RU2717893C1 - Method of forming precision bihepaticojejunoanastomosis after iatrogenic damage of confluence of hepatic ducts without replaceable transhepatic drainages - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical gastroenterology. It is followed by formation of high-precision bihepaticojejunoanastomosis after iatrogenic damage of hepatic duct confluence without replaceable hepatic ducts, including formation of bihepaticojejunoanastomosis with Roux loop eliminated. Artificial confluence is pre-created after iatrogenic injures of the right and left hepatic ducts by stapling the medial walls of the right and left hepatic ducts. It is followed by forming bihepaticojejunoanastomosis along the perimeter from the walls of the right and left bile ducts and the posterior wall of the small intestine, eliminating the use of replaceable transversal drainages.

EFFECT: method enables reducing the risk of postoperative complications and length of admission, improving patient's quality of life.

1 cl, 4 dwg, 2 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to surgical gastroenterology, in particular, to a method for the formation of precision bighepaticoyunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drainages and can be used in the treatment of iatrogenic injuries of the bile ducts, as well as high strictures and tumors.

State of the art

A known method of forming hepatikoejunostomoz A.A. Shalimov, in which the author, with damage to the hepatic ducts at or above their fusion, stitched the internal semicircles of the right and left hepatic duct with the formation of a biliodigestive anastomosis. For this, a loop of the jejunum 30-40 cm long from the Treitz ligament is carried out behind (less often in front) of the transverse colon, biliodigestive anastomosis is formed by single-row sutures. After applying the posterior row of sutures, drainage with a split end is introduced upwards through the incision of the intestinal wall, the halves of which are installed in the hepatic ducts. Impose the front row of sutures between the serous-muscular layer of the intestine and the wall of the stitched ducts. Around the anastomosis, the intestine is sutured to the capsule of the liver. The tube is immersed in the oblique canal of Witzel and fixed to the intestine with a purse string suture. An anastomosis is formed between the leading and outlet loops of the jejunum with the plug of the leading loop. The outer end of the Felker drainage is removed through a separate puncture of the abdominal wall and attached with sutures to the parietal peritoneum and skin. In cases where one hepatic duct is longer than the other, a short duct is sutured into the side of a long atraumatic suture material. Subsequently, hepatikoejunostomy is performed (see Shalimov A.A., Kopchak V.M., Derevyanko A.Yu. Surgical tactics in the treatment of cicatricial strictures of the extrahepatic bile ducts // Reconstructive surgery. - Rostov-on-Don, 1990. - S. 169-171).

The disadvantage of this method is that they install removable transhepatic drains (STD), which significantly worsen the quality of life of the patient. STD is established from 6 months to 2 years, and it is necessary to change the drainage, which is extremely inconvenient for the patient, disrupting his ability to work.

There is a method of temporary external shunting for intra-intestinal removal of bile from the liver with iatrogenic damage to the bile ducts, characterized in that at the first stage the proximal stump of the hepatic choledochus is externally drained with a “T-shaped” tubular drainage so that the short ends of the drainage are installed in the left and right lobar ducts and the long horizontal part is brought out to the anterior abdominal wall, then at a distance of 60.0 cm from the Treytz ligament 80.0 cm of the jejunum are mobilized and an intestinal anastomosis is formed o Ru end - in - side, the isolated isolated loop of the jejunum is placed in the right subhepatic space and drained by the type of suspended enterostomy, using a "T-shaped" tubular drainage, the long horizontal end of which is led to the anterior abdominal wall, and then to the second stage in the postoperative period after the cholangitis has subsided, the hepatic choledoch stump drainage and enterostomy drainage brought to the abdominal wall are connected to each other, forming a temporary shunt, through which bile enters from the liver into the skinny intestine (see. US Pat. RU No. 2580753, IPC А61В 17/00, publ. 04/10/2016).

The disadvantage of this method is that the drainage tube can migrate from the anastomosis, "cutting through" the liver parenchyma, thereby leaving the anastomosis without frame drainage, which creates the risk of anastomosis failure.

