RU2741408C1 - Method for forming pancreatogastroanastomosis in robot-assisted and laparoscopic pancreaticoduodenal resections - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery. Suture-holder on the non-traumatic needle with the absorbable suture is applied on the pancreatic stump on the upper and lower edges and at distance of 0.8–1.0 cm from the edge of the cut and by 0.5–0.7 cm from the upper and lower edges in the direction to Wirsung duct with suture sagging conditions between fixed edges. In the gastric silicone probe with diameter of 4.5–5.1 mm, deepening of 2–3 mm is made in the distal hole. Silicone conductor is introduced into the gastric probe so that the latter passes through the obtained recess and rested against the distal end of the probe, then the gastric probe is brought into the stomach through the nasal passage into the gastrotomic opening on the posterior wall of the stomach, and brought into the abdominal cavity. After that, in the opposite direction, the conductor is tightened by 3–4 cm, freeing from the conductor a recess in the probe, into which the holder thread is immersed and blocked by inserting the conductor above the suture. Probe is pulled in 4–5 cm in the proximal direction; a distal semi-circle of the gastrotomic opening is pulled on the posterior surface of the pancreatic stump throughout its mobilized segment. Suture with which the gastric throat proximal to the anterior surface of the pancreas is sutured, the suture is continued in the opposite direction to fix the distal semi-circle of the gastrotomy opening and the posterior surface of the pancreatic stump to the beginning of fixation.

EFFECT: method enables the whole volume of the surgical intervention intracorporeally without wide accesses, improves the reliability of the anastomosis, reduces the period of using narcotic analgesics in the postoperative period, as well as the number of hospital stay days.

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Description

The proposed invention relates to medicine, namely surgery, and can be used for pancreatoduodenal resections using robot-assisted and laparoscopic techniques, without resorting to open access when forming pancreatogastroanastomosis.

The use of laparoscopic and robot-assisted methods of pancreatoduodenal resection opens up new perspectives in the study and improvement of modifications in the formation of pacreatodigestive anastomoses. Analysis of the literature (Khatkov I.E., Tsvirkun V.V., Izrailov R.E. 2007) showed that the disparate messages that appear do not allow one to get a clear idea of both the approaches to performing a high-tech operation and the choice of the method of forming a pancreatodigestive anastomosis; at the same time, the obtained treatment results demonstrate the possibility of performing both all the nuances of the operation and reducing the trauma of the surgical intervention, while maintaining the oncological principles, i.e. are feasible and comparable to open surgery with the benefits of minimally invasive treatment (P. Giulianotti 2012). The proposed methods for the formation of pancreatogastroanastomosis by foreign authors (Bassi at all 2006), as well as patented domestic methods for the formation of a pancreatodigestive anastomosis (Propp A.R., Lobanov V.G., Poluektov V.L., Stefanovsky V.G., Norka A.E. 2003) do not correspond to the concept of minimally invasive methods due to their complexity and extremely difficult implementation with endoscopic instruments. Thus, it is required to create a simple and reliable method of pancreatogastroanastomosis, equally successfully performed both laparoscopically and robotic. When analyzing complications according to Neidergethmann et al. A 2010 study linked the method of including the pancreatic stump in the gastrointestinal tract with the risk of developing pancreatic fistula during pancreatoduodenal resection, the authors concluded that pancreatogastroanastomosis may be the most unified method of pancreatodigestive anastomosis.

The known method of pancreatogastroanastomosis (Propp A.P. (RU), Lobanov V.G. (RU), Poluektov V.L. (RU), Stefanovsky V.G. (RU), Norka A.E. (RU) Patentee: GOU VPO Omsk State Medical Academy), patent №RU 2003 122 549 A. The invention can be used for resection of the pancreas. A double-row suture is applied between the stump of the pancreas and the posterior wall of the stomach. At the same time, a U-shaped serous-muscular flap is cut out on the back wall of the stomach. The first row of the posterior lip is performed at the base of the flap. Then the inner row of sutures of the posterior lip is applied, anastomosing the edge of the gastric mucosa. Muscle, submucosa and mucous membranes of the stomach are sutured along the corner sutures and in the anastomotic anterior lip. The inner row is fixed with two continuous threads. The ends of the threads are tied together in tension. The outer row of sutures of the anterior lip is performed with a sleeve-like peritonization of the anastomosis with a cut-out U-shaped flap.

