotsky. - M .: Medicine, 1972. - 183 p .; Nikitin N.A. “Difficult” duodenal stump in urgent surgery of duodenal ulcer [Text] / N.A. Nikitin // Surgery. - 1990. - No. 9. - S. 103-107; Rudik A.A. Comparative results of various types of surgical treatment for complicated duodenal ulcer [Text]: dis. ... Dr. honey. sciences / A.A. Rudik. - Khabarovsk, 2001 .-- 331 s .; Tsyganov N.N., Senko V.P., Griko S.I. et al. Insufficiency of sutures of the duodenal stump after gastrectomy for gastroduodenal ulcers. Vestn, chir. 1980; No. 3: 33-36; Bachev I.I. Early reoperations after gastrectomy. Surgery 1982; No. 3: 56-58; Launois B., Bourdonec P., Paul J. L. et al. Les aspects chirurgicaux des hemmoragies des ulceres duodenaux. Chir Mem Acad Chir 1986; 112: 2: 109-114; Vantsyan E.N. et al. 1976, Karaman N.V. et al. 1976. Orlov P.A. et al., 1985, Vitebsk Y.D. et al. 1985, Smotrov N.A. 1989; Zemlyanoy A.G. Prevention of failure of sutures of the stump of the duodenum during gastrectomy for pyloroduodenal ulcers. Vestn. chir. 1985; 26-31; Gavrilescu S., Vereanu I. Rezectia de excludere modalitate particulara de rezolvare a unor ulcere complicate. Chirurgia 1986; 35: 4: 253-262; Rossi J.A. External duodenal fistula: causes, complications and treatment / J.A. Rossi, L.L. Sollenberger, R.V. Rege, J. Glenn, R.J. Joehl // Curr. Chir. - 1987. - Vol. 44. - No. 6. - P. 524-529]. The frequency of inconsistency of sutures of the stump of the duodenum during emergency operations reaches 26-40% according to some authors [Nikitin N.A. Insufficiency of sutures of the duodenal stump in urgent surgery of peptic ulcer / N.A. Nikitin // Kirov: Vyatka. - 2002. - 215 p.].

This problem at the moment cannot be solved only by the use of modern suture materials and “hardware” mechanical sutures, the formation of a “reliable” duodenal stump requires an additional search and development of new, more reliable methods and techniques [Mshrek Ali. The effectiveness of various methods of closing the stump of the duodenum after resection of the stomach. Materials of the All-Russian scientific-practical. conferences with international participation. - Sochi, 2006 // Bulletin of surgical gastroenterology. - 2006. - No. 1. - S. 43-43]. Despite the modern possibilities for minimally invasive removal of bile, in case of failure of the sutures of the stump of the duodenum, this complication often leads to disability and death [Vinogradov I.A. Morphology of the wound process with the development of insolvency of sutures of the duodenal stump after resection of the stomach / I.A. Vinogradov // Materials total. conf. Military science islands of listeners and residents of I fact., April 4. 2007 / Military. - honey. Acad. - SPb .: VMedA, 2007. - S. 21-22].

The choice of a method for closing the stump of the duodenum, especially in difficult cases (with severe edema or in conditions of tissue deficiency), remains an urgent problem for surgeons. When forming the stump of the duodenum, the surgeon must correctly calculate the diameter of the immersion suture in order to achieve tightness, without forming closed cavities, the appearance of which can lead to microabscesses and granulomas, not to disturb blood circulation in the organ wall and the outflow of bile from the Vater’s nipple, to use suture material taking into account future exposure of duodenal contents to it.

Various methods of treatment are used to prevent such complications. All methods of treatment have certain advantages and significant disadvantages.

In particular, due to “local” problems with the duodenal stump (edema, short posterior wall, etc.), it is not always possible to avoid such postoperative complications as impaired bowel integrity and suture integrity, maintain adequate blood supply to the stump walls, and reduce the invasiveness of manipulations on the head of the pancreas, to achieve technical simplicity when immersing the stump, to minimize the length of stay of patients in the hospital. All this emphasizes the relevance of improving methods for closing the stump of the duodenum, for the prevention of possible complications.

