RU2768180C1 - Method for performing reconstructive surgery on extrahepatic bile ducts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to hepatosurgery. Anterior and posterior walls of the stomach are dissected to a mucous membrane at 1.0–2.5 cm from the lesser curvature line. Incisions are continued from both sides in the proximal length of 10–12 cm. Further, both incisions are connected to each other along a lesser curvature. Thereafter, the mucosa is sutured along the dissection line to form a tubular stalk. Stapling machine suture is peritonised with separate serous-muscular sutures. Formed stalk is brought to extrahepatic bile ducts and hepaticogastroanastomosis is formed with pre-prepared from serous-muscular layer of gastric mucosa by single-row continuous suture. Then serous-muscular layer of stomach is pulled upwards and formed fistula is closed, forming antireflux valve and fixing it to tissues of hepatoduodenal ligament.

EFFECT: method allows to maintain close to physiological processes of digestion, reducing the length of the surgical intervention, reducing postoperative complications, minimizing the risk of anastomosis leakage, enabling the endoscopic approach to the formed anastomosis.

1 cl, 1 dwg, 3 ex

Description

The invention relates to medicine, and can be used in surgical departments for reconstructive and restorative operations on the extrahepatic bile ducts.

Bile duct injury is a severe, disabling complication after cholecystectomy (Hariharan D., Psaltis E., Scholefield J., Lobo DN Quality of life and medico-legal implications following iatrogenic bile duct injuries. World J. Surg. 2017; 41 (1) : 90-9), and occurs in 0.1-1.0% of cases when performing open CE and laparoscopic - in 0.4-3.5%, then when recalculating the average frequency of injury by the number of CE performed per year, we get thousands of patients with duct injury annually.

There is a known method for the formation of hepaticoduodenoanastomosis during reconstructive surgery for post-traumatic strictures of the extrahepatic bile ducts (P.V. Markov, V.I. Onoprienko. Restoration and reconstruction of extrahepatic bile ducts with high strictures with an autograft from the small intestine of variable diameter. Surgery. 2015; 8 :29-34). The small intestine graft was formed of variable diameter at a distance of 30-40 cm from the ligament of Treitz. The intestine was crossed along the selected boundaries so as to obtain an isolated area. From the entire circumference of the intestine, the proximal part of the cut out segment of the small intestine was left. Further, by resection of the wall along the protivomesenteric edge, it was narrowed so that it retained a cylindrical shape for 6-8 cm. The distal anastomosis was formed with the duodenum at the level of the border of the middle and lower thirds of its vertical branch, while the graft was placed parallel to the vertical branch of the duodenum and connected to the latter at an acute angle to enhance the antireflux properties of the created structure. The disadvantages of this operation are:

- technical difficulties in the formation of a small bowel graft of variable diameter, associated both with resection of the antimesenteric edge and with many sutures on the intestinal wall, and with the formation of an anastomosis between the graft and the duodenum;

- formation of the graft anastomosis at the level of the vertical part of the duodenum, where there is a higher pressure than in its distal parts. In this regard, the risk of reflux of duodenal contents into the graft and intrahepatic bile ducts remains.

- this method of reconstruction involves 3 anastomoses (hepaticojejuno-, duodenojejuno- and interintestinal), which increases the risk of complications, in particular, insolvency.

A known method of hepaticojejunostomy (RF Patent 2124866, IPC A61V 17/11, 00, publ. 1999), in which a rectangular flap is cut out in the transverse direction from the wall of the small intestine, facing the base to the mesentery. The antimesenteric edge of the flap is demucosed to the submucosa for 2 mm. An end-to-end anastomosis is performed with single-row microsutures. The antimesenteric edge of the flap is sutured along the circumference of the common hepatic duct. The connective layer of the duct and the serous-muscular case with the submucosa of the jejunum are captured in the seam at the site of demucosation. The tube is formed by suturing the lateral edges of the jejunal flap with two rows of sutures. The first row captures the submucosa. The second row captures the serous-muscular case end-to-end.

The disadvantages of this method of hepaticojejunostomy are:

- use for hepaticojejunostomy of the small intestine according to Roux, turns off a segment 60-80 cm long from digestion.

- the flow of bile through the formed hepaticojejunal fistula into the small intestine, excludes its participation in the duodenal phase of digestion.

- the formation of a flap from the wall of the small intestine for hepaticojejunoanastomosis technically complicates the operation, increasing the risk of its failure.