This method of treatment has the following disadvantages:

1. The complexity of the method is practically impracticable for the laparoscopic and robot-assisted method.

2. Cutting out a U-shaped flap of the posterior wall of the stomach has a greater risk of ischemic changes due to greater trauma.

3. Continuous double-row anastomosis in relation to pancreatogastroanastomosis has a higher risk of ischemia and as an outcome - suture failure, because the formation of a pancreatogastroanastomosis is primarily dictated by the "complex" stump of the pancreas.

4. The absence of elastic compression from the side of the anastomosed stomach wall, the creation of tightness only due to a continuous suture contributes to an increase in the number of complications.

The closest analogue: a method of forming a pancreatogastroanastomosis during pancreatoduodenal resection (Alibegov Magomedrasul Abakarovich, Sergeev Oleg Anatolyevich, Volynets Alexander Borisovich, Prokhorenko Tatyana Igorevna, Efimkin Andrey Sergeevich Patentee: GOU Medical No. HPO 1 Smolensk State Patent) 7 The invention can be used for pancreatoduodenal resection. When the diameter of the main pancreatic duct is less than or equal to 3 mm, after removal of the pancreatoduodenal complex, the pancreas is invaginated into the posterior wall of the stomach with sutures. In this case, an incision of the posterior wall of the stomach is made 1/3 less than the stump of the pancreas. The intussusception of the stump is carried out to a depth of 3-4 mm.

Two fillet sutures and two interrupted sutures are applied on the anterior and posterior semicircles of the anastomosis of the pancreas and stomach. They retreat 4 cm from the edge of the pancreatic stump. The method makes it possible to reduce the risk of anastomotic leakage due to suture eruption, to reduce the trauma of the gland parenchyma.

This method of treatment has the following disadvantages:

1. Immersion of the pancreatic stump into the posterior wall of the stomach with this method is possible only by the laparotomic (open) method, in which, in contrast to laparoscopic and robotic techniques, there remains a higher risk of a suppurative process from the postoperative wound, and there is also a greater traumatic effect on patient;

2. The inability to perform the operation completely laparoscopically or robotic when using this technique of pancreatogastroanastomosis leads to a longer period of medical and social rehabilitation of the patient, as well as a longer recovery period before the next stage of treatment (adjuvant therapy).

Tasks:

one). Ensure complete (100%) sealing and reliability of pancreatogastroanastomosis;

2). Reduce the length of hospital stay for patients;

3). Reduce the time of formation of pancreatogastroanastomosis;

4). Minimize surgical trauma in the area of intervention;

five). Maintain adequate blood supply to the walls of the stomach and reliable hemostasis of the pancreatic stump;

6). Minimize the amount of mobilization from the side of the pancreatic stump;

7). Provide congruent adherence of the serous membrane of the stomach wall to the capsule of the pancreatic stump, excluding the second row of sutures;

8). To minimize the overall traumatic effect on the patient.

The essence of the invention is: a suture-holder on an atraumatic needle with an absorbable suture is applied to the stump of the pancreas at the upper and lower edges and at a distance of 0.8-1.0 cm from the edge of the cut and 0.5-0.7 cm from the upper and the lower edges towards the center of the gland, with the conditions for sagging the thread between the fixed edges; preliminarily, in a gastric silicone probe with a diameter of 4.5-5.1 mm, a 2-3 mm depression is made in the distal opening, a dense silicone conductor is inserted into the gastric tube, so that the latter passes through the cavity obtained and rests against the distal end of the probe. Then the gastric tube is inserted into the stomach through the nasal passage into the gastrotome opening on the posterior wall of the stomach, its abdominal cavity is removed, after which the conductor is pulled in the opposite direction by 3-4 cm, freeing from the conductor a depression in the probe, into which the retaining thread is immersed and blocked it by introducing a conductor over the thread; the probe is moderately pulled up by 4-5 cm in the proximal direction, the distal semicircle of the gastrotome opening is pulled over the posterior surface of the pancreatic stump along the entire length of its mobilized area; With a thread, which was used to sew the proximal semicircle of the gastrotome opening to the anterior surface of the pancreas, the suture is continued in the opposite direction, fixing the distal semicircle of the gastrotome opening and the posterior surface of the pancreatic stump to the beginning of fixation.

