RU2645116C2 - Method for laparoscopic intracorporal manual gastroenteroanastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: endosurgical resection of the stomach is performed. A loop is formed with a linear stapler as per Roux. A laparoscopic intraocorrection manual gastroenteroanastomosis is made by a combined double-row suture. At the anastomosis corners, nodal sutures are applied to join the edges of the stomach and intestine walls. When stitching the edges of the stomach and intestine, in the inner suture row, an intestinal atraumatic clamp with metric marks 0.7 and 1.0 cm on branches is used. When the intestine is pierced, the injection is carried out at a distance of 0.7 cm, for the stomach - 1.0 cm from the edge.

EFFECT: method can reduce gastroenteroanastomosis performance time, increase the viability of sutures, capture depth accuracy and quality of adaptation of the stomach and intestine walls through the use of intestinal atraumatic clamp with metric marks 0,7 and 1,0 cm.

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Description

The invention relates to medicine, namely to laparoscopic surgery.

There are many ways to connect the hollow organs of the gastrointestinal tract. In laparoscopic surgery, endostaplers and staplers are used, manual gastroenteroanastomosis has not lost its relevance. Modern staplers are not always applicable in everyday surgical practice. With a defect in the wall of a hollow organ up to 0.5 cm, which can be closed with 1-2 interrupted sutures, the use of staplers is impractical. The use of staplers is limited if it is necessary to stitch complex shapes. Manual seam is a full-fledged alternative to hardware and is devoid of the above disadvantages, which expands the scope of its application. From practice, the advantages of manual anastomoses are known - a decrease in the incidence of insolvency and strictures of anastomoses, a decrease in the cost of consumables, the possibility of more careful control of hemostasis along the anastomosis line. The disadvantage that limits the widespread use of laparoscopic manual anastomoses is the complexity and need for a high technique of the surgeon to adapt the walls of anastomosed organs, and an increase in the time required to complete the anastomosis.

The advantages of a continuous manual suture in comparison with individual nodal sutures are technical accessibility to a wide circle of surgeons, low cost of suture material and time when anastomosis is applied, the best hemostasis along the suture line, the disadvantage is the poor adaptation of the sutured organs, especially with uneven seam line length and thickness the walls of organs compared in the anastomosis, narrowing of the anastomosis, which is associated with screwing in the edges of the stitched organs, a tendency to stenosis, a higher likelihood of the dissolution of the suture and claim failure upon application of an anastomosis in adverse conditions of reduced blood supply to the stomach or intestine loop stump, uneven tension bodies walls [1, 2]. Laparoscopic intracorporeal gastroenteroanastomosis with single sutures is deprived of the noted drawbacks of the continuous suture, however, this significantly increases the time and laboriousness of its implementation, as well as the lower tightness of the disadvantages of single sutures. When creating gastrointestinal anastomoses, the surgeon almost always faces the need to unevenly capture the depth of the wall of the stomach and intestines, to apply leveling sutures - to capture more tissue on the side of the excess length of the suture line, which is much more difficult metrically when applying laparoscopic gastroenteroanastomosis compared to open because of image distortion on a video monitor in planar vision and the use of 30 ° optics.

In the study of patent literature, the following methods, devices, and threads have been identified used for laparoscopic sutures and anastomoses, as well as methods for connecting the stomach to the small intestine.

The well-known "Method of gastroduodenostomy and restoration of topographic and anatomical proportions of organs after distal resection of the stomach" [RU 2124317, published January 10, 1999], in which serous-muscular layers of the stomach stump are dissected along the greater curvature upwards with the formation of the anterior wedge-shaped edge. Seam the tube. The end of the tube is lowered. The end of the tube is sutured to the edges of the duodenal mucosa with the capture of the muscle layer. U-shaped seams form transverse folds on the back and front surfaces of the tube. An anterior wedge-shaped edge of the stomach stump is sutured into the duodenal cleft. Lesser curvature is sutured to the glisson capsule of the liver and the upper parts of the hepatic-gastric ligament. U-shaped rags on a leg are cut from a bunch. Surround the flaps with a circular suture of the gastroduodenal anastomosis. The lower edges of the hepatic-gastric ligament are sutured to the suture line of the gastric stump.

