RU2625446C1 - Method for renovascular hypertension surgical treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: second and third jejunal arteries and veins are selected. The third jejunal artery is crossed at its origin from the superior mesenteric artery. Direct artery and veins, departing from the "vascular arcades", are tied between the second and third jejunal vessels, and the "vascular arcades" between the second and third jejunal vessels are retained. Then a portion of the jejunum in the projection of the intersected direct vessels, is resected and an intestinal anastomosis is applied. Then the "vascular arcades" are intersected between the first and second, and third and fourth jejunal arteries, as a result, a vascular leg is formed from the second jejunal artery, "vascular arcades" between the second and third jejunal arteries and the third jejunal artery, and a vascular anastomosis is imposed between the third jejunal artery and renal artery.

EFFECT: method will improve the results of renovascular hypertension surgical treatment by restoring blood flow in both right and left renal arteries.

1 ex, 1 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used to treat vasorenal hypertension.

Vasorenal hypertension is a syndrome that is caused by constant ischemia of one or both kidneys due to stenosis, occlusion, or aneurysm of one or both renal arteries (Evdokimov A.G., Topolyansky V.D. Diseases of arteries and veins: a manual. M .: Publishing center. M: Publishing center "Academy", 2006. - S. 114-127).

The presence of arterial hypertension in a patient with revealed stenosis or aneurysm of the renal artery is an indication for surgery, as a rule, reconstruction of the renal artery (Belov Yu.V., Stepanenko AB, Kosenkov A.N. Surgery of vasorenal hypertension. = M .: LLC “Medical Information Agency”, 2007. - p. 90-91).

With severe aortic atheromatosis with its calcification, as well as with repeated operations, especially in patients with aortoarteritis or undergoing deep suppuration of the wound, methods of renal revascularization from large branches of the aorta are used (Yu.V. Belov Guide to vascular surgery with an atlas of surgical equipment. - 2 -th ed., rev. and add. - Medical Information Agency LLC, 2011. - p. 203-235).

There is a method of revascularization of the left kidney by performing splenorenal bypass surgery (Zarins K.K., Gevers B.L. Atlas of vascular surgery / Christopher K. Zarins, Bruce L. Geverts; ill. Keti Hirsch; translated from English under the editorship of A. V. Pokrovsky. - M.: GEOTAR-Media, 2009 .-- S. 166-171). As surgical access, a laparotomy or left-sided thoracophrenolumbotomy is performed. They mobilize the body and tail of the pancreas. Mobilize the left renal artery. The splenic artery is secreted along the upper edge of the pancreas, while its numerous branches are ligated to the pancreas. This technique allows the free movement of the splenic artery to the left renal artery. The splenic artery is crossed in the distal third, and the proximal segment is used to impose an end-to-end or end-to-side vascular anastomosis.

The disadvantage of this method is its technical difficulty, due to the anatomical features of the splenic artery - its fragility and the presence of many branches (Zarins K.K., Gevers B.L. Atlas of vascular surgery / Christopher K. Zarins, Bruce L. Gevers; ill. Keti Hirsch ; translated from English under the editorship of A.V. Pokrovsky. - M.: GEOTAR-Media, 2009. - p. 170-171). Mobilization of the splenic artery carries a risk of injuries to the spleen and pancreas, which can lead to undesirable consequences both during the operation and to complications in the postoperative period.

Also, the disadvantages of this method include the fact that it is applicable only for revascularization of the left renal artery.

The closest in technical essence to the proposed is a method of surgical treatment of vasorenal hypertension, including the selection of the renal artery distal to stenosis and renal revascularization by mesenteric shunting (Belov Yu.V. Guide to vascular surgery with an atlas of surgical equipment. - 2nd ed., Rev. And add. - Medical Information Agency LLC, 2011. - p. 228-229).

The known method is as follows. For shunting, an autovenous graft is used - a large saphenous vein of the leg. Autoveins are taken according to the technique generally accepted in vascular surgery. The right renal artery is isolated distal to stenosis. The right colonic artery, which is a branch of the superior mesenteric artery, is also isolated. A vascular anastomosis of the end-to-side type is applied between the end of the autovenous graft and the right rim of the artery. The autoevens lead the other end to the right renal artery and anastomose with it according to the type “end to side” or “end to end”, without tension, depending on the operating situation.