Technical result

The set tasks are achieved by performing the surgical intervention intracorporeally without wide access (laparoscopic, robot-assisted). Due to the suture of the holder made of absorbable material with the condition of the sagging thread, traction of the pre-fixed stump of the pancreas into the lumen of the stomach is possible by blocking the thread in a specially prepared gastric tube led into the abdominal cavity through the gastrotome opening on the posterior wall of the stomach. Thus, thanks to the traction of the pancreatic stump, a fulcrum is created for stretching the stomach wall with elastic compression at the site of the anastomosis, which makes it possible to impose a continuous suture between the stomach wall and the pancreatic capsule with minimal trauma to the latter, and complete tightness of the anastomosis is achieved. A single-row continuous suture in this case excludes the formation of a free space between the wall of the stomach and the stump of the pancreas, in which fluid can accumulate (infection of this fluid causes the formation of an abscess, as the cause of failure of the sutures). Also, the time of imposition of the anastomosis was reduced due to the refusal of conversion to laparotomy, from the anterior gastrotomy in order to further strengthen the anastomosis. Due to the use of the advantages of the minimally invasive method, a significant decrease in indicators was noted on the pain syndrome assessment scale, the period of use of narcotic analgesics in the postoperative period, as well as the number of bed-days of inpatient treatment. Thanks to the use of a minimally invasive method of treatment, the reparative properties of tissues are improved, and in the event of complications, it provides more opportunities for the successful use of minimally invasive interventional methods of treatment.

The method was tested on 15 patients for two years in a surgical department. Good results have been 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 trauma of surgical treatment (without wide open access), which improves the results of treatment, and also reduces the number of bed-days of inpatient treatment. There were no complications in the form of pancreatogasroanastomosis failure. The developed algorithm of laparoscopic and robotic-assisted formation of pancreatogastroanastomosis by monofilament, without interruption, with endogastric traction of the pancreatic stump, as well as the possibility of elastic compression from the side of the stomach wall, proved in practice the possibility of 100% achievement of a guaranteed result of sealing pancreatogastroanastomosis and ease of implementation.

The method is further illustrated in FIG. 1-9 step-by-step schemes for the implementation of the proposed method of treatment, where

fig. 1 - stump of the pancreas;

fig. 2 - continuous suture between the capsule of the anterior surface of the pancreatic stump and the proximal edge of the gastrotome opening;

fig. 3 - the imposition of an absorbable suture-holder with the condition of sagging the suture on the pancreas stump;

fig. 4 - formed seam - holder with the condition of sagging thread;

fig. 5 - fixation of the pancreas stump with a pre-prepared silicone gastric tube;

fig. 6 - pulling the stump of the pancreas into the lumen of the stomach;

fig. 7 - pulling the distal semicircle of the gastrotome opening onto the pancreas stump;

fig. 8 - the imposition of a continuous monofilament-suture between the capsule of the posterior surface of the pancreas and the distal semicircle of the gastrotomy opening;

fig. 9 - view after tying the threads,

where item 1 is the stump of the pancreas, item 2 is the posterior wall of the stomach, item 3 is a non-absorbable monofilament thread, item 4 is a holder suture, item 5 is a silicone gastric tube with a guide.

