RU2746438C1 - Method for application of anti-reflux biliodigestive anastomosis in benign diseases of extrahepatic ducts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to hepatosurgery. After the gall bladder is separated from the bottom, a gallbladder is excised to its neck with diameter of 2.0 cm, while maintaining the integrity of the cystic duct and the cystic artery. Then the cystic duct is examined with a bougie with a bulbous probe, separated to the place of confluence of hepaticocholedochus. After mobilization of duodenum Kocher duodenotomy is performed, formed wound does not exceed diameter of neck of gallbladder. Anastomosis is formed by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the serous-muscular-submucous layer of the duodenum.

EFFECT: method enables reducing the risk of developing early and late postoperative complications, including stenosis of the developed fistula.

1 cl, 6 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, and can be used for benign diseases of the extrahepatic bile ducts.

There are many ways to apply biliodigestive anastomoses. Most often, supraduodenal choledochoduodenostomy is performed according to Jurash, Finsterer and Flerken. When imposing an anastomosis, a mandatory manipulation is the mobilization of the duodenum according to Kocher, followed by opening the common bile duct in a longitudinal incision at the edge of the duodenum. When applying an anastomosis according to Jurash, the duodenal incision is made in the transverse direction, according to Finsterer - in the longitudinal direction, according to Flerken - in the longitudinal and perpendicular to the incision in the common bile duct. Anastomosis is applied with interrupted single-row sutures with an atraumatic needle. (BA Petrov, EI Halperin. Surgery of the extrahepatic bile ducts. M .: Medicine: Medicine, 1971, p. 184). Less commonly used choledochoduodenostomy of the "end-to-side" type, among which Sterling's methods and the papillary invagination Kocher-Mamman deserve the greatest attention, as well as the invagination cuff-type method (A. A. Shalimov, 1970), the essence of which is the invagination of the common bile duct into the duodenum.

In 10-35% of operated patients in the immediate and late postoperative periods, the development of various complications is noted, such as: cicatricial strictures of anastomoses, cholestatic hepatitis, reflux cholangitis, liver cirrhosis, which significantly worsen the quality of life of patients (Shalimov A.A. et al. , "Surgery of the liver and biliary tract" 1993 p. 145). These complications are associated with the free communication of the bile ducts with the gastrointestinal tract and, as a consequence, with constant infection of bile in the extrahepatic bile ducts, and sometimes in the intrahepatic ducts. Despite the introduction of new (including minimally invasive) technologies into surgical practice, in many cases, the formation of a biliodigestive anastomosis is the only possible option for completing the surgical intervention. (Galperin EI et al., "Cicatricial strictures of the bile ducts", p. 245, 1982).

This prompts surgeons to develop and introduce into clinical practice new techniques for making areflux anastomoses between the extrahepatic bile ducts and parts of the gastrointestinal tract, which would reduce these complications.

The prototype of the proposed method is the method of suproduodenal choledochoduodenostomy according to Yurash as modified by Vinogradov. To do this, the common bile duct is opened wide enough (2.5-3 cm) with a longitudinal incision in the supraduodenal part to the transitional fold between it and the lateral edge of the intestine. According to the place where the duct was opened, a cross section of the duodenal wall is made, which is actually a continuation of the wound of the bile duct to the intestine. The anastomosis is formed through all layers of the duodenum wall and the common bile duct. Sutures are placed at a distance of 2-3 mm from each other, stitching the duct wall from the outside to the inside, and then bringing the needle out of the intestinal lumen (Sergienko V.I., "Topographic anatomy and operative surgery", p. 255, 2014) For this the way the characters are common to supraduodenal choledochoduodostomy shortcomings. In operated patients in the immediate and late postoperative periods, the development of complications characteristic of all choledochoduodenoanastomoses is noted, such as: - cicatricial strictures of anastomoses,

- cholestatic hepatitis,

- reflux - cholangitis,

- cirrhosis of the liver.

The aim of the present invention is to reduce the risk of early and late postoperative complications.

The specified technical result is achieved by the fact that after the isolation of the gallbladder "from the bottom", the gallbladder is resected to its neck with a diameter of 2.0 cm, while maintaining the integrity of the cystic duct and the cystic artery, then the cystic duct is bougiened with a bulbous probe, isolated to the place where it flows into hepaticoholedochus; after mobilization of the duodenum according to Kocher, duodenotomy is performed, the resulting wound does not exceed the diameter of the neck of the gallbladder; form an anastomosis by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the serous-muscular-submucosal layer of the duodenum.

The essence of the invention is illustrated by drawings, where:

FIG. 1 - The gallbladder is highlighted "from the bottom".

FIG. 2 - The neck of the gallbladder was left with a diameter of 2.0 cm, while maintaining the integrity of the cystic duct and cystic artery.

FIG. 3-Duodenum, mobilized according to Kocher is brought to the neck of the gallbladder.