The closest is a method for treating diseases and traumatic injuries of the extrahepatic bile ducts, including revision of the subhepatic space, making an incision on the stomach in the immediate vicinity of the lesser curvature, creating an anastomosis between the bile ducts and the gastrointestinal tract (Filizhanko V.N., Lobakov A. I., Sidorenko A.B. A method of reconstructive surgery on the extrahepatic bile ducts with the formation of an access for minimally invasive interventions. Almanac of Clinical Medicine. 2014. No. 33. P. 77-80). To form an anastomosis on the stomach, in its middle third, in close proximity to the lesser curvature, a 3–4 cm long incision is made. In this case, the distal end of the internal drainage is brought out through the opening of the gastrojejunostomy into the stomach cavity.

The disadvantages of this operation are:

- to perform this method of reconstruction from digestion, a longer than usual loop of the small intestine, about 90 cm, is turned off;

- three anastomoses are formed (hepaticojejuno-, gastrojejuno- and inter-intestinal), which increases the risk of their failure;

- conditions are created for the development of bacterial overgrowth syndrome (SIBO) of the small intestine, which is typical for Ru-loop.

- there is a risk of reflux into the intrahepatic bile ducts with the development of cholangitis, both through the Ru-loop, and aggressive gastric contents through gastrojejunostomy.

The objective of the invention is to eliminate these shortcomings, increase the efficiency of surgical treatment of patients with post-traumatic strictures of the extrahepatic bile ducts, maintain digestion processes close to physiological, reduce the risk of postoperative complications, and provide the possibility of endoscopic access to the area of the formed anastomosis.

To solve the problem when performing a reconstructive operation on the extrahepatic bile ducts, including revision of the subhepatic space, making an incision on the stomach in the immediate vicinity of the lesser curvature, creating an anastomosis between the bile ducts and the gastrointestinal tract, it was proposed to dissect the anterior and posterior walls of the stomach to the mucosa at a distance of 1.0-2.5 cm from the line of lesser curvature. At the same time, the incisions are continued from both sides proximally with a length of 10-12 cm, and then both incisions are connected to each other along the lesser curvature. After that, along the dissection line, the mucosa is stitched with a hardware suture, forming a tubular stem. Next, the staple hardware suture is peritonized with separate serous-muscular sutures, after which the formed stalk is brought to the extrahepatic bile ducts and a hepaticogastroanastomosis is formed with a single-row continuous suture previously dissected from the serous-muscular layer of the gastric mucosa. Then the serous-muscular layer of the stomach is pulled up and the formed fistula is closed, forming an antireflux valve and fixing it to the tissues of the hepatoduodenal ligament.

The advantage of this method of restorative and reconstructive-restorative intervention in

post-traumatic strictures of the bile ducts, in comparison with the known ones, are:

- the presence of only one hepaticogastric anastomosis minimizes the risk of postoperative complications.

- close to the physiological flow of bile into the stomach.

- ensuring the passage of bile through the duodenum and the duodenal phase of digestion.

- preservation of the anatomical dimensions of the small intestine (the Roux-loop is not used for the formation of hepaticojejunostomy, the prevention of bacterial overgrowth syndrome (SIBO) of the small intestine) and, accordingly, the processes of absorption of food nutrients are not disturbed.

- endoscopic access to hepaticogastroanastomosis for the purpose of its dynamic assessment, and, if necessary, performing various corrective endoscopic interventions in the anastomosis zone with stricture of the latter (balloon dilatation, stenting, nasobiliary drainage in obstructive jaundice).

- the possibility of performing cholangiography through nasobiliary drainage.

- nasogastric sounding of the stomach after surgery allows you to control the functioning of the hepaticogastroanastomosis (the flow of bile through the probe).

- no need for adhesiolysis, which happens during the formation of the Ru-loop during the adhesive process in the abdominal cavity.

- Reducing the time of surgery.

The drawing shows a diagram of the operation, where 1 - tubular stem, 2 - serous-muscular suture on the lesser curvature of the stomach, 3 - hepaticogastroanastomosis, 4 - mouth of the gastric stalk.

The method is carried out as follows.

After isolating the stump of the common hepatic duct from the scar tissues and excising its edge to the unchanged walls, from the lesser curvature of the stomach, a tubular stem 1 is formed by dissecting the stomach wall to the mucous membrane at a distance of 1.0-2.5 cm from the line of lesser curvature along the anterior and posterior walls. The incision continues on both sides proximally up to 10-12 cm long, then both incisions are connected to each other along the lesser curvature. Then a hardware suture of the mucosa is made, the mucosa is dissected between the stapled sutures. Thus, a tubular gastric flap is formed, the inner diameter of which is about 1.0-2.5 mm. The exposed gastric mucosa along the lesser curvature of the stomach and the formed gastric flap is covered by applying separate serous-muscular sutures 2 with atraumatic thread 3.0. The blood supply of the formed tubular gastric flap is carried out by the right gastric artery.