The method is carried out as follows

After the resection stage and mobilization of the pancreatic stump (1) for up to 3.0 cm (Fig. 1, Fig. 3), a reconstruction is performed, in which a gastrotomy is performed on the posterior wall of the stomach (2) in the transverse direction, with the size of the gastrotome opening up to 1/3 of the surface area of the cut of the stump of the pancreas (1); fixation of the proximal semicircle of the gastrotome opening of the posterior wall of the stomach (2) to the anterior surface of the pancreas is performed with a non-absorbable monofilament (3) (Fig. 2). A holder suture (4) is applied to the stump of the pancreas on an atraumatic needle with an absorbable thread on the upper and lower edges and at a distance of 0.8-1.0 cm from the edge of the cut, 0.5-0.7 cm from the upper and lower edges to the center of the gland with the conditions of sagging thread between the fixed edges (Fig. 4); a pre-prepared gastric silicone probe (5) with a diameter of 4.5-5.1 mm with a guidewire, in the distal opening of which a recess of 2-3 mm is made, is inserted into the stomach through the nasal passage (Fig. 5). Then the gastric tube (5) with a guide, inserted into the stomach, is brought out through the gastrotome opening into the abdominal cavity, after which the guide is pulled in the opposite direction by 3-4 cm, freeing the depression in the probe, into which the holder thread (4) is immersed and blocked it by introducing a conductor over the thread (4) (Fig. 5); the probe is moderately pulled up by 4-5 cm in the proximal direction, pulling the distal semicircle of the posterior wall of the stomach (2) on the posterior surface of the pancreatic stump (1) throughout its mobilized area (Fig. 6, Fig. 7); thread (3), which stitched the proximal semicircle of the gastrotome opening of the posterior wall of the stomach (2) to the anterior surface of the pancreatic stump (1), the suture is continued in the opposite direction (Fig. 8), fixing the distal semicircle of the gastrotome opening and the posterior surface of the pancreatic stump to the beginning of the proximal semicircle of the gastrotome opening. Thus, a single-row continuous pancreatogastroanastomosis is formed with additional elastic compression from the side of the stomach wall (2) onto the pancreatic stump (1) (Fig. 9). By removing the guide wire after completing the suture, the holding thread is unlocked by itself, since there is no holding component. The holding thread (4) (Fig. 4) is absorbed by hydrolysis in the gastric environment. The gastric tube (5) (Fig. 5) remains in the stomach for the purpose of decompression and minimization of the effect on the anastomosis during the next 2-3 days of the postoperative period.

Example No. 1 Patient K. 70 years old

Diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) C24.0 Malignant neoplasm of the extrahepatic bile duct. С-r choledoch cT2N1Mo, s / p stenting of the choledoch under Rg-control, III В Art. 2 class gr. A functioning stent of the common bile duct.

Concomitant: Hypertension II stage Risk 3. CHF I, FC I according to NYHA. Curved septum of the nose. Chronic pharyngitis. Functional dysphonia. Focal neoplasm S2 of the right lung (4.5 mm). Chronic pyelonephritis of a single right kidney / Cyst of the right kidney. С-r of the left ureter pT1NoMo, с / п radical surgical treatment (2015)

Operation: Robot-assisted pancreatoduodenal resection.

Description of the operation: (see fig. 10)

