RU2710349C1 - Method of pancreas transection when performing pancreatic resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery and oncology, and can be used in surgical management of pancreatic tumors. A tunnel is formed under pancreatic tissue. Resected portion of the gland is ligatured and dissected away by 4–5 mm from the filament towards the remaining portion of the gland with subsequent haemorrhage stopping from the remaining portion of the gland.

EFFECT: method enables reducing a pancreatic injury, reducing blood loss, improving the reliability of preventing implantation metastases accompanying transverse pancreas transection when performing pancreatic resection by preventing pancreatic juice efflux with tumor cells and good imaging of bleeding sources.

1 cl, 2 ex

Description

The invention relates to medicine, namely to surgery and oncology, and can be used in the surgical treatment of pancreatic tumors.

A known method of crossing the pancreas when performing a resection of the pancreas, which consists in the following: preparation and formation of a tunnel under the pancreatic tissue, between the posterior surface of the isthmus of the pancreas and the portal and superior mesenteric veins. After determining the level of pancreatic intersection, atraumatic clamps are applied to it to reduce bleeding from the crossed pancreas and to prevent pancreatic juice from flowing into the abdominal cavity, since pancreatic juice flowing from the removed part of the gland with tumor cells can lead to implantation metastases. The pancreas is crossed with scissors between the clamps, and the pancreatic duct of the part of the gland to be removed is sutured with interrupted sutures to prevent the expiration of pancreatic juice after removing the clamps. After removing the clamps, thorough hemostasis is performed by flashing the ends of the pancreas. The author draws attention to that hemostasis of the crossed gland should be complete: this will allow to avoid bleeding in the postoperative period, which can be quite strong. (Emilio Etala. Atlas of abdominal surgery (translated from English edited by Martov, Yu.B.). M.: Medical literature, 2006. - T. 1. - pp. 357-368).

The disadvantages of the method: the transverse application of clamps to the tissue of the left part of the pancreas can lead to crushing of the parenchyma of the gland, the development of pancreatic necrosis and the failure of pancreatic-enteroanastomosis.

The clamps applied for the purpose of temporary hemostasis are subsequently removed, after which bleeding occurs, which requires the completion of all measures of final hemostasis (flashing according to the recommendation of the author) from both ends of the crossed gland.

To prevent implantation metastasis caused by the outflow of pancreatic juice into the abdominal cavity from the part of the gland affected by the tumor, the author recommends suturing the pancreatic duct with nodal sutures before removing the clamp from the part of the gland to be removed. Since the wall of the pancreatic duct is usually thin and fragile, when suturing it, it can be injured with the formation of microdefects. Therefore, suturing of the pancreatic duct with interrupted sutures does not guarantee a complete cessation of the expiration of pancreatic juice.

EFFECT: reduced pancreatic injury, decreased blood loss, increased reliability of prevention of implant metastasis during transverse pancreatic crossing during pancreatic resection.

This problem is solved by preliminary ligation with a thread of the entire tissue array of the removed part of the pancreas in the transverse direction with its further intersection with a scalpel, retreating 4-5 mm from the thread towards the remaining part of the gland. In this case, bleeding and leakage of pancreatic juice from the removed part of the gland is completely absent. After crossing, bleeding from the remaining part of the gland is stopped by diathermocoagulation or flashing.

The method is as follows. After mobilization of the isthmus of the pancreas and the creation of a tunnel between the posterior surface of the pancreas and the superior mesenteric and portal veins, a thread (for example, nylon No. 3-4) is tightened into the tunnel, which tightens the isthmus of the gland, preventing its eruption. After that, an instrument, for example, a grooved probe, is inserted into the tunnel under the isthmus of the pancreas to protect the portal and superior mesenteric veins, and the isthmus of the pancreas is crossed with a scalpel above it, stepping 4-5 mm from the thread towards the remaining part of the gland. After crossing the isthmus, bleeding from the remaining part of the gland is stopped by diathermocoagulation. If necessary, flashing of bleeding vessels is performed. The method allows you to reliably completely prevent bleeding from the removed part of the crossed gland and at least 2 times reduce blood loss. Reducing blood loss is also facilitated by the fact that with bleeding that continues from only one end of the crossed gland, there is no interference with the visualization of bleeding sources in the form of blood running from the other end of the crossed gland. In addition, with this method of crossing the gland, the outflow of pancreatic juice containing cancer cells from the removed part of the gland is completely eliminated, which excludes implantation metastasis.

With further operation, the thread, which bandages the removed part of the isthmus of the gland, serves as a holder and facilitates the preparation of the head of the gland.

The method was used to perform 22 pancreatic resections with a good clinical result.

Case Studies

Example 1

Patient K., 52 years old.

