RU2800103C1 - Method of anti-migration fundoplication cuff for hernia of the esophageal opening of the diaphragm - Google Patents

Abstract

FIELD: medicine; surgery; gastroenterology.

SUBSTANCE: complete circular fundoplication cuff is performed. A "window" is formed into the omental sac through the lesser omentum due to partial skeletonization of the stomach along the lesser curvature between the posterior trunk of the vagus nerve in the subcardial region 2 cm above and below the cardia under the control of the anterior and posterior trunk of the vagus nerve. Partial selective proximal vagotomy is performed by crossing the vessels and nerves passing between the posterior vagus nerve trunk and the wall of the lower third of the esophagus, the subcardial part of the lesser curvature of the stomach, while excluding the posterior vagus nerve trunk from entering the cuff and slipping the cuff. The His angle is formed under the control of intraoperative video esophagogastroscopy. Interrupted sutures are placed between the left wall of the esophagus and the fundus of the stomach.

EFFECT: method provides prevention of postoperative complications associated with cuff slippage and torsion of the esophagus, eliminates damage to the posterior vagus nerve trunk and restores the physiological valvular mechanism of the cardia, improves the patients’ quality of life.

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Description

The invention relates to medicine, namely to surgery, and can be used to treat patients with hiatal hernia.

POD (esophageal opening of the diaphragm) hernias remain the most urgent problem of modern surgery and occupy the 3rd place in the structure of the pathology of the gastrointestinal tract.

An important role in the treatment of subcutaneous hernias is given to conservative therapy, which is aimed at eliminating the symptoms of reflux disease, preventing complications associated with it, and includes not only drug therapy, but also lifestyle changes and diet therapy. However, conservative therapy is not always effective, requires a long course of treatment, and does not affect the pathogenesis of gastroesophageal reflux disease.

In the absence of the effect of conservative therapy, surgical treatment is performed.

The most common operation for pod hernias is the Nissen operation, which, with the development of laparoscopic surgery, has become widespread and has undergone a number of modifications.

The technique of the well-known Nissen operation is as follows.

Upper median laparotomy is performed. The left triangular ligament of the liver is dissected. The stomach is removed from the peritoneal cavity and stretched. Dissect the upper half of the lesser omentum. The fundus of the stomach is partially mobilized, for which it is necessary to ligate 1-2 short gastric arteries passing in the gastrosplenic ligament. The esophagus is isolated from the surrounding tissues and taken on a holder. Sew the legs of the diaphragm. The bottom of the stomach, like a cuff, envelops the esophagus. With several sutures that capture the esophagus, the walls of the stomach are fixed around the esophagus. The cuff is formed on a thick gastric tube.

In practice, there are the most common mistakes in the Nissen fundoplication. For example, fixation of the stomach to the diaphragm and to other organs, insufficient mobilization of the fundus of the stomach, when forming the cuff, the wall of the esophagus is not taken into the suture, which leads to straightening and (or) slipping of the cuff. (Hiatal hernia. Author Puchkov K.V., Filimonov V.B., Medpraktika-M, 2003).

The disadvantage of these methods is a high percentage of relapses, up to 20-30% according to different authors, associated with slippage of the fundoplication cuff, the development of dysphagia, technical errors in the formation of the fundoplication, damage to the vagus nerve.

The Toupet and Dor technique is known, which consists in the fact that the esophagus is not completely wrapped, but the fundus of the stomach is partially displaced anterior to the esophagus (Dor) or backwards (Toupet). Toupet proposed to form a fold of the fundus of the stomach not for the entire circumference, but for 180°, corrugating it mainly along the back surface. Later, a technique for forming a fold along a circumference of up to 270° was presented. Studies have shown that this technique does indeed reduce the incidence of postoperative dysphagia.

Indications for fundoplication according to Toupet and Dor occur during surgery, when a pronounced cicatricial or adhesive process is detected in the space behind the esophagus, which is a technical obstacle to sufficient mobilization of the gastroesophageal junction and performing posterior partial fundoplication according to Toupet. (hernia of the esophageal opening of the diaphragm, K.V. Puchkov, V.B. Filimonov, p. 101).

The disadvantages of the Toupet fundoplication is that it results in poorer anti-reflex properties compared to the circular cuff. Dor fundoplication also has poorer anti-reflex properties and is most commonly used after serotomy for achalasia.

https://meduniver.com/Medical/Xirurgia/metodi_fundoplikacii.html

Gil's gastropexy involves suturing the lesser curvature of the stomach to the preaortic fascia, which provides secure fixation of the esophagus in the intra-abdominal position, but neither the angle of His nor the lower esophageal sphincter is created.