Under endotracheal anesthesia, after treatment of the surgical field in the infraumbilical region, a trocar was inserted into the abdominal cavity, and carboxyperitoneum was imposed. Additional trocars were introduced through the standard points. The robotic complex - Da Vinci is connected. During revision: in the abdominal cavity, a pronounced adhesive process involving the greater omentum, loops of the small intestine; no effusion in the abdominal cavity, no carcinomatosis in the abdominal cavity; the gallbladder was removed earlier, in this area the adhesive process is also determined. In the projection of the head / terminal part of the common bile duct, a volumetric formation is determined, of dense consistency with instrumental palpation up to 3 cm in diameter; in the area of the lesser omentum, conglomerates of small lymph nodes are determined. Adhesiolysis with a harmonic knife; a lymphatic dissection of the hepatic-duodenal ligament was performed with the release of the portal vein and hepatic artery, the common hepatic artery has a typical structure; the common bile duct was transected in the area of the liver hilum, the edge of the cut was sent to express PGI - no tumor growth was found. A. gastro-duodenale is isolated at the base, clipped 2 + 1, crossed. The Kocher mobilization of the DPK was carried out. The large oil seal is mobilized. The omental bursa was opened through the gastrocolic ligament. The pancreas is processed along the upper and lower edges, the space between the gland and v.portae is tunneled; in the area of the isthmus, an infiltrative process is determined; signs of tumor invasion into a vein are not revealed. Pancreas was cut in the isthmus to the left of the portal vein - hemostasis by suturing, the pancreatic duct was visualized, up to 3 mm in diameter. The consistency of the gland parenchyma is soft, easily vulnerable, the diameter of the stump is up to 21-22 mm. The gland stump was mobilized for 25-27 mm. With the help of an endostepler, the stomach was cut in the area of the antrum (above the pylorus), and the jejunum was cut off with the endostepler apparatus at a distance of 10 cm from Treitz's ligament and brought to the upper floor of the abdominal cavity. The organocomplex was step-by-step separated from the portal vein with ligation and clipping of its tributaries, mobilization of the uncinate process of pancreas was performed with associated lymphadenectomy along the right semicircle of the superior mesenteric artery, invasion into a. mesenterica superior not noted. Reconstructive stage: taking into account the unexpressed pancreatic duct, soft consistency of the pancreas stump, it was decided to perform a submerged pancreatogastroanastomosis using endogastric capture of the pancreas stump. In the projection of the gland stump on the posterior wall of the stomach, a gastrotomy opening is made in the transverse direction (2) with an area of up to 1/3 of the cut area of the pancreatic stump; the anterior surface of the pancreas stump (1) is fixed with a continuous 4-0 ppm suture (3) to the proximal semicircle of the gastrotomy foramen 3 cm from the cutting edge of the gland; two sutures were applied with one Vicryl 3-0 thread on the pancreas stump like a holder at the upper and lower edges of the gland by 0.5 mm to the center, from the edge of the cut by 0.8 mm, subject to the sagging of the thread between the fixed edges, thread length 5 , 0 cm (4); through the gastrotomy opening into the abdominal cavity, the distal end of a specially prepared (with a deepened distal opening of 3 mm) gastric tube with a guidewire 5.1 mm in diameter (5) inserted through the nasal passage is inserted. The sagging thread (4) was captured in the deepened distal opening of the probe by pulling the guide wire 3-4 cm proximally and blocking the thread when it was immersed back over the thread. By smoothly pulling the gland stump into the stomach lumen by 4-5 cm and pulling the free stomach wall onto the pancreas stump (1) using anatomical atraumatic endoscopic clamps, a continuous 4-0 ppm suture is continued between the distal semicircle of the gastrotomy opening and the posterior surface of the gland along its entire length mobilization. The thread is tied with the thread of the beginning of the continuous suture fixation (3).

The first loop from the Treitz ligament of the small intestine was mobilized, a place for choledocho-enteroanastomosis was indicated, intracorporeal imposition of continuous choledocho-enteroanastomosis was performed with a 5-0 suture, 20 cm distal from the distal two-row continuous monofilament suture, gastro-entero-enteroanastomosis was also imposed.

The organocomplex was immersed in an Endobag container and removed through an extended supraumbilical approach. Installed PVC - drainage - on the right - in the subhepatic space under the hepatoduodenal ligament, the end of the drain is brought into the area of the omental bursa. Control of hemostasis - dry. The napkin count is everything. Layer-by-layer stitching of wounds. Aseptic dressing.

Operation time: from 10:10 to 14:00

Macrodrug: Organocomplex (head of the pancreas, common bile duct, duodenum with pylorus, tissue of the greater and lesser omentum with l / u).

There were no complications in the immediate and late postoperative period.

Example No. 2 Patient B. 59 years old

Diagnosis according to the International Statistical Classification of Diseases and Related Health Problems (ICD10) C24.1 Malignant neoplasm of the ampulla of the Vater papilla cT2N0M0, IB Art, after endoscopic biopsy of the OBD, endostenting of the bile ducts 12/17/2019, 2 cells. gr.