The closest in technical essence and the achieved positive effect and adopted by the authors for the prototype is a method of surgical treatment of high stricture of the common hepatic duct, including the isolation of the duct proximal to the stricture over the scar tissue, dissection of the left hepatic duct, shutting off the segment of the small intestine along the Roux, formation of the posterior one, and then the anterior lip of the hepaticoyunoanastomosis with a precision single-row suture, the hepaticoyunoanastomosis is formed by a continuous suture with a separate thread for each lip s, at the same time, the suture stitching the rear lip is tied both before and after stitching, leaving loose ends, then one or more drainage tubes are installed in the lobar ducts of the liver, the total outer diameter of which does not exceed half the diameter of the anastomosis, and the second thread form the front lip of the anastomosis similarly to the back, the free ends of adjacent pairs of threads are connected to each other; after that, the distal ends of the drainage tubes lead to the anterior abdominal wall. The distal ends of the drainage tubes are brought out through the end section of the “blind” section of the segment of the small intestine, immersing them with invaginating sutures with the formation of a “cuff-spill” for each tube. After the formation of hepaticoejunoanastomosis, the diverting loop of the small intestine and one of the drainage tubes are temporarily squeezed, 20-30 ml of intact fluid is injected into the other drainage tube, in case of leakage of fluid from the joints of the hepaticojejunoanastomosis, intraoperative correction of the tightness of the joints of the anastomosis is carried out, then the intestinal tube and drainage are removed which bring the distal ends of the drainage tubes to the anterior abdominal wall (see US Pat. RU No. 2254823, IPC A61B 17/11, publ. June 27, 2005).

The disadvantage of this method is the installation of replaceable transhepatic drains, which significantly worsen the quality of life of the patient. CTD is established from 6 months to 2 years, and drainage is necessary, which is extremely inconvenient for the patient, disrupting his ability to work, and the drainage tube can migrate from the anastomosis, "cutting through" the liver parenchyma, thereby leaving the anastomosis without frame drainage, which creates a risk of insolvency anastomosis.

Disclosure of Invention

The objective of the invention is to develop a method for the formation of precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drainages, with the help of which good mechanical strength of the suture is achieved, which helps to reduce the risk of postoperative complications, periods of hospitalization, and also conditions are created for not using removable transhepatic drains, which improves the quality of life of the patient and contributes to the rapid restoration of labor bnosti.

The technical result, which can be obtained using the present invention, boils down to the formation of a hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without replaceable transhepatic drains, which has a reduced risk of postoperative complications, terms of hospitalization and improved quality of life of the patient.

The technical result is achieved using the method of forming a precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains, including the formation of a hepaticojejunoanastomosis with the jejunum loop turned off, while creating an artificial confluence after iatrogenic hepatic lesions of the right and left and the left hepatic ducts, and then form a hepaticojejunoanastomosis in perimeter from the walls of the right and left bile ducts and the posterior wall of the small intestine, excluding the use of removable transhepatic drainages.

Thus, inadvertent damage to the bile duct was and remains one of the most pressing problems in surgery. According to E.I. Halperin, iatrogenic damage to the extrahepatic bile ducts is the most serious complication of cholecystectomy, which for many patients becomes the beginning of a long tragedy (see Halperin E.I., Kuzovlev N.F., Karagyulyan S.R. Cicatricial strictures of the bile ducts. - M: Medicine , 1982.- 240 p.). The frequency of damage to the bile ducts with open cholecystectomy remains stable and amounts to 0.05-0.2% (see Halperin EI, Chevokin A.Yu. "Fresh" damage to the bile ducts. Surgery. 2010; 10: 4-10) . The widespread occurrence of laparoscopic interventions contributed to an increase in iatrogenic injuries by 2-10 times, to the level of 0.08-2.7% (see Borisov A.E. Guide to surgery of the liver and biliary tract. - In two volumes. - St. Petersburg: Scythia, 2003 .-- 488 p.).