In the scientific journal "Advances in Modern Natural Science" (2015, No. 1 pp. 370-372) in the article Surgical method for the complete cure of GERD, the authors Zalevsky A.A., Gorbunov N.S. et al. investigate the issue of restoring the angle of His by suturing the fundus of the stomach with the esophagus under or above the diaphragm, analyze the shortcomings and failures of surgical intervention.

The prototypes are the most commonly used variants of antireflux operations: fundoplication by Nissen (Nissen), Toupet and Dor, gastropexy by Hill (Hill).

All modern antireflux surgical interventions pursue the following goals:

1) Functional - getting rid of the symptoms of gastroesophageal reflux disease while maintaining a normal (usual for each person) diet, drinking and, if necessary, belching and vomiting.

2) Anatomical - restoration of the physiological valve mechanism of the cardia. Includes:

- fixation of the distal esophagus in the intra-abdominal position,

- reconstruction of the acute angle of His,

- increased tone of the lower esophageal sphincter.

At the same time, all the problems associated with similar surgical interventions have not been resolved.

The technical result of the invention is the prevention of complications associated with slippage of the cuff and torsion of the esophagus, the exclusion of damage to the posterior trunk of the vagus nerve and the restoration of the angle of His.

A method is proposed for an anti-migration fundoplication cuff for hernias of the esophageal opening of the diaphragm, which includes surgical intervention using laparoscopic technique, for which 5 incisions are made on the anterior abdominal wall for the installation of trocars, trocars are installed for the introduction of a laparoscope and instruments, the left lobe of the liver is retracted, the esophageal-phrenic ligament is crossed, and the abdominal esophagus is mobilized.

The difference is that a complete circular fundoplication cuff is performed with passing the posterior half of the cuff through the formed “window” into the omental bag by performing posterior selective proximal vagotomy by crossing the vessels and nerves passing between the posterior trunk of the vagus nerve and the wall of the lower third of the esophagus, the subcardial part of the lesser curvature of the stomach, while excluding the posterior trunk of the vagus from entering the cuff. nerve and slippage of the cuff, in addition, form the angle of His under the control of intraoperative video esophagogastroscopy, impose one or two interrupted sutures between the right wall of the esophagus and the fundus of the stomach.

The essence of the proposed method is shown in Fig. 1 and FIG. 2, where the esophagus is labeled 1, the stomach is 2, the anterior vagus nerve is 3, the formed angle of His is 4, the posterior vagus nerve is 5, the crura of the diaphragm is 6, and the fundoplication cuff is 7.

In FIG. 1 shows the stage of mobilization, the beginning of the formation of the angle of His, the imposition of a leading suture between the stomach and esophagus. In FIG. 2 shows the final stage of the operation, the formed fundoplication cuff.

Access for fundoplication is performed according to the principle of vagotomy. Mobilization of the lesser curvature of the stomach begins with the esophagus and continues down. The stomach after dissection of the adhesions is lowered into the abdominal cavity. The esophagus is mobilized 6 cm above the cardia. Formation of a “window” into the omental sac through the lesser omentum due to partial skeletonization of the stomach along the lesser curvature between the posterior trunk of the vagus nerve in the subcardial region 2 cm above and below the cardia under the control of the anterior and posterior trunk of the vagus nerve (partial posterior selective prosimal vagotomy). The esophagus is mobilized. Through the formed "window" they gain access to the omental sac, dissect the fundo-diaphragmatic ligament under the esophagus, clip short vessels, and maintain the tension of the structures in the area of surgical intervention.

A complete circular fundoplication is performed with 3 interrupted sutures with fixation to the esophagus: the posterior half of the cuff is held in the formed "window" of the lesser omentum between the posterior trunk of the vagus nerve and the lesser curvature of the stomach, the distal part of the esophagus. (Fig. 1)

The presented method differs in that the posterior half of the cuff of a complete circular fundoplication cuff is passed through the formed “window” into the omental bag by performing a posterior selective proximal vagotomy by crossing the vessels and nerves passing between the posterior trunk of the vagus nerve and the wall of the lower third of the esophagus, the subcardial part of the lesser curvature of the stomach, while excluding entry into the cuff of the posterior trunk of the vagus nerve and slippage of the cuff. In addition, the angle of His is formed by applying one or two interrupted sutures between the right wall of the esophagus and the fundus of the stomach under the control of intraoperative video esophagogastroscopy with visualization of the border between the esophagus and stomach. (Fig. 1) One, two, three interrupted sutures, their number is determined by the anatomical features during the operation, but two sutures are always enough for the correct formation of the angle of His. When applying two interrupted sutures, they are placed at a distance of 1 cm from each other. Tying interrupted sutures ensures reliable convergence of muscle fibers and the correct formation of the His angle. The formation of nodal sutures is carried out with strict observance of the requirements for tying knots, depending on the suture material used, without pulling the knot. Use knotted suture. Since in this case a better restoration of the His angle is obtained.