A known method of suturing stump using UKL-60. This method uses a linear stapler, a thread with a needle / cm. Appendix 1: copy from the book. "Atlas of operations on the esophagus of the stomach and duodenum." Stitch suturing using UKL-60 - A.A. Shalimov, V.N. Half-pan. 1975, p. 254-256 /.

The treatment method is performed as follows, after a laparotomy, revision of the abdominal cavity organs, mobilization of the stomach and duodenum, then UKL-60 is placed on it before the duodenum is cut off from the pylorus and the bowel is stitched with tantalum brackets. The bowel is cut off above the brackets, so it is hermetically sewn. A purse-string serous-muscular silk suture is placed on the base of the stump, into which the intestinal stump is immersed, which is shown in Fig. 483 p. 256 (see appendix 1).

From fig. 483 p. 256 (see Appendix 1), it is seen that instead of the posterior wall of the duodenum, the capsule of the pancreas is stitched with a purse-string serous-muscular silk suture, in the future it turns out that the stump is not submerged, but covered only by a curtain.

This method of treatment has the following disadvantages.

1. It is not possible to provide conditions for the prevention of postoperative complications in the form of insolvency of the suture of the duodenal stump and the development of purulent-septic complications in the abdominal cavity (peritonitis, etc.), which, as a result, leads to an increase in postoperative mortality.

2. The layers of the same name of the anterior and posterior walls of the duodenum are not compared with the second row of sutures, namely, they violate the main rule of operative surgery - joining when stitching homogeneous tissues, such imaginary immersion is fraught with inconsistency of sutures and the occurrence of spilled peritonitis.

3. It is impossible to ensure the full reliability of the seam with respect to the tightness of the stump after the formation of the stump.

4. Does not provide a tight fit of tissues to the hardware suture, which leads to the formation of free space in the stump of the duodenum, in which fluid can accumulate (infection of this fluid causes the formation of an abscess, which leads to failure of the stump of the duodenum).

5. There are no conditions for ensuring the repair properties of the stump.

For the closest analogue, a method for the formation of a duodenal stump is adopted. In this method, a thread with a needle / cm is used. Appendix 2: copy from the book. "Operative surgery and topographic anatomy." A method for treating a duodenal stump, p. 347-348. Ed. V.V. Kovanova. 4th ed., Supplemented. - M .: Medicine 2001.- 408 p. ISBN 5-225-04710-6 /.

A method of forming a stump of the duodenum is as follows. After mobilization with the intersection and suturing of the duodenal stump with a continuous twisting stitch according to the generally accepted method, two half-mesh sutures are applied to the stump base with its subsequent immersion, then nodular silk serous-serous sutures are performed on top of them. After applying sero-serous sutures, peritonization of the duodenal stump is performed, hemming it to the capsule of the pancreas.

This method of treatment has the following disadvantages.

1. It is not possible to guarantee conditions for the prevention of postoperative complications in the form of insolvency of sutures of the duodenal stump and the development of purulent-septic complications in the abdominal cavity (peritonitis, etc.) and, as a result, to exclude postoperative mortality, since the sutures were not performed continuously in a single block with one thread.

2. It is impossible to ensure the sealing and reliability of the stitches of the duodenal stump due to the open zone in the center of the duodenal stump after the formation of semi-ketal sutures, even after additional reinforcements by serous-serous sutures over them along the suture fixation line, it remains a weak point, since the threads increase the tension of the intestinal wall in the area of fixation of sutures, which subsequently leads to ischemia and a decrease in the repair properties of tissues, and, as a result, subsequent failure of sutures at all levels.

3. Does not provide a snug fit to the first line of the suture and leads to the formation of free space after immersion of the duodenal stump, where fluid can accumulate (infection of this fluid causes the formation of an abscess, which can lead to failure of the stitches of the duodenal stump).