Diagnosis: Adenocarcinoma of the pancreatic head. Obstructive jaundice.

Hospitalization on an emergency basis. Complaints of weakness, yellowness of the skin, pain in the epigastric region of low intensity. The state of moderate severity. The skin is icteric. Respiratory rate - 18 respiratory movements per minute. Pulse 82 beats / min, rhythmic. HELL 130/70 mm Hg Heart sounds are clear. The abdomen is involved in the act of breathing, moderately painful in the epigastrium and in the right hypochondrium. Computed tomography of the abdominal cavity revealed a tumor-like formation in the head of the pancreas. After stenting of the common bile duct performed during endoscopy, the bilirubin level decreased from 167 μmol / L to 38 μmol / L. The patient was operated on: pancreatoduodenal resection was performed. After performing the upper midline laparotomy, the duodenum was mobilized according to Kocher, the elements of the hepatoduodenal ligament were prepared. A preparation was made between the posterior surface of the pancreas and the superior mesenteric and portal veins, and a tunnel was formed into which a thread was made from nylon No. 3-4, which tightly bandaged the isthmus of the pancreas. A grooved probe is inserted into the space between the isthmus of the gland and the portal vein, and the isthmus is crossed with a scalpel simultaneously over the probe 4 mm to the left of the thread. After crossing the isthmus, bleeding from the end of the remaining part of the gland is stopped by diathermocoagulation. The amount of blood loss during this stage was minimal. The further course of the operation without features. The postoperative period is smooth. On the 9th day from receipt, the sutures were removed from the surgical wound. On the 10th day with clinical recovery, the patient was discharged for outpatient aftercare by a surgeon at the place of residence. Control examination after 6 months after surgery - the condition is stable, satisfactory, no signs of metastasis were found on computed tomography.

Example 2

Patient U. 53 years old.

Diagnosis: Adenocarcinoma of the large duodenal papilla of the duodenum. Obstructive jaundice.

Hospitalization on an emergency basis. Complaints of yellowness of the skin. The state of moderate severity. The temperature is 36.6 degrees. The skin is rich yellow. Breathing is not quickened - 18 respiratory movements per minute. Pulse 92 beats / min, rhythmic. HELL 120/80 mm Hg Heart sounds are clear. The abdomen is involved in the act of breathing, soft, moderately painful in the epigastrium. In the right hypochondrium, the painful bottom of the gallbladder is palpated. Computed tomography revealed a neoplasm of the large duodenal papilla of the duodenum. On endoscopy revealed a neoplasm of the large duodenal papilla 2 by 2 cm. A biopsy was taken - conclusion: adenocarcinoma. For the purpose of preoperative preparation, the patient underwent laparoscopic cholecystostomy. After a 7-day preoperative preparation, bilirubin levels decreased from 342 μmol / L to 45 μmol / L. The patient was operated on: pancreatoduodenal resection was performed. After performing a laparotomy, mobilization of the duodenum and preparation of the elements of the hepatoduodenal ligament, the isthmus of the pancreas is mobilized and separated from the portal and superior mesenteric veins. In the formed tunnel under the isthmus of the gland, a nylon thread (nylon No. 3-4) was drawn. The removed part of the gland is tied with this thread in the transverse direction and crossed with a scalpel along the grooved probe 5 mm to the left of the thread. After crossing the pancreas, the bleeding from the remaining part of the gland was stopped using diathermocoagulation and flashing of bleeding sites. Blood loss when crossing the gland was minimal. The further course of the operation took place without features. The postoperative period is smooth. On the 11th day after the operation, the patient was discharged for outpatient treatment by a surgeon at the place of residence. The control examination of the patient took place 6 months after the operation - the patient's condition is stable, satisfactory, no signs of metastasis were found on computed tomography.

Observational data indicate that the proposed method for crossing the pancreas with preliminary ligation of the entire array of tissue of the removed part of the pancreas with thread is an effective and safe way to reduce trauma to the resected pancreas, prevent bleeding from the removed part of the pancreas, and a reliable way to prevent implant metastasis when performing pancreatic resection glands in patients with pancreatic cancer.

The method is described for the most problematic pancreas transection in the isthmus area during resection of the gland for a malignant tumor, but can be used to cross the gland at any other level in operations performed both for a pancreatic tumor and for complications of chronic pancreatitis.

Claims (1)

A method for crossing the pancreas when performing a pancreatic resection by forming a tunnel under the pancreatic tissue, characterized in that after the tunnel is formed under the pancreatic tissue, the resected part of the gland is ligated and cut off, departing 4-5 mm from the thread towards the remaining part of the gland followed by stopping bleeding from the remaining part of the gland.