When selecting suture material, preference is given to suture materials with biocompatibility. Biocompatibility in this case means the absence of an allergenic, teratogenic and toxic effect. Preference is given to thin non-absorbable synthetic threads.

Advantages: the migration of the fundoplication cuff is excluded, leading to the “telescope” symptom with dysphagia, the posterior trunk of the vagus nerve is not damaged and not compressed, the twisting of the esophagus leading to dysphagia is excluded, the angle of His formed in this way eliminates a technical error due to the imposition of an interrupted suture between the esophagus and stomach under the control of intraoperative video esophagogastroscopy to form the angle of His with visualization of the border between the esophagus om and stomach (without EGDS it can be difficult to determine this border in the presence of a hernia) overlaying a fundoplication cuff on the body of the stomach. In addition, getting into the cuff of the posterior trunk of the vagus nerve and slipping of the cuff is excluded.

Example:

Patient K, 57 years old, was hospitalized with complaints of pain in the epigastrium after eating, constant heartburn, aggravated by work in an incline, and belching with air. From the anamnesis it is known the duration of the disease for 6 years, when heartburn first began to bother after eating, there was pain in the epigastrium. An outpatient examination revealed a hernia of the POD. Conservative therapy was carried out by a gastroenterologist with a moderate positive effect for 5 years. Further therapy for a year without effect, the symptoms intensified. Hospitalized for planned surgical treatment.

Diagnosis: Hernia of the esophageal opening of the diaphragm type 3. GERD. Reflux esophagitis 3 tbsp.

After the necessary examinations, the patient was transported to the operating room. A pneumoperitoneum was placed under the ETN at the upper paraumbilical point. Trocars were inserted into the standard points. The stomach is of normal size, the pyloroduodenal zone is not externally changed. The revision revealed a mixed hernia of the esophageal opening of the diaphragm 7×8 cm containing the cardiac section and 1/3 of the body of the stomach. The stomach after dissection of the adhesions was brought down into the abdominal cavity. The esophagus was mobilized 6 cm above the cardia. Formation of a “window” into the omental sac through the lesser omentum due to partial skeletonization of the stomach along the lesser curvature between the posterior trunk of the vagus nerve and the wall of the stomach and esophagus in the subcardial region 2 cm above and below the cardia under the control of the anterior and posterior trunk of the vagus nerve (partial posterior selective prosimal vagotomy). The stomach was mobilized along the greater curvature with the intersection of short gastric vessels. The legs of the diaphragm were isolated without signs of atrophy. POD dimensions 5×5 cm, posterior crurorrhaphy was performed with 2 interrupted sutures. Excised hernial sac. An angle of His was formed with fixation of the fundus of the stomach to the left side wall of the esophagus under the control of video esophagogastroscopy with visualization of the border between the esophagus and stomach. A complete circular fundoplication was performed with 3 interrupted sutures with fixation to the esophagus: the posterior half of the cuff was placed in the formed "window" of the lesser omentum between the posterior trunk of the vagus nerve and the lesser curvature of the stomach. Hemostasis control. Removed trocars. Stitches on the wound.

The p/o period proceeded without complications. On the first day of activation of the patient, it is allowed to drink. Food is allowed on the 2nd day. On the 5th day, the patient was discharged for outpatient treatment. X-ray control was carried out.

Thus, 20 operations were performed in the clinical hospital in patients with hernias of the esophageal opening of the diaphragm. Complications were not observed. The technical result associated with the prevention of complications associated with slippage of the cuff and torsion of the esophagus has been confirmed in practice. The technology of the operation excludes damage to the posterior trunk of the vagus nerve.

Claims (2)

A method for an anti-migration fundoplication cuff for hernias of the esophageal opening of the diaphragm, which includes surgical intervention using laparoscopic techniques, for which 5 incisions are made on the anterior abdominal wall for the installation of trocars, trocars are installed for the introduction of a laparoscope and instruments, the left lobe of the liver is retracted, the esophageal-phrenic ligament is crossed, and the abdominal esophagus is mobilized, characterized in that a full circular is performed a “window” into the omental sac through the lesser omentum due to partial skeletonization of the stomach along the lesser curvature between the posterior trunk of the vagus nerve in the subcardial region 2 cm above and below the cardia under the control of the anterior and posterior trunk of the vagus nerve, performing a partial selective proximal vagotomy due to the intersection of the vessels and nerves passing between the posterior trunk of the vagus giving nerve and the wall of the lower third of the esophagus, the subcardial part of the lesser curvature of the stomach, while excluding the posterior trunk of the vagus nerve from getting into the cuff and slipping of the cuff, in addition, the angle of His is formed under the control of intraoperative video esophagogastroscopy, interrupted sutures are applied between the left wall of the esophagus and the fundus of the stomach.