4. The technique of suture formation excludes the possibility of a uniform and tight fit of comparable tissues during invagination of the inner row of sutures and after suturing of the duodenal stump to the pancreatic capsule, which does not provide optimal repair properties of the stump.

The objectives of this proposal are:

1) to develop a method for the formation of a duodenal stump, which has technical simplicity of execution and reliability, the ability to perform by a surgeon with minimal experience in such operations for use in planned and emergency surgery;

2) guarantee the technical conditions for the prevention of postoperative complications in the form of insolvency of the suture of the duodenal stump and the development of purulent-septic complications in the abdominal cavity (peritonitis, etc.) and, as a result, eliminate postoperative mortality;

3) to ensure full (100%) sealing and reliability of the suture of the stump of the duodenum due to the formation of a single thread, without interruption in a single unit;

4) to reduce the length of stay of patients in the hospital by eliminating complications;

5) reduce the time of formation of the duodenal stump due to the preservation of tissues due to the lack of tissue tension directed in different directions and the use of one thread;

6) minimize trauma to the tissues of the stump of the duodenum and capsule of the pancreas by eliminating tension and eruption of sutures;

7) maintain adequate blood supply to the walls of the duodenal stump;

8) minimize the amount of mobilization of the wall of the duodenum from the pancreas, sufficient to ensure the anatomical adaptation of stitched tissues during the formation of a stump, excluding tissue tension;

9) to ensure congruent fit of the serous wall of the intestine to the hardware suture, eliminating the formation of free space in which fluid can accumulate (infection of this fluid causes the formation of an abscess, which leads to failure of the sutures);

10) create conditions for a uniform and dense, but without tension of tissues, fit of the stump of the duodenum to the capsule of the pancreas, which will provide additional peritonization and improve the repair properties of tissues.

The objectives are achieved in that they sequentially perform the imposition of a hardware suture with simultaneous cutting off of the duodenum from the stomach and immersion of the duodenal stump by continuously stitching one non-absorbable monofilament thread equipped with needles at both ends, serous-muscular-submucosal mucous membrane of the purpurea of the caudal side, tighten it until the tissue touches and knot the ends of the threads over the hardware seam with a knot, then with the same thread, without interrupting, they extend the suture on the cranial semicircle of the intestine, begin from the wall closer to the head of the pancreas with the transition to the front part and the last stitch is applied caudally 6-8 mm from the previous knot, then the thread is pulled until the tissue touches and knotted with a knot with the opposite end of the thread, and then one from the ends of the thread, the capsule of the pancreas is stitched from the center of its head in the cranial direction, then the needle and thread are rotated along the edge of the stump and the lower edge and front wall of the semicircle of the intestines are stitched with it on the caudal side, the pancreatic capsule is sutured at the second end of the thread from the center of its head in the caudal direction under the previous thread with its grasp, then the needle and thread are rotated along the edge of the stump and the upper edge and front wall of the intestinal semicircle are stitched from the cranial side, the threads are tightened evenly so that the duodenal stump is firmly fixed to the capsule of the pancreas, and the ends of the threads are tied.

Technical result: this method for the formation of a duodenal stump allows the prevention of postoperative complications during and after surgery, strengthens the tightness of the mechanical suture and fully isolates the intestinal microflora (due to the formation of the stump by the developed algorithm with one thread, without interruption in a single block). Provides anatomical atraumatic adaptation of stitched tissues by eliminating teething and economical mobilization, is characterized by simplicity in execution and is a leader in comparative reliability, with the ability to perform surgeons with minimal experience in such operations, in planned and emergency surgery, minimizes the risk of complications, which reduces the length of stay the patient in the hospital does not affect the reduction of trophic tissue of the intestinal wall and pancreatic tissue. A congruent uniform and tight fit of the serous wall of the intestine to the hardware suture ensures optimal repair properties of the stump and eliminates the formation of free space in which fluid can accumulate (infection of this fluid leads to abscessing and the development of suture failure).

