RU2804730C1 - Method of forming hepaticojejunostomy - Google Patents

Abstract

FIELD: medicine; hepatobiliary surgery.

SUBSTANCE: before the formation of the posterior wall of the anastomosis on the side walls of the bile duct and the loops of the small intestine, "hold" sutures are applied. When forming the posterior wall of the anastomosis, single precision interrupted sutures are applied, the knots of which are tied inside the lumen, all the ligatures are cut off except for one of them. Then, at a distance of 10–12 cm from the anastomosis, a hole is formed in the wall of the efferent intestine, through which a drainage tube is inserted into the lumen of the bile ducts and fixed with the ends of the left ligature. The anterior wall of the anastomosis is sutured with a continuous twisting suture, while the knot is left outside the lumen of the anastomosis, after which the “hold” sutures are removed.

EFFECT: possibility to form a hepaticojejunostomy when performing reconstructive operations on the extrahepatic bile ducts in case of their damage, while avoiding the rotation of the walls of the common hepatic duct and their trauma, ensuring reliable fixation of the drainage in the bile duct, preventing its dislocation into the intestinal lumen; the method is technically simple.

1 cl, 3 dwg, 1 ex

Description

The present invention relates to the field of medicine, namely to hepatobiliary surgery.

It is known that one of the most difficult problems of hepatobiliary surgery is reconstructive surgery of the extrahepatic biliary tract. In case of damage to the bile ducts, the incidence of complications after reconstructive operations reaches 48%, failure of biliodigestive anastomosis occurs in 42-65% (Kurbonov, K.M. Failure of sutures of biliodigestive anastomosis / K.M. Kurbonov, N.M. Daminova, D.A Abdulloev // Ann. Surgeon Hepatol. - 2009. - No. 14. - P. 36-40). In the long-term postoperative period, cicatricial strictures of hepaticojejunostomy occur in 8.4-28.3% of cases (Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy / S.C. Schmidt [et al.] // Surgery. - 2004. - Vol. 135, N 6. - P. 613-618), and long-term unsatisfactory results reach 38% (Features of treatment of hepaticojejunostomy stenosis / Chikaev V.F., Mingazetdinov M.A., Sharafislamov I.F., Bondarev Yu. V., Petukhov D.M., Bukushkina V.A. // Bulletin of modern clinical medicine. 2020. T. 13. No. 5. P. 85-89).

There are various methods for forming hepaticojejunostomy.

A well-known method involves the formation of terminolateral hepaticojejunostomy on a switched-off loop of jejunum according to Roux using hepaticodigestive transhepatic drainage. Before the formation of the biliodigestive anastomosis, a transhepatic drainage tube is carried out, then the loop of the small intestine is disconnected along Roux and the formation of a hepaticojejunostomy is started at 4-5 cm from the blind end of the intestine, the wall of which is sutured with interrupted serous-muscular sutures to the scar tissue of the posterolateral wall of the duct on the left and right. Then they begin to form the posterior semicircle of the anastomosis - interrupted sutures are placed through all layers of the wall of the duct and intestine without capturing its mucous membrane. To do this, use 4-0 monofilament; the seams are not tied, but held on holders. 10-15 cm distal to the anastomosis, a purse-string suture is placed on the wall of the outlet loop of the intestine, in the center of which a small hole is made through which the intestinal end of the transhepatic drainage is passed, after which the purse-string suture on the outlet tube is tightened. Next, all the