FIG. 4 - A duodenotomy was performed, the resulting wound does not exceed the diameter of the gallbladder neck.

FIG. 5 - The posterior lip of the anastomosis is formed by the imposition of single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the edge of the dissected serous-muscular-submucosal layer of the duodenum.

FIG. 6 - Anastomosis was formed by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the edge of the dissected serous-muscular-submucosal layer of the duodenum. The sutures are placed at a distance of 2-3 mm from each other.

This method was developed on 14 mongrel dogs on the basis of the Department of Operative Surgery of the Astrakhan State Medical University, and also introduced into the clinic of the Clinical Medical Center of St. Luke in Simferopol. Below is the result of testing.

Patient E., 68 years old, operated on 08/10/19. Received 07/30/19 in HO with a diagnosis of cholelithiasis. Choledocholithiasis. Obstructive jaundice. Ultrasound examination: The liver is not enlarged, increased echogenicity; intra- and extrahepatic ducts are moderately dilated; choledoch up to 1.4 cm; in the cavity of the gallbladder, single stones up to 1.5 cm in diameter. Concrements in the common bile duct are not visualized. Endoscopic retrograde cholangiopancreatography was performed: stricture was found in the suproduodenal part of the common bile duct, the shadows of calculi were not detected. Bilirubin in the blood is 74 μmol / l. Diagnosis before surgery: gallstones. Chronic calculous cholecystitis. Cicatricial stricture of the supraduodenal part of the common bile duct. Operation: Laparotomy. Intraoperative cholecystocholangiography. Cholecystectomy leaving the gallbladder neck. Imposition of biliodigestive anastomosis. Drainage of the subhepatic space. An upper median laparotomy was performed. The gallbladder is 8 × 4 × 4 cm in size, not tense, single stones are palpable in the lumen. The cystic duct was expanded to 8 mm, the common bile duct was expanded to 1.4 cm. The gallbladder was punctured, intraoperative cholecystocholangiography was performed: in the supraduodenal part of the common bile duct for 1.5 cm, there was a narrowing of the lumen to 2 mm. Considering the diameter of the cystic duct, common bile duct, stricture of the supraduodenal common bile duct, it was decided to carry out cholecystectomy with leaving the neck of the gallbladder and applying biliodigestive anastomosis according to the proposed method. The gallbladder is isolated "from the bottom" (Fig. 1), the neck of the gallbladder with a diameter of 2.0 cm is left, while maintaining the integrity of the cystic duct and the cystic artery (Fig. 2). The cystic duct is bougienated with a bulbous probe, isolated up to the place where it flows into the hepaticoholedoch. Through the cystic duct into the hepaticoholedoch, a PVC drainage was introduced, the common bile duct was flushed, and a thorough hemostasis was performed. The neck of the gallbladder is brought to the mobilized duodenum according to Kocher (Fig. 3). Performed duodenotomy, the diameter of which is equal to the diameter of the neck of the gallbladder (Fig. 4). Formed the posterior lip of the anastomosis by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the edge of the dissected serous-muscular-submucosal layer of the duodenum (Fig. 5). Anastomosis was formed by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the edge of the dissected serous-muscular-submucosal layer of the duodenum. The sutures are placed at a distance of 2-3 mm from each other (Fig. 6). The PVC drainage was connected to the anastomosis, into the subhepatic space after sanitation. The operating wound was sutured tightly. In the postoperative period, she received complex infusion therapy, hepatoprotectors. The postoperative period was uneventful. On the 14th day, the control FGDS was performed: The OBD area was not changed. The anastomotic area is moderately edematous. The flow of bile is noted both from the anastomotic zone and, in part, from the side of the Vater's nipple. She was discharged in satisfactory condition on 08/24/19.

The proposed method is aimed at reducing the risk of early and, especially, late postoperative complications. In biliary hypertension, bile enters the path of least resistance through d. cisticus into the intestinal tract. The neck of the gallbladder also does not limit the diameter of the anastomosis, the diameter of the bile duct. With the proposed method of imposing a biliodigestive anastomosis, the created anastomosis does not participate in the cicatricial process, and therefore reduces the likelihood of stenosis to a minimum.

Claims (1)

The method of imposing an areflux biliodigestive anastomosis in benign diseases of the extrahepatic bile ducts, which consists in the formation of an anastomosis with the duodenum, characterized in that after the release of the gallbladder "from the bottom", the gallbladder is resected to its neck with a diameter of 2.0 cm while maintaining the integrity and integrity of the cystic duct the cystic artery, then the cystic duct is bougiened with a bell-shaped probe, isolated up to the place where it flows into the hepaticoholedoch; after mobilization of the duodenum according to Kocher, duodenotomy is performed, the resulting wound does not exceed the diameter of the neck of the gallbladder; form an anastomosis by imposing single-row interrupted sutures passing through the serous-muscular layer of the gallbladder neck and the serous-muscular-submucosal layer of the duodenum.

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