The essence of the method is that after the application of a hardware suture with simultaneous cutting off of the duodenum from the stomach and immersion of the duodenal stump by continuous flashing of one non-absorbable monofilament suture equipped with needles at both ends, serous-muscular-submucosal mucous membrane of the mucous membrane of the mucous membrane of the intestinal seam hand, tighten the thread until the fabric touches and knot the ends of the threads over the hardware seam in a knot, then continue with the same thread, without interrupting, continue the seam to the cranial semicircle of the intestine starting from the wall closer to the head of the pancreas with the transition to the front part and applying the last stitch caudal to 6-8 mm of the previous node, then the thread is tightened until the tissue touches and knotted with a knot with the opposite end of the thread, after which one of the threads is sutured the capsule of the pancreas from the center of its head in the cranial direction, then the needle and thread are rotated along the edge of the stump and the lower edge and the anterior wall of the intestinal semicircle are sutured from the caudal side, second the pancreas capsule is pierced from the center of its head in the caudal direction under the previous thread with its grasp (in the cross position relative to the previous thread), then the needle and thread are rotated along the edge of the stump and the upper edge and front wall of the semicircle of the intestine with the cranial are stitched with it on the other hand, the threads are tightened evenly so that the stump of the duodenum is firmly fixed to the capsule of the pancreas, and the ends of the threads are tied. Formed by a single thread, continuously in a single block, the duodenal stump provides 100% sealing and reliability of sutures and eliminates multidirectional tension of tissues and violation of trophic tissue, which minimizes the risk of failure of sutures and guaranteedly increases the reliability of all manipulations.

The method was tested on 78 patients for five years in the conditions of the 1st and 2nd surgical departments of the GBUZ "Research Institute - Regional Clinical Hospital No. 1 named. Professors C.B. Ochapovsky "Ministry of Health of the Krasnodar Territory, good results were obtained.

In all patients, as well as in the group of elderly and debilitated patients with severe concomitant diseases, it was possible to reduce the time of anesthesiological aid and surgical treatment when forming a duodenal stump with scarred tissues and a short stump, which improves the treatment results and also reduces the cost of the method. There were no complications in the form of insolvency. The developed algorithm for the formation of a duodenal stump with a single thread, without interruption in a single block, proved in practice the possibility of 100% achievement of the guaranteed result of sealing the duodenal stump and the reliability of the joints.

The method is shown in Fig. 1-10 phased implementation schemes of the proposed method of treatment: Fig. 1 - a stump of the duodenum with a hardware suture, Fig. 2 - seam along the edge of the semicircle of the intestine from the caudal side, Fig. 3 - tightening the threads until the fabric touches, fig. 4 - knotted ends of the threads over the hardware seam, Fig. 5 - seam along the cranial semicircle of the intestine from the wall closer to the head of the pancreas with the transition to the front part and the last stitch overlay caudal 6-8 mm from the previous node, Fig. 6 - tightening the threads to the contact of fabrics, Fig. 7 - knotted ends of the threads, Fig. 8 - a stitched capsule of the pancreas from the center of its head in the cranial direction, then the needle and thread are turned along the edge of the stump and the lower edge and the anterior wall of the semicircle of the intestine are sewn from the caudal side, Fig. 9 - the second end of the thread is a stitched capsule of the pancreas from the center of its head in the caudal direction under the previous thread and its capture, then the needle and thread are rotated along the edge of the stump and the upper edge and front wall of the semicircle of the intestine are sewn from the cranial side, fig. 10 - tightening the threads evenly until the tissue touches, on which item 1 is the duodenum, top and front view, 2 - non-absorbable monofilament thread equipped with needles at both ends, 3 - seam along the edge of the semicircle of the intestine from the caudal side, 4 - view with tightening the threads, 5 - view after tying the threads, 6 - suture on the cranial semicircle of the intestine, 7 - pancreas, 8 - hardware suture, 9 - stitched capsule of the pancreas from the center of its head in the cranial direction, 10 - suture along the lower edge and front half-wall zhnosti bowel caudal side 11 - stitched capsule of pancreas from the center of the head in a caudal direction 12 - a previous suture thread and grip 13 - seam along the upper edge and the front wall of the intestine semicircle on the cranial side.