The ratio of laparoscopic to open cholecystectomy is approximately 4 to 10: 1. With the number of cholecystectomies exceeding 500,000 per year in the United States, with a damage frequency of 0.3 to 0.6%, 1500-3000 patients with biliary tract injuries per year are potentially possible (see Brazhnikova N.A., Merzlikin N.V. ., Tskhai V.F., Khlebnikova Yu.A., Eskov I.M., Shelepov S.V., Saipov MB, Kuracheva N.A. Direct results of corrective operations of injuries of the bile ducts during cholecystectomies. . 2012; 1: 141-149.).

Classification of bile duct injuries according to Strasberg SM (see Syed A.K., Syed IK, Roma P., Thomas K. 1., Imran I. European Society of Gastrointestinal Endoscopy on Bile Duct Injuries. J. Surg. 2014; 2 ( 6): 82-87. Https://doi.org/10.11648/j.js.20140206.11.).

• Type A - damage to small ducts without loss of continuity of the bile tree (failure of the cystic duct, damage to the duct in the bed of the bladder;

• Type B - damage (occlusion) of the aberrant right ducts;

• Type C - damage (dissection) of the aberrant right ducts;

• Type D - lateral damage to hepatocholedochus, can lead to progression of damage and transition to type E;

• Type E - damage to the main bile ducts:

E1 - complete dissection of the OP with a stump of more than 2 cm.

E2 - complete dissection of the OP with a stump less than 2 cm.

E3 - complete dissection of the AKI at the place of its formation.

E4 - complete dissection along with the separation of both lobar ducts.

E5 - intersection at the bifurcation level in combination with damage to the right lobar duct.

Damage and stricture scheme according to E.I. Halperin (see Halperin EI, Chevokin A.Yu. "Fresh" damage to the bile ducts. Surgery. 2010; 10: 4-10). Where six types stand out: "+2" - the stump of the modified AKP more than 2 cm; "+1" - the stump of the OPP 1-2 cm; "0" - the stump of the AKI less than 1 cm; “-1” - there is no AKP stump, the upper-posterior arch of the confluence of PP is preserved; "-2" - the confluence zone of PP is destroyed, stumps of the lobar ducts are preserved; "-3" - cicatricial inflammatory lesion of the segmental ducts.