Then the formed tubular gastric flap is brought to the stump of the common hepatic duct and an anastomosis is formed with the gastric mucosa previously dissected from the serous-muscular layer, separate atraumatic sutures 4.0. After that, the serous-muscular layer of the stomach, pulling up, closes the formed fistula and is fixed to the scar tissues of the hepatoduodenal ligament, thus, the hepaticogastroanastomosis is finally formed 3.

The mouth of the tubular gastric stalk 4 is located at a distance of 3-5 cm from the pylorus and turned towards it, along the course of peristalsis, which enhances its antireflux properties, minimizing the risk of reflux of gastric contents into the area of the hepaticogastric anastomosis.

Example 1

Patient K., aged 36, was admitted for treatment to the Clinic with a diagnosis of post-traumatic extended strigsture of the common hepatic duct. Complete external biliary fistula. Condition after PTCS in 2020. The diagnosis was confirmed clinically by MRI, endoscopy of the stomach and duodenum, fistulocholangioscopy. Operation: Laparotomy, hepaticogastrostomy using a tubular gastric stalk. The anterior and posterior walls of the stomach were dissected to the mucosa at a distance of 2.5 cm from the line of lesser curvature 10 cm long, after that, along the dissection line, the mucosa was sutured with a hardware suture, a tubular stalk was formed, which was then brought to the extrahepatic bile ducts and hepaticogastroanastomosis was performed.

The postoperative period proceeded without complications. Ultrasound control on the 7th day: no free fluid was found in the area of the formed anastomosis. She was discharged on the 10th day after the operation in a satisfactory condition.

Example 2

Patient D., aged 45, was admitted for treatment at the Clinic with a diagnosis of post-traumatic extended stricture of the common hepatic duct. Complete external biliary fistula. Condition after PTCS in 2020. The diagnosis was confirmed clinically by MRI, endoscopy of the stomach and duodenum, fistulocholangioscopy. Operation: Laparotomy, hepaticogastrostomy using a tubular gastric stalk. The anterior and posterior walls of the stomach were dissected to the mucosa at a distance of 2.0 cm from the line of lesser curvature 12 cm long, after that, along the dissection line, the mucosa was sutured with a hardware suture, a tubular stalk was formed, which was then brought to the extrahepatic bile ducts and hepaticogastroanastomosis was performed.

The postoperative period proceeded without complications. Ultrasound control on the 8th day: no free fluid was found in the area of the formed anastomosis. She was discharged on the 11th day after the operation in a satisfactory condition.

Example 3

Patient D., aged 47, was admitted for treatment to the Clinic with a diagnosis of post-traumatic stricture of the common hepatic duct. Complete external biliary fistula. Condition after PTCS in 2020. The diagnosis was confirmed clinically by MRI, endoscopy of the stomach and duodenum, fistulocholangioscopy. Operation: Laparotomy, hepaticogastrostomy using a tubular gastric stalk. The anterior and posterior walls of the stomach were dissected to the mucosa at a distance of 1.0 cm from the line of lesser curvature 11 cm long, after that, along the dissection line, the mucosa was sutured with a hardware suture, a tubular stalk was formed, which was then brought to the extrahepatic bile ducts and hepaticogastroanastomosis was performed.

The postoperative period proceeded without complications. Ultrasound control on the 7th day: no free fluid was found in the area of the formed anastomosis. Discharged on the 9th day after the operation.

According to the proposed method, 9 operations were performed on patients with post-traumatic strictures of the extrahepatic bile ducts with satisfactory immediate and long-term results.

The method is distinguished by ease of performing hepaticogastroanastomosis, reduction of postoperative trauma and time of surgical intervention, minimization of the risk of anastomosis failure and its endoscopically controlled functioning in the postoperative period.

Claims (1)

A method for performing a reconstructive operation on the extrahepatic bile ducts, including revision of the subhepatic space, making an incision on the stomach at the lesser curvature, creating an anastomosis between the biliary tract and the gastrointestinal tract, characterized in that the anterior and posterior walls of the stomach are dissected to the mucous membrane at a distance 1.0-2.5 cm from the line of lesser curvature, the incisions are continued on both sides proximally with a length of 10-12 cm, then both incisions are connected to each other along the lesser curvature, after that, along the dissection line, the mucosa is stitched with a hardware suture, forming a tubular stalk, then the staple hardware suture is peritonized with separate serous-muscular sutures, after that the formed stalk is brought to the extrahepatic bile ducts and a hepaticogastroanastomosis is formed with a single-row continuous suture pre-dissected from the serous-muscular layer of the gastric mucosa, then the serous-muscular layer of the stomach is pulled up and closed formed fistula, forming an antireflux valve and fixing it to the tissues of the hepatoduodenal ligament.

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