The method is as follows.

Under combined anesthesia, after processing the surgical field with performing the upper median laparotomy, revision of the abdominal cavity organs, mobilization of the duodenum and stomach, application of a hardware suture (8) with simultaneous cutting of the duodenum (1) from the stomach and immersion of the duodenal stump (1) continuous flashing with one non-absorbable monofilament thread equipped with needles at both ends (2), a serous-muscular-submucous purse string suture along the edge of the intestinal semicircle with caudal sides (3), tighten the threads (4) until the tissue touches and knot (5) the knots of the ends of the threads over the hardware suture (8), then with the same thread, without interrupting, continue the seam on the cranial semicircle of the intestine (6) starting from the wall closer to head of the pancreas (7), with the transition to the front part and application of the last stitch caudal 6-8 mm more than the previous node, then the thread is tightened (4) until the tissue touches and knotted (5) with a knot with the opposite end of the thread, then one of the ends the threads are stitching the capsule of the pancreas from the center of her g traps in the cranial direction (9), then the needle with the thread (2) is rotated along the edge of the stump and it is used to stitch the lower edge and the anterior wall of the intestinal semicircle from the caudal side (10), the capsule of the pancreas is stitched with the second end of the thread from the center of its head in the caudal direction (11) under the previous thread with its grip (in a cross position relative to the previous thread) (12), then the needle and thread are rotated along the edge of the stump and the upper edge and front wall of the semicircle of the intestine are sewn from the cranial side (13), the thread is tightened evenly so that the stump of the duodenum (1) is firmly fixed to the capsule of the pancreas (7), and the ends of the threads are tied.

Using this method of treatment, the formation of a duodenal stump with the possibility of preventing postoperative complications in the form of insolvency of the suture of the duodenal stump and the development of purulent-septic complications in the abdominal cavity (peritonitis, etc.), and, as a consequence, the exclusion of postoperative mortality, are ensured. Simple in execution and in comparative reliability, with the ability to be performed by a surgeon of any skill, and used in planned and emergency surgery, reduces the length of a patient’s hospital stay, does not affect trophic tissue of the duodenum and pancreas. They create conditions for a uniform and tight fit of the serous surface of the intestine to the hardware suture, which ensures optimal repair properties of the stump and eliminates the formation of a free space in which fluid can accumulate (infection of which causes the formation of an abscess and leads to failure of the sutures of the duodenal stump).

The duodenal stump formed in this way in all patients, as well as in the group of elderly and weakened patients with severe concomitant diseases, allowed to reduce the time of anesthetic management and surgical treatment during the formation of the duodenal stump with scarred tissues and a short stump, which improved the treatment results, and also cheaper the way. There were no complications in the form of insolvency. The developed algorithm for the formation of a duodenal stump with a single thread, without interruption in a single block, proved in practice the possibility of 100% achievement of the guaranteed result of sealing the duodenal stump and the reliability of the joints.

Example 1. Patient, 82 years old.

Diagnosis: peptic ulcer of the stomach and duodenum, cicatricial ulcer deformation of the duodenal bulb and pylorus, ulcer of the posterior wall of the duodenal bulb with penetration into the pancreatic head, decompensated pyloric stenosis.

Operation: distal gastric resection according to Balfour.

Under combined anesthesia, after processing the surgical field with a cut from the xiphoid process to hypogastrium, the abdominal cavity was opened in layers from the navel to the left. During the audit: the duodenal bulb is deformed by scars, there is an ulcer penetrating into the head of the pancreas 1.0 × 1.2 cm, the pylorus and the anterior wall of the duodenal bulb are deformed by scars, grade 3 stenosis. The liver is not enlarged. The abdominal esophagus, small intestine and its mesentery, spleen - without features.