The disadvantages of this method include its technical complexity. Performing mesenteric shunting by this method involves the application of several vascular anastomoses, which complicates the course of the operation. In addition, during the operation, there is a need to collect an autovenous graft; this manipulation, in addition to complicating the operation, is associated with performing surgical access on the lower limb. This increases surgical trauma and may increase the risk of wound complications. In the postoperative period, there is a risk of thrombosis of the autovenous shunt, which may affect the effectiveness of the operation.

Also the disadvantages of this method include the fact that for technical reasons it cannot be carried out for revascularization of the left kidney.

The task of the invention is the development of a method for the surgical treatment of vasorenal hypertension.

The technical result of the proposed method is to increase the efficiency of surgical treatment of patients with vasorenal hypertension, by ensuring the technical feasibility of revascularization of both the right and left kidneys.

The technical result is achieved by the fact that the method of surgical treatment of vasorenal hypertension includes the selection of the renal artery distal to the stenosis and revascularization of the kidney by mesenteric bypass grafting.

The differences of the proposed method from the known one are that they secrete the second and third jejunal arteries and veins, the third jejunal artery is crossed at the place where it departs from the superior mesenteric artery. The direct arteries and veins extending from the "vascular arcades" are ligated between the second and third jejunal vessels, and the "vascular arcades" between the second and third jejunal vessels are preserved.

Distinctive techniques of the proposed method also consist in the fact that a section of the jejunum, in the projection of the crossed straight vessels, is resected and an intestinal anastomosis is applied. After that, the "vascular arcade" intersect between the first and second, and third and fourth jejunal arteries.

The main difference of the proposed method is that they form a vascular pedicle, consisting of a second jejunal artery, "vascular arcades" between the second and third jejunal arteries and the third jejunal artery. A vascular anastomosis is placed between the third jejunum and renal arteries.

Comparative analysis with the prototype showed that the proposed method differs from the known above methods and, therefore, meets the patentability criterion of "novelty."

From the analysis of patent and specialized literature, the authors found that the proposed method has features that distinguish it not only from the prototype, but also from other technical solutions in this and related fields of medicine.

Anatomical studies of the authors of the proposed method indicate that the use of the proposed technical solution allows to restore the arterial blood flow of both the right and left kidneys without the use of an autovenous graft.

The use of the jejunal artery to perform revascularization of the kidney provides lengthening of the vascular pedicle due to the possibility of using "vascular arcades" between the jejunal arteries and resection of the jejunum. These techniques allow you to use the inventive method for revascularization of both the right and left kidneys.

The advantages of the proposed method over the known are as follows:

- simplifies the course of the operation due to the absence of the need for an autovenous graft;

- favorable course of the postoperative period due to the lack of additional surgical access on the lower limb;

- the claimed method allows mesenteric bypass surgery using only one vascular anastomosis, which also simplifies the technique for its implementation;

- the use of the proposed method allows you to successfully perform mesenteric bypass surgery of both the right and left renal artery.

The above allows us to conclude that the claimed technical solution meets the criterion of "inventive step".

A method of surgical treatment of vasorenal hypertension, comprising the claimed invention, is intended for use in medical practice. The implementation of its capabilities is confirmed by the methods and means described in the application, therefore, the claimed invention meets the patentability condition “industrial applicability”.

The essence of the proposed method is illustrated by the figure, which shows the mobilization of the vascular pedicle used to restore the arterial blood flow of the kidney, where: 1 - jejunum, 2 - second jejunal artery, 3 - second jejunal artery, 4 - third jejunal artery, 4 '- proximal a segment of the third jejunal artery, 5 - the third jejunal vein, 5 '- the proximal segment of the third jejunal vein, 6 - the first jejunal artery, 7 - the first jejunal vein, 8 - the fourth jejunum artery, 9 - the fourth jejunum on, 10 - "vascular arcades", 11 - direct arteries, 12 - straight veins, 13 - superior mesenteric vein, 14 - superior mesenteric artery, 15 - vascular clamp.

The proposed method is as follows.