Concomitant: Hypertension 1 degree 2 stage risk 3. CHF 1 tbsp., 11 FC according to NYHA. Hyperlipidemia.

The name of the surgical intervention: Laparoscopic PDR.

Operation description:

Under endotracheal anesthesia, after processing the surgical field in the infraumbilical region, a trocar was inserted into the abdominal cavity, a carboxyperitoneum was imposed, and an Olympus video endoscopic system was connected. Additional trocars were introduced through the standard points. During revision: there is no effusion in the abdominal cavity, there is no carcinomatosis in the abdominal cavity; gallbladder 65 × 35, not tense, the wall is not thickened. In the area of the lesser omentum, conglomerates of lymph nodes from 0.7 to 1.2 cm are determined. Cholecystectomy, lymphodissection of the hepato-duodenal ligament with release of the portal vein and its own hepatic artery were performed, the common hepatic artery has a typical structure; the common bile duct is crossed above the discharge of the cystic duct in the area of the gate of the liver with the formation of a single block. A. gastro-duodenale is isolated at the base, clipped 2 + 1, crossed. The mobilization of the KDP was carried out according to Kocher. The large oil seal is mobilized. The omental bursa was opened through the gastrocolic ligament. The pancreas is processed along the upper and lower edges, the space between the gland and v.portae is tunneled; no infiltrative process was revealed in the isthmus, no signs of invasion of the duodenal tumor into the vein were found. In the area of the common hepatic artery, a pronounced infiltrative process is determined, due to the conglomerate of l / y, lymphadenectomy of the area of the common hepatic artery was performed with a separate block. Pancreas was cut in the isthmus to the left of the portal vein, its approximate diameter is up to 25 mm in the largest dimension - hemostasis by suturing, the pancreatic duct is visualized - 3 mm in diameter; the consistency of the gland parenchyma is soft, easily vulnerable. With the help of an endostepler, the stomach was cut in the area of the antrum. Also, with the help of an endostepler, the jejunum was transected at a distance of 10 cm from the Treitz's ligament; the intestinal stump was brought into the upper floor of the abdominal cavity. The organocomplex was stage-wise separated from the portal vein with ligation and clipping of its tributaries, mobilization of the uncinate process of the pancreas was performed with associated lymphadenectomy along the right semicircle of the superior mesenteric artery. No invasion of the superior mesenteric artery was noted.

Reconstructive stage: considering the unexpressed pancreatic duct, as well as the soft parenchyma ("juicy") pancreas, it was decided to perform a submerged pancreatogastroanastomosis using endogastric capture of the pancreas stump. In the projection of the gland stump, a gastrotomy opening is made in the transverse direction on the posterior wall of the stomach in diameter up to 0.7 cm; the anterior surface of the pancreas is fixed with a continuous 4-0 ppm suture to the proximal semicircle of the gastrotomy orifice 3 cm from the cutting edge of the gland; the imposition of two sutures with one Vicryl 3-0 thread on the pancreas stump was performed as a holder at the upper and lower edges of the gland 0.7 cm to the center, from the edge of the cut 1.0 cm, provided that the thread sagged between the fixed edges with a long thread to 5.0 cm; through the gastrotomy opening into the abdominal cavity, the distal end of a specially prepared (deepened by 2 mm distal opening) gastric probe with a diameter of 4.5 mm with a guidewire inserted through the nasal passage is inserted. The sagging thread was captured in the deepened distal opening of the probe by pulling the guidewire 3-4 cm proximally and blocking the thread when it was immersed back over the thread. By smoothly pulling the gland stump into the gastric lumen by 4-5 cm and pulling the free stomach wall onto the pancreas stump using anatomical atraumatic endoscopic clamps, a continuous 4-0 ppm suture was continued between the distal semicircle of the gastrotomy opening and the posterior surface of the gland throughout its mobilization. The thread is tied with the continuous suture start thread. The first loop from the Treitz ligament of the small intestine was mobilized, a place for the biliodigestive anastomosis was indicated, intracorporeal imposition of a continuous choledocho-enteroanastomosis was performed with a 5-0 suture.