The technical methods of the method used to eliminate the mismatch in the size of the anastomosed organs cannot be carried out laparosocpically, which is its drawback.

The well-known "Method for the imposition of gastroenteroanastomosis" [RU 2136226, published 09/10/1999]. In which an anastomosis is formed between the stomach and small intestine according to the type of "side to side". At the same time, the loop of the small intestine is hemmed to the greater curvature of the stomach. On the front wall of the stomach and the wall of the small intestine impose holders at the base and top of each proposed flap. Orient the base in the oral, and the apex in the aboral direction. Full-layer gastric and small intestinal flaps are formed on a wide base outside the holder. Tie the threads of the holder with a flap. Form a valve. Next, the second row of the posterior lip of the anastomosis is formed. Double-row interrupted sutures form the anastomosis anterior lip.

The technical methods of this method of applying a gastroenteroanastomosis are not intended for its implementation by the laparoscopic method, there are no methods that improve the adaptation of the edges of anastomosed organs of various thicknesses and lengths.

The well-known "Method of laparoscopic anastomosis and a device for its implementation" [RU 2141263, published November 20, 1999]. Under laparoscopic observation, the anastomosed parts of the hollow organs are brought together. The lumen of the hollow organs is opened and a stapler is introduced through the formed openings. The device contains two turns of wire from a material with shape memory that are in contact along the generatrix. The surface of the turns is arcuate covered by the working part of the thermocouple. After the introduction of the device, its cooling by a thermocouple is stopped and the walls of the organs are connected by their metered compression. During tissue compression, the device separates itself from the thermocouple, which is removed from the abdominal cavity. The walls of the organs are connected with the subsequent dissection of tissues inside the device and the suturing of the defect in the anastomosis.

The disadvantages of the method are associated with its limited use when adapting the edges of anastomosed organs of various thicknesses and lengths; the proposed device cannot be used to perform gastroenteroanastomoses of complex shape.

The famous "Apparatus O.B. Ospanova for the application of anastomoses ”[RU 2193358, published November 27, 2002], designed to connect the hollow organs of the abdominal cavity. The apparatus for applying anastomoses includes a removable compression element with power turns and a tubular body made for insertion through a laparoscopic trocar, which consists of movable parts interconnected with the possibility of axial rotation and fixation, and contains a drive located at one end kinematically connected to those located on the other end with cutting working parts. The latter are equipped with fastening means for a removable compression element installed with the possibility of interaction with the end of the pusher installed in a tubular housing and having a kinematic connection with the drive. The tubular body has an additional movable part that is installed with the possibility of bending and fixing, and the cutting working parts are made in the form of scissors or biting cloths and have means for attaching a removable compression element in the form of internal hooks at the end of the pusher and external grooves and / or protrusions at its free ends . The pusher is made with the possibility of contact and interaction with the plot of the bend of the removable compression element. The maximum outer dimension of the power turns of the removable compression member in the end bend portion is not less than 1/3 of the maximum outer dimension of the removable compression member.

The disadvantages of the method are associated with its limited use when adapting the edges of anastomosed organs of various thicknesses and lengths, the proposed device cannot be used to perform non-linear gastroenteroanastomoses.

It is known "Device for laparoscopic anastomosis" [RU 2241391 published 10.12.2004], containing a compression clip of titanium nickelide with shape memory effect and superelasticity and a conveyor for its delivery and installation through the lumen of the trocar. The compression clip is made in the form of two oblong U-shaped wire branches. The branches are arranged in a row with a touch along the entire length. The active element in the form of a cylindrical wire spiral leads to the compression interaction of the jaw. The spiral is symmetrically located in the plane of the branch and oriented orthogonally to them. The first ends of the branches are connected to the ends of the spiral. The second ends of the jaw are bent into its lumen. The conveyor is made in the form of a tube under the clip with two elongated symmetrical end protrusions. The protrusions are made to fix the jaws.

The disadvantages of the method are associated with its limited use when adapting the edges of anastomosed organs of various thicknesses and lengths, the proposed device cannot be used to perform non-linear gastroenteroanastomoses.