To date, there is no generally accepted algorithm for the surgical treatment of patients with iatrogenic injuries of the extrahepatic bile ducts. The questions of choosing the method of operation, depending on the time of the injury and the optimal time for repeated intervention, remain open. An important problem is the technical support of surgical interventions and painstaking performance of all stages of the operation (see Guidelines for biliary tract surgery. Edited by E. Galperin, PS Vetsheva M .: Vidar-M, 2009. 561 pp.). The main principles of the formation of a biliodigestive anastomosis: excision of scar tissue, precision adaptation of the mucous membranes of the hepatic ducts and intestines, the creation of a wide fistula without tension, the length of the intestine “disconnected” along the Ru no less than 80 cm. From technical points it should be noted that the introduction of precision (from French precision - accuracy) of a single-row nodal suture using atraumatic needles and inert suture materials contributes to good adaptation of the mucous membrane of the duct and intestine. In the formation of the gall-intestinal anastomosis, monofilament filaments are considered the best suture material, from non-absorbable ones (prolene 5-7.0) from absorbable ones (maxon, vicryl, polydioxanone 4-5.0) (see Fedorov I.V., Sigal L .E., Chugunov AN Damage to the bile ducts during cholecystectomy. M., 2003. 72 p.). According to a number of authors, with large duct injuries diagnosed during surgery or in the early postoperative period, biliary surgery is indicated. Early reconstructive or reconstructive surgery is possible under certain conditions: with a duct width of at least 10 mm, the absence of pronounced inflammatory changes, sufficient qualification of the surgeon and the presence of atraumatic suture material (see Emelyanov S.I., Matveev N.L., Fedenko V.V. Laparoscopic surgery: past and present. Endoscopic surgery. 1995; 1: 5-8.). In the later stages, the method of choice is reconstructive surgery: hepatic or hepaticojejunostomy on kakarstny drainage. The success of the operation is determined by the timing of the injury, the adequacy of the intervention method, the experience of the surgeon and the precision of the technique (see Kurbanov D.M., Rasulov N.I., Ashurov A.S. Complications of laparoscopic cholecystectomy. Surgery News. 2014; 22 (3): 366 -373.). The main principles of the formation of hepatikoyunoanastomosis are: the creation of a wide (at least 2 cm) anastomosis, minimal mobilization of the wall of the bile duct, a precision technique (see Benkabbou A., Castaing D., Salloum Ch., Adam R., Azoulay D., Vibert E. Treatment of failed Roux-en-Y hepaticojejunostomy after post-cholecystectomy bile ducts injuries. Surgery. 2013; 1535 (1): 95-102. Https://doi.org/10.1016/j.surg.2012.06.028.). At low and medium injuries, the anterior duct wall is dissected in the proximal direction towards the left hepatic duct for at least 2 cm. With high injuries, the left hepatic duct and the site of its confluence with the right are extracted after the portal plate is reduced and dissected. High-quality reconstructive surgery without frame drainage is possible with the proximal sections of the hepatic ducts expanding at least 10 mm (see Emelyanov S.I., Panchenkov D.N., Mamalygina L.A. Surgical treatment of intraoperative injuries of the extrahepatic bile ducts. Annals of surgical hepatology. 2005; 10 (3): 55-61.). Hepaticojejunostomy using removable transhepatic drains (STD) allows for prolonged decompression of the biliary tract, helps to prevent suture failure and narrowing of the anastomosis (see Kurbanov D.M., Rasulov N.I., Ashurov A.S. Complications of laparoscopic cholecystectomy. Surgery News 2014 2014. ; 22 (3): 366-373.). With the existing variety of options for wireframe interventions, we dwell on the more common ones. Through frame drainage, proposed by J. Saypol et K. Kurian, involves the passage of a tube through the liver, duct, anastomosis, intestine with the withdrawal of both ends to the skin. This principle allows holding drainage for a long time, changing it every 3 months. In the author's version, the operation is performed as follows. The hepatic duct at the gate of the liver is isolated and opened, the mucous membrane of the duct is turned out in the form of a socket and is hemmed to the capsule of the liver. A loop of the jejunum turned off along the Ru with an un sewn end is connected to the capsule of the liver with interrupted sutures behind the hepatic duct. A curved clamp is inserted into the left or right hepatic duct, pass through the liver parenchyma, grab the tube and extend through the opening of the common hepatic duct. At the opening of the hepatic duct, the intestine is opened and the posterior row of sutures is inserted through the edges of the duct and intestine. A tube with lateral openings is carried out into the lumen of the intestine and discharged through its open end. This end of the intestine is closed with interrupted sutures around the tube. To conduct drainage through the liver parenchyma, a special metal probe with removable olives is used. The probe is sent from the hepatic duct to the lobar, in the III or VI segment of the liver. The probe, brought to the front of the liver, connects to a drainage tube with lateral openings, which is carried out transhepatically through hepaticoyunoanastomosis into the loop of the intestine. Drainage at the exit from the liver is fixed with a catgut suture to prevent the exit of bile and blood into the subdiaphragmatic space. Both ends of the drainage exit to the anterior wall below the costal arch (see Bergman JJ, van den Brink GR, Rauws EA, de Wit L., Obertop H., Huibregtse K., Tytgat G., Gouma DJ Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut. 1996; 38 (1): 141-147. Praderi-R. Smith suggested leaving one end of the drainage in the lumen of the gut intestinal anastomosis and the other leading out through the liver. This type of drainage contributes to reliable drainage, but there are difficulties with its replacement (see Bismuth N., Majno R.E. Biliary strictures: classification based on the principles of surgical treatment. World J. Surg. 2001; 25 (10): 1241-1244.). In patients with a wide orifice of the hepatic duct E.I. Galperi He et al. used an invagination hepatikojejunostomy on STD. The method consists in tightening the purse string suture around the drainage loop of the intestine so that the intestinal mucosa does not sink into its lumen, but turns out. The intestine is pulled to the gates of the liver, and the outlet from the mucous membrane is invaginated into the lumen of the duct, so that the mucous membranes of the duct and intestines are in close contact. With a narrow mouth of the hepatic duct, the authors performed submersible hepatikoejunostomy on STD. Drainage was performed through the right hepatic duct and liver parenchyma. Loop, intestines isolated according to Brown. They opened the lumen of the small intestine with two small incisions at a distance of 10-15 cm from each other. Through these holes spent STD. A purse string suture was placed on the intestine around the hepatic opening and tube, when tightened, the mucous membrane was immersed into the lumen and the intestine was pulled to the gates of the liver. The intestine was sutured to the duct wall and surrounding scar tissue in the back and front. The seams are not tied. After tying the nodal sutures around the drainage, the intestine was additionally fixed to the capsule of the liver and an intestinal anastomosis was formed side to side (see Briskin BS, Gudkov AN, Brunin NV. Optimization of mini-access cholecystectomy with elements of an open laparoscopic technique. Materials All-Russian Conference "Endoscopically Assisted Operations". Ekaterinburg, 1999. P. 79).