After laparotomy and revision of the abdominal cavity, the right or left renal artery is distal to the level of stenosis. In the mesentery of jejunum 1, the second jejunum artery 2 and the second jejunum vein 3 are isolated. The third jejunum artery 4 and the third jejunum vein 5 are also isolated. The mesentery of the jejunum 1 is dissected between the first jejunum artery 6 and the second vein 7, and then 2 vein 3. The mesentery is also dissected between the third jejunal artery 4 and vein 5, and the fourth jejunum artery 8 and vein 9. During the dissection of the mesentery, the “vascular arcades” 10 are ligated and intersected between the first jejunal artery 6 and vein 7, the second and jejunal artery 2 and the vein 3; and also between the third jejunal artery 4 and vein 5 and the fourth jejunum artery 8 and vein 9. The straight arteries 11 and the straight veins 12, extending from the “vascular arcades” 10 between the second and third jejunal vessels to the jejunum 1 are crossed and ligated. "Vascular arcade" 10 between the second and third jejunal vessels is maintained. The third jejunal vein 5 is crossed and its proximal segment 5 'is ligated at the place of its inflow into the superior mesenteric vein 13, the distal end of the third jejunal vein 5 is also ligated. The third jejunal artery 4 is intersected at the place of its departure from the superior mesenteric artery 14, while the proximal segment of the artery 4 'is ligated, and a vascular clamp 15 is applied to the distal segment of the jejunal artery (this segment is subsequently used to apply a vascular anastomosis). With these techniques, a vascular pedicle is formed, consisting of a second jejunal artery 2, “vascular arcades” 10 located between the second 2 and third 4 jejunal arteries and the third jejunal artery 4. The blood flow in the kidney will be restored by retrograde blood flow in the third jejunal artery 4. The formed vascular leg carried through a hole in the mesentery of the transverse colon (Fig. not shown) and lead to the right or left renal artery. Then impose vascular

end-to-end or end-to-side anastomosis between the renal artery and the third jejunal artery 4. During the operation, the jejunum 1 is resected, in the projection of the intersection of the direct arteries 11 and veins 12, and an intestinal anastomosis is applied. This technique is performed to eliminate the risk of jejunum necrosis 1 in the area of impaired blood supply.

The proposed method for the surgical treatment of vasorenal hypertension is illustrated by an example of a specific implementation.

The study was conducted in the Irkutsk Regional Bureau of Forensic Medicine on 12 corpses (5 female and 7 male), who died from natural causes. 8 corpses had a normosthenic constitution, 2 had an asthenic constitution, and 2 had a hypersthenic constitution. The growth ranged from 150 to 172 cm, the average height was 163.5 ± 7.5 cm. The weight of the corpses ranged from 56 kg to 89 kg, the average weight was 68.9 ± 10.5 kg.

In all cases, vascular mobilization was performed and a vascular pedicle formed. The largest length of the vascular pedicle was 29 cm, the minimum was 24 cm, the average length was 26.5 ± 1.6 cm. The average diameter of the vessel used to apply the mesenteric anastomosis was 3.6 ± 0.5 mm. In all cases, it was possible to impose a vascular anastomosis without tension. Subsequently, in the projection of the intersection of the direct vessels, the jejunum was resected and intestinal anastomosis was applied. The average length of the resected segment of the jejunum was 10.8 ± 1.2 cm. In no case was a resection of more than 13 cm of the jejunum required.

Thus, the proposed method will improve the results of surgical treatment of vasorenal hypertension through the use of a universal and reliable method of mesenteric shunting. The inventive method does not require the use of an autovenous shunt and can be used to restore blood flow in both the right and left renal arteries.

The proposed method can be used in the clinic for operations for vasorenal hypertension. With appropriate preparation, the method can be performed by surgeons of urological hospitals.

Contraindications to the implementation of the proposed method include stenosis of the superior mesenteric artery.

Claims (1)

A method of surgical treatment of vasorenal hypertension, including the selection of the renal artery distal to stenosis and renal revascularization by mesenteric bypass surgery, characterized in that the second and third jejunal arteries and veins are isolated, the third jejunal artery is intersected at the place where it departs from the superior mesenteric artery, and the superior mesenteric artery from the "vascular arcades", bandaged between the second and third jejunal vessels, and the "vascular arcades" between the second and third jejunal vessels they are removed, then a section of the jejunum, in the projection of the crossed straight vessels, the intestinal anastomosis is resected and imposed, after which the “vascular arcades” intersect between the first, and second, and third, and fourth jejunal arteries, as a result of which from the second jejunal artery, “vascular arcade ”between the second and third jejunal arteries and the third jejunal artery form a vascular pedicle and impose a vascular anastomosis between the third jejunum and renal arteries.

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