The well-known "Method of laparoscopic pyloroplasty resection of the stomach" [RU 2262895, published October 27, 2005]. In which laparoscopic resection of the stomach is performed while preserving the pylorus. Impose gastro-gastroanastomosis. At the same time, in the area of the proximal line of resection, serous-muscular layers of the stomach cross. Cross and stitch the mucous-submucous layers of the stomach, forming an excess sufficient to form the antireflux flap. Similarly, the stomach is crossed in the area of the distal line of resection. When anastomosis is formed, the mucous-submucous layers of the stomach are sutured, forming holes for the jaw of the stapler so that the stump length of the mucous-submucous layers is sufficient to form a valve. After stitching the mucous-submucous layers of the stomach, sero-muscular sutures are applied in the anastomosis of the front lip, covering the stumps of the mucous-submucous layers.

The disadvantages of the method are associated with its limited use when adapting anastomosed organ edges of various thicknesses and lengths, the proposed method cannot be used for a small stomach stump, for example, for subtotal gastrectomy, gastrojuncture bypass surgery, and also bariatric surgery.

The well-known "Thread having fixing elements with a coating for fixing in biological tissues, and the method of its production" [RU 2528077, published 10.09.2014]. The thread can be used for overlaying a knotless or self-locking seam. The thread contains an elongated base with protruding elements for fixing in biological tissues, in particular in human tissues. The fastening elements contain a coating that gives rigidity.

The disadvantages of the invention are due to the uncertainty of methods that allow you to adapt the edges of organs of unequal thickness and length in laparoscopic gastroenteroanastomosis.

Known "Coated thread with fixing elements for fixing in biological tissues" [RU 2529400, published 09.27.2014]. The thread is intended for use as a knotless or self-fixing surgical suture material, contains a base and fixing elements. The fastening elements are fixed with the coating in a specific position on the surface of the warp yarn, and at least some of the fastening elements are completely immersed in the coating. Also claimed is a kit, an implant containing a thread, a method of manufacturing a thread.

The disadvantages of the invention are due to the uncertainty of methods that allow you to adapt the edges of organs of unequal thickness and length in laparoscopic gastroenteroanastomosis.

The prototype of the invention, as the closest in combination of features to the claimed method, is the “Method of gastroduodenostomy in case of laparoscopic resection of the stomach in case of gross cicatricial and ulcerative deformities of the duodenal bulb” [RU 2201717, published April 10, 2003], in which endoscopic resection of the stomach by Billroth- I. In this case, the duodenum is stitched with a linear stapler below the scar-ulcerative deformity. Excesses of the anterior intestinal wall are formed by axial rotation of the stapler at 60-90 °. Similarly, the stomach is stitched along the resection line along the entire length of the diameter with the formation of an excess of its front wall. The front walls of the stumps of the stomach and duodenum are adapted by applying gray-serous sutures over the lines of mechanical sutures. Through the holes on the front walls of the anastomosed organs, branches of a linear stapler are inserted. Flashing the walls with the formation of anastomosis. The defect in the area of introduction of the jaw of the stapler is sutured.

The disadvantages of the method are due to the limitation of its use with a significant difference in wall thickness, compared in the anastomosis of organs, as well as with subtotal resection of the stomach, gastrojuncture bypass surgery, as well as bariatric surgery. The use of the method is associated with the disadvantages of using staplers - anastomosis failure in the early and stenosis in the distant postoperative periods.

The task of the invention is to improve the quality of laparoscopic intracorporeal manual gastroenteroanastomosis.

The task is achieved by the fact that linear staplers perform a resection of the stomach according to Ru, when performing gastroenteroanastomosis, a combined two-row continuous and nodal suture is used, single sutures are applied at the corners of the anastomosis, as well as when aligning sections of the suture line that are inappropriate along the length, a continuous suture with biodegradable thread 2 / 0, having fixing elements, is superimposed on the comparable sections of the walls of the stomach and intestines, when stitching the edges of the stomach and intestines in the inner row of sutures use intestinal atraumatic clamp with metric marks on branches 0.7 and 1.0 cm from the edge, when flashing the intestines, injections are carried out at a distance of 0.7 cm, when flashing the stomach 1.0 cm from the edge, respectively.