The essence of the method for the formation of precision bighepaticoyunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains is as follows. After the iatrogenic damage of the right and left hepatic ducts 1 and 2 is detected, respectively, the remaining parts of the right and left hepatic ducts 1 and 2, respectively, are isolated. With insufficient clearance of the stumps (not shown in FIG.) Of the isolated hepatic right and left ducts 1, 2, additional sections 3 of the lateral walls of the right and left hepatic ducts 1 and 2 are made to create a wider anastomosis, respectively. Then, single vicryl sutures 4 are applied with a 4/0 Vikril thread (not shown in Fig.) On the medial walls of iatrogenically damaged right and left hepatic ducts 1 and 2 with the creation of artificial confluence.

Then turn off the jejunum 5 Y-shaped method according to Ru. The jejunum 5 intersects transversely at a distance of about 18-20 cm from the duodenojejunal junction (not indicated in FIG.). Its distal end is drowned out with either twisting, or stapling, or purse-string sutures (not indicated in FIG.), And the proximal end is sutured into the jejunum 5 40-60 cm below the intersection by applying an end-to-side inter-intestinal anastomosis 6. Next, perform a hepatopathy-unanastomosis 7 around the perimeter of the walls of the right and left hepatic ducts 1 and 2 and the posterior wall (not shown in Fig.) Of the jejunum 5 using thin vicryl threads for suture (Vikril 4/0), excluding the use of removable transhepatic drains.

Brief description of drawings and other materials

In FIG. 1 shows a method for the formation of precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains, detection and isolation of iatrogenic damaged right and left bile ducts.

In FIG. 2, also, the formation of dihepaticojejunoanastomosis along the perimeter from the walls of the right and left bile ducts and the posterior wall of the small intestine with the loop of the jejunum turned off along the Ru.

In FIG. 3, the scheme of damage and strictures according to E.I. Halperin.

The implementation of the invention.

Examples of a specific implementation of the method of forming a precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains on patients.

Example. The implementation of the method of forming a precision bighepaticoyunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains (see Fig. 1, 2) is carried out as follows. After the iatrogenic damage of the right and left hepatic ducts 1 and 2 is detected, respectively, the remaining parts of the right and left hepatic ducts 1 and 2, respectively, are isolated for as long as possible. With insufficient clearance of the stumps of the isolated hepatic right and left ducts 1, 2, additional sections 3 of the lateral walls of the right and left hepatic ducts 1 and 2 are made to create a wider anastomosis, respectively. Then, single vicryl sutures 4 are applied with a 4/0 Vikril thread (not shown in Fig.) On the medial walls of iatrogenically damaged right and left hepatic ducts 1 and 2 with the creation of artificial confluence.