The duodenum was mobilized, its tight joints with the hepatoduodenal ligament were disconnected, the duodenum was cut off from the head of the pancreas in the penetration zone, the right gastric and gastro-omental vessels were ligated and crossed. The duodenum is stitched with the UO-40 device and at the same time it is crossed below the pylorus and the duodenal stump is immersed by continuous stitching of one non-absorbable monofilament thread equipped with needles at both ends of the duodenum, the serous-muscular-submucous purse-string mucous suture along the margin of the caudarum is closed along the margin until the tissue touches and knot the ends of the threads over the hardware suture, then with the same thread, without interrupting, continue the seam on the cranial semicircle of the intestine on another from the wall closer to the head of the pancreas, with transition to the front part and application of the last stitch caudal 6-8 mm more than the previous knot, then the thread is pulled until the tissue comes into contact and knotted with a knot with the opposite end of the thread, after which the pancreatic capsule is stitched with one of the ends glands from the center of its head in the cranial direction, then the needle and thread are rotated along the edge of the stump and the lower edge and the anterior wall of the intestinal semicircle are sutured on the caudal side, the caps are stitched with the second end of the thread the ulcer of the pancreas from the center of its head in the caudal direction under the previous thread with its capture (in a cross position relative to the previous thread), then the needle with the thread is rotated along the edge of the stump and the upper edge and the front wall of the semicircle of the intestine are sewn from the cranial side, the threads are tightened evenly so that the duodenal stump is firmly fixed to the capsule of the pancreas, and the ends of the threads are tied.

The stomach is mobilized distally by 2/3, resected, the lesser curvature is formed by the UO-60 apparatus in addition to a manual biosin 3/0 winding suture.

In the window of the mesentery of the transverse colon, the first loop of the jejunum was made and a transverse gastroenteroanastomosis with Brown intestinal anastomosis was formed. Through contraception in the right hypochondrium, drainage was placed in the subhepatic space. A nasointestinal probe for enteral nutrition was carried out, an additional probe into the stomach. Hemostasis control is dry. Napkin count - 3 pcs. (right). The wound is sutured in layers tightly. Alcohol on the skin. Aseptic dressing. The volume of blood loss during surgery: about 100.0 ml.

Macro drug: 2/3 of the distal part of the stomach.

Postoperative diagnosis: gastric and duodenal ulcer, duodenal ulcer and pyloric ulcer, ulcer of the posterior wall of the duodenal bulb with penetration into the head of the pancreas, decompensated pyloric stenosis after surgical treatment.

There were no complications in the near and distant postoperative period.

Example 2. Patient, 56 years old.

Diagnosis: c-g stomach T3NxM0, 2 cells column

Operation: extended (D2) subtotal distal gastric resection according to Balfour.

Under combined anesthesia, after processing the surgical field with a cut from the xiphoid process to hypogastrium, the abdominal cavity was opened in layers from the navel to the left. During the audit: a tumor in the antrum of the stomach along the posterior wall 1.5 × 1.5 cm with the lower edge lying on the pylorus, enlarged l / nodes in the area of the right gastrointestinal artery. The liver is not enlarged. The abdominal esophagus, duodenum, small intestine and its mesentery, spleen without features.

Given the localization and the form of tumor growth, it was decided to perform an extended subtotal distal gastric resection according to Balfour with a resection of the part of the duodenal bulb.