The method is as follows. Linear staplers perform endosurgical resection of the stomach according to Ru. An isoperistaltic small-intestinal anastomosis side-by-side is applied at a distance of 35 cm to 40 cm from the planned gastroenteroanastomosis [Fig. 1 item 1] and at a distance of 25 cm to 30 cm from the ligament of Treitz [Fig. 1 item 2]. When forming the loop, a linear stapler with a 55 mm suture length is used, incisions for introducing a stapler and, if necessary, hardware sutures are sealed with separate, nodular, gray-serous intracorporeal sutures. Gastroenteroanastomosis is positioned vertically along the front wall of the stomach 3 cm proximal to the sutures of the gastric stump. When performing laparoscopic intracorporeal manual gastroenteroanastomosis, the outer row of the posterior lip for 6.5 cm is performed with a serous-muscular continuous suture with biodegradable suture 2/0 (USP) having fixing elements [Fig. 1 item 3], the ends of the thread are fixed with clips. At a distance of 1.5 cm from the edges of the first row of the serous-muscular suture, the lumen of the stomach and intestines is opened for 3.5 cm [Fig. 1 item four]. Two nodal sutures with biodegradable suture 2/0 (USP) are applied to the edges of the anastomosis and tied intracorporally [Fig. 2 poses 1], when capturing the walls of stitched organs, an atraumatic intestinal clamp is used that has marks at the ends of the branches at a distance of 0.7 and 1.0 cm, while the intestinal wall is taken at a distance of 0.7 cm, the stomach is 1.0 cm. The clamp and needle holder the suture line is stretched to control the matching of the edges of the anastomosis, if there is a mismatch, on each side, one intracorporeal suture is applied, and the wall of the stomach and intestines are captured alternately. According to the length of the gastric and intestinal walls, the inner row of the posterior lip of the gastroenteroanastomosis is performed with a sero-muscular-submucosal continuous suture with a biodegradable suture 2/0 (USP), which has fastening elements over 3.5 cm [Fig. 2 poses 2]. To form the front wall of the anastomosis, single nodular sero-muscular-submucosal sutures are placed at the edges with a knot tied into the lumen of the anastomosis [Fig. 3 poses 1], before aligning the length of the gastric and intestinal walls. After making sure that they are well adapted by stretching the angular ligatures, the anastomosis is completed by continuous suture with a biodegradable thread 2/0 (USP) having fixing elements [Fig. 4 poses 1], control the tightness of the anastomosis by air breakdown.

The method was tested in 36 patients in the Department of Surgery No. 1 NUZ "Road Clinical Hospital at the station. Rostov-Glavny, JSC Russian Railways, Rostov-on-Don.

An example of a specific implementation of the method

Patient Sh.E.V., 48 years old, was hospitalized in the Department of Surgery No. 1 of the NIH "Road Clinical Hospital at the station. Rostov-Glavny, JSC Russian Railways, Rostov-on-Don, in a planned manner with a diagnosis of total polyposis of the stomach body. 11/27/2015 performed laparoscopic subtotal resection of the stomach. The skin is treated with solutions of antiseptics. Under ETN, through a Veress needle inserted paraumbilically, a carboxyperitoneum of 10 mm Hg was created, trocars were installed: paraumbilical, along the midclavicular line in the right hypochondrium, along the midclavicular line in the left hypochondrium, along the midclavicular line in the right iliac region, along the midclavicular line in left iliac area. Linear staplers performed endosurgical resection of the stomach according to Ru. An isoperistaltic small-intestinal anastomosis side-by-side was performed at a distance of 35 cm from the planned gastroenteroanastomosis and at a distance of 25 cm from the ligament of Treitz. When forming the loop, a linear stapler with a 55 mm suture length was used; incisions for introducing the stapler were sealed with separate nodular gray-serous intracorporeal sutures. Gastroenteroanastomosis was oriented vertically along the front wall of the stomach 3 cm proximal to the sutures of the gastric stump. When performing laparoscopic intracorporeal manual gastroenteroanastomosis, the outer row of the back lip for 6.5 cm was performed with a serous-muscular continuous suture with a biodegradable suture 2/0 (USP), which has fixing elements, the ends of the suture were fixed with clips. At a distance of 1.5 cm from the edges of the first row of the serous-muscular suture, the lumen of the stomach and intestines was opened for 3.5 cm. Two nodular sutures were applied to the edges of the anastomosis with biodegradable suture 2/0 (USP), and atraumatic intestinal was used to capture the walls of the stitched organs. a clip having at the ends of the jaw marks at a distance of 0.7 and 1.0 cm, while the wall of the intestine was taken at a distance of 0.7 cm, the stomach is 1.0 cm. With a clamp and needle holder, the suture line was stretched to control the matching of the edges of the anastomosis, a mismatch was found edges of the anastomosis. On each side, one intracorporeal suture was applied, grabbing the walls of the stomach and intestines in turn. Correspondence of the edges of the anastomosis was established. The inner row of the posterior lip of the gastroenteroanastomosis was performed with a serous-muscular-submucosal continuous suture with a biodegradable suture 2/0 (USP), which had fixing elements over 3.5 cm. The walls of the sutured organs were grabbed by an atraumatic intestinal clamp with a mark at the ends at a distance of 0 7 and 1.0 cm. For the formation of the anastomosis anterior wall, single nodular sero-muscular-submucosal sutures were placed at the edges with a knot tied into the lumen of the anastomosis, the lengths of the gastric and intestinal walls were leveled, completed e anastomosis continuous suture thread biodegradable 2/0 (USP), having anchoring elements. The tightness of the anastomosis was controlled by air breakdown. The course of the early postoperative period is smooth. Discharged on December 7, 2015 in satisfactory condition. The remote postoperative period was uneventful.