Then turn off the jejunum 5 Y-shaped method according to Ru. The jejunum 5 intersects transversely at a distance of about 18-20 cm from the duodenojejunal junction (not indicated in Fig.). Its distal end is drowned out with either twisting, or stapling, or purse-string sutures (not indicated in FIG.), And the proximal end is sutured into the jejunum 5 40-60 cm below the intersection by applying an end-to-side inter-intestinal anastomosis 6. Next, perform a hepatopathy-unanastomosis 7 around the perimeter of the walls of the right and left hepatic ducts 1 and 2 and the posterior wall (not shown in Fig.) Of the jejunum 5 using thin vicryl threads for suture (Vikril 4/0), excluding the use of removable transhepatic drains.

A method of forming a precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without replaceable transhepatic drainages on patients is as follows.

Example 2. Patient P., 56 years old, was hospitalized in the department with a diagnosis of Iatrogenic damage to the right and left hepatic ducts after laparoscopic cholecystectomy. After preoperative preparation, the patient underwent surgical intervention in the amount of formation of precision bighepatikoyunoanastomosis 7 after iatrogenic damage to the confluence of the right and left hepatic ducts 1 and 2 without removable transhepatic drains.

An upper midline laparotomy was performed, partial viscerolysis was performed, and organs of the upper abdominal cavity were revised. After the iatrogenic damage of the right and left hepatic ducts 1 and 2 is detected, respectively, the remaining parts of the right and left hepatic ducts 1 and 2, respectively, are isolated for as long as possible. If the stumps of the isolated hepatic ducts of the right and left ducts 1,2 are insufficient, to create a wider anastomosis, additional incisions are made of 3 lateral walls of the right and left hepatic ducts 1 and 2, respectively, and single vicryl sutures are applied with 4 Vikril 4/0 sutures (in Fig. not indicated) on the medial walls of iatrogenic damaged right and left hepatic ducts 1 and 2 with the creation of artificial confluence.

Then turn off the jejunum 5 Y-shaped method according to Ru. The jejunum 5 intersects transversely at a distance of about 18-20 cm from the duodenojejunal junction. Its distal end is drowned out either with twisted, or staple, or purse-string sutures (not indicated in FIG.), And the proximal end is sutured into the jejunum 5 40-60 cm below the intersection by applying an end-to-side inter-intestinal anastomosis 6.

Next, hepatecticoyunoanastomosis 7 is performed along the perimeter of the walls of the right and left hepatic ducts 1 and 2 and the posterior wall (not shown in Fig.) Of the jejunum 5 using thin vicryl threads for suture (Vikril 4/0), excluding the use of removable transhepatic drains.

The operation was completed with two rubber drains in the right hypochondrium, connected to the hepatopathyunoanastomosis 7 and bypass enteroenteroastomosis. Replaceable transhepatic drains were not installed.

The postoperative period was uneventful. Drainages were removed on the 5th and 6th days of the postoperative period. The patient was discharged on the 12th day of the postoperative period in a satisfactory condition.

A method of forming a precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without replaceable transhepatic drainage was performed in 11 patients with thoracoabdominal surgery. In all patients, the postoperative period was uneventful. Patients were prescribed on 14 ± 2 days of the postoperative period in a satisfactory condition. The late postoperative period of patients was monitored: patients were in satisfactory condition, patients denied complaints from the gastrointestinal tract. According to the survey, the quality of life of patients was not affected.

The invention in comparison with the prototype and other known technical solutions has the following advantages:

- good mechanical strength of the seam;

- reduction of risks of postoperative complications;

- terms of hospitalization;

- improving the quality of life of the patient;

- faster recovery of disability.

Literature

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Claims (1)

   A method of forming a precision hepaticojejunoanastomosis after iatrogenic damage to the confluence of the hepatic ducts without removable transhepatic drains, comprising forming a hepaticojejunoanastomosis with the jejunum loop turned off, characterized in that an artificial confluence is created after iatrogenic lesions of the right and left hepatic ducts from the right and left liver ducts ducts, and then form a hepaticojejunoanastomosis along the perimeter of the walls of the right and left of the bile ducts and posterior wall of the small intestine, excluding the use of removable transhepatic drainages.

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