The paraumbilical approach was expanded (up to 4-5 cm). The organocomplex was removed. A loop of the small intestine and a stomach stump are inserted into the wound; retreating 20 cm distal to the efferent small intestine, the postcolic formation of gastroenteroanastomosis is performed end to side. Installed PVC drainage - on the right - in the subhepatic space under the hepatoduodenal ligament, the end of the drain is brought into the area of the omental bursa. Control of hemostasis - dry. The napkin count is everything. Removed carboxyperitoneum. Layer-by-layer closure of wounds. Aseptic dressing.

Operation time: from 9:45 to 15:40

Macrodrug: 1. The head of the pancreas with a tumor, gallbladder, duodenum, distal common bile duct;

2. L / in the common hepatic artery;

Postoperative clinical diagnosis: malignant neoplasm of the ampulla of the Vater papilla cT2N0M0, IB grade, after endoscopic biopsy of the OBD, endostenting of the gastrointestinal tract 17.12. gr.

There were no complications in the immediate and late postoperative period.

Sources of scientific medical information: RU 2192794 C2, 20.11.2002. SU 1705858 A1, 15.01.1992. SU 1165375 A, 07.07.1985. RU 94041049/14 A1, 20.09.1996. RU 2123293 C1, 20.12.1998. RU 2003120993/14 A, 20.02.2005. Rospatent database wwwl.fips.ru

Danilov M.V. and other Surgery of the pancreas. - M .: Medicine, 1995, p. 413-425. WO 2004032758, 22.04.2004. TAKADA T. Duodenum-preserving total pancreatic head resection and pancreatic head resection with segmental duodenostomy. Nippon Geka Gakkai Zasshi. 2003 Jun; 104 (6): 476-80 $

V.A. Kubyshkin and other Pancreatic cancer. M., 2003, 234 RU 2195204 C2, 27.12.2002. RU 2195207 C2, 27.12.2002. RU 2007126 C1, 15.02.1994. SATO N. et all Preoperative exocrine pancrestic function predicts risk of leakage of pancreaticojejunostomy. Surgery 1998, 124 (5), 871-6.

Claims (1)

A method for the formation of pancreatogastroanastomosis during robotic-assisted and laparoscopic pancreatoduodenal resections, including gastrotomy on the posterior wall of the stomach in the transverse direction with the formation of a gastrotome opening, up to 1/3 of the cut area of the pancreatic stump, fixing the proximal semicircle of the gastrointestinal opening of the anterior wall , characterized in that the suture-holder on an atraumatic needle with an absorbable suture is applied to the stump of the pancreas at the upper and lower edges and at a distance of 0.8-1.0 cm from the edge of the cut and 0.5-0.7 cm from the upper and the lower edges towards the Wirsung duct with the sagging conditions of the thread between the fixed edges; preliminarily in the gastric silicone probe with a diameter of 4.5-5.1 mm, a depression of 2-3 mm is made in the distal opening, a silicone conductor is inserted into the gastric tube so that the latter passes through the resulting cavity and rests on the distal end of the probe, then the gastric the probe is inserted into the stomach through the nasal passage into the gastrotome opening on the back wall of the stomach, taken out into the abdominal cavity, after which the conductor is pulled in the opposite direction by 3-4 cm, freeing the recess in the probe from the conductor, into which the holder is immersed and blocked by introducing a conductor over the thread; the probe is pulled up by 4-5 cm in the proximal direction, the distal semicircle of the gastrotome opening is pulled over the posterior surface of the pancreatic stump along the entire length of its mobilized area; With a thread, which was used to sew the proximal semicircle of the gastrotome opening to the anterior surface of the pancreas, the suture is continued in the opposite direction, fixing the distal semicircle of the gastrotome opening and the posterior surface of the pancreatic stump to the beginning of fixation.

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