Compared with the prototype method has the following advantages.

1. Increases the accuracy of the depth of capture of the joints and the quality of adaptation of the walls of the stomach and intestines due to the use of intestinal atraumatic clamp with metric marks of 0.7 and 1.0 cm.

2. The time and complexity of performing laparoscopic intracorporeal manual gastroenteroanastomosis due to the use of single and continuous sutures is reduced.

3. The reliability of the anastomosis in the continuous weld zone is increased due to the use of a biodegradable thread with fixing elements 2/0, while narrowing the width of the anastomosis and, as a result, its subsequent stenosis are prevented.

4. The method is feasible with a small cult of the stomach, for example, with subtotal resection of the stomach, with gastrojuncture, as well as bariatric surgery.

The method allows to improve the quality of treatment of patients with indications for gastric resection, including subtotal, as well as gastrojuncture bypass during bariatric operations by applying laparoscopic intracorporeal manual gastrointestinal anastomosis.

Bibliography

1. Dong Zhou, Quan-Xing Liu, Xu-Feng Deng, Jia-Xin Min, Ji-Gang Dai / Comparsion of two different mechanical esophagogastric anastomosis in esophageal cancer patients: a meta-analysis // Journal of Cardiothoracic Surgery (December 2015 ) 10:67.

2. Qureshi A., Podolsky D., Cumella L., Abbas M., Choi J., Vemulapalli P., Camacho D. / Comparsion of stricture rates using three different gastrojejunostomy anastomotic techniques in laparoscopic Roux-en-Y gastric bypass / / Surg Endosc (2015) 29: 1737-1740.

Claims (1)

Method of laparoscopic intracorporeal manual gastroenteroanastomosis, characterized in that the outer row of sutures of the posterior lip of the anastomosis is performed by a serous-muscular continuous suture, at a distance of 1.5 cm from which the lumen of the stomach and intestines is opened, two nodal sutures are applied to the edges of the anastomosis, and the intestinal wall is taken at a distance of 0.7 cm, the stomach is 1.0 cm from the edge of the incision, the suture line is stretched to control the matching of the edges of the anastomosed organs, if there is a mismatch, one intracorporal is applied on each side the seam, according to the length of the gastric and intestinal wall, the inner row of the posterior lip of the anastomosis is performed with a sero-muscular-submucosal continuous suture, to form the anterior wall of the anastomosis, single nodular serous-muscular-submucous sutures are applied along the edges with a knot tied into the lumen of the anastomosis, the suture line is stretched to control the comparison of the edges of the anastomotic organs, when the length of the gastric and intestinal walls matches, the anastomosis anterior lip is completed with a continuous suture, when the edges of the stomach and intestines are stitched the inner row of sutures use an intestinal atraumatic clamp with metric marks on branches 0.7 and 1.0 cm from the edge.

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