The stomach was mobilized with lymphodissection retro-pancreatoduodenally and along the hepatoduodenal ligament, the right gastric vessels were treated, the small omentum was separated at the base of the liver, the peritoneum was opened above the esophagus and along the anterior edge of the right diaphragm leg, and lymphodissection was performed along the hepatic artery. The coronary vein and the left gastric artery are processed in stages, - are bandaged, crossed. Mobilized: large omentum - from the transverse colon, the gastro-colon ligament is dissected, the gastro-splenic ligament is processed to the spleen gate, the right and left gastro-omental vessels. The stomach is resected subtotally distally, along the greater curvature to the lower pole of the spleen, the lesser curvature is formed by the UO-60 device, with the PDS-3/0 seaming suture, the duodenum is stitched by the UO-40 device with a resection of the part of the duodenal bulb (departing 3.0 cm from the lower edge of the tumor) and the stump of the duodenum was immersed by continuously flashing one non-absorbable monofilament thread equipped with needles at both ends of it, a serous-muscular-submucous purse string suture along the edge of the semicircle ki from the caudal side, tighten the threads until the tissue touches and knot the ends of the threads over the hardware suture with a knot, then with the same thread, without interrupting, continue the suture on the cranial semicircle of the intestine starting from the wall closer to the head of the pancreas, with the transition to the front part and overlay of the last the stitch is caudal by 6-8 mm of the previous knot, then the thread is pulled until the fabrics come into contact and knotted with a knot with the opposite end of the thread, after which one of the threads sews the capsule of the pancreas from the center of its th the ovaries in the cranial direction, then the needle with the thread is rotated along the edge of the stump and it is used to stitch the lower edge and the anterior wall of the semicircle of the intestine from the caudal side, the capsule of the pancreas from the center of its head in the caudal direction under the previous thread with its capture is stitched with the second end of the thread (in cross position relative to the previous thread), then the needle with the thread is rotated along the edge of the stump and it is used to stitch the upper edge and the front wall of the semicircle of the intestine from the cranial side, the threads are tightened evenly, h Oba duodenal stump tightly fixed to the capsule of the pancreas, and tie the ends of the strands.

In the window of the mesentery of the transverse colon, the first loop of the jejunum was made and a transverse gastroenteroanastomosis with Brown intestinal anastomosis was formed. Through contraception in the right hypochondrium, drainage was placed in the subhepatic space. A nasointestinal probe was performed for enteral nutrition below the inter-intestinal anastomosis. Hemostasis control is dry. The napkin count is 6 pieces (true). The wound is sutured in layers tightly. Alcohol on the skin. Aseptic dressing. The volume of blood loss during surgery: about 100.0 ml.

Macrodrug:

1. Lymph nodes retropancreatoduodenal.

2. Stomach, oil seals.

Postoperative diagnosis: c-g stomach T2NxM0 after surgical treatment, 2 cells. column

There were no complications in the near and distant postoperative period.

Claims (1)

A method of forming a stump of the duodenum, including mobilization with intersection and suturing of the stump of the duodenum, suturing the base of the stump with its subsequent immersion and suturing to the capsule of the pancreas, characterized in that after the application of the hardware suture with simultaneous cutting off of the duodenum and duodenum from the stomach of the duodenum by continuous flashing of one non-absorbable monofilament thread equipped with needles at both ends of it, serous mouse with a submucosal purse string suture along the edge of the intestinal semicircle from the caudal side, tighten it until the tissue touches and knot the ends of the threads over the hardware suture, then with the same thread, without interrupting, continue the suture on the cranial semicircle of the intestine starting from the wall closer to the head of the pancreas with by moving to the front part and applying the last stitch caudally 6-8 mm from the previous knot, then the thread is tightened until the fabrics come into contact and knotted with a knot with the opposite end of the thread, after which one of the ends of the thread the capsule of the pancreas is sutured from the center of its head in the cranial direction, then the needle and thread are rotated along the edge of the stump and the lower edge and the front wall of the intestinal semicircle are sutured from the caudal side, the capsule of the pancreas is sutured from the center of its head in the caudal direction underneath the previous thread with its capture, then the needle and thread are turned along the edge of the stump and it is used to stitch the upper edge and the front wall of the semicircle of the intestine from the cranial side, the threads are tightened evenly, so that Both stumps of the duodenum were firmly fixed to the capsule of the pancreas, and the ends of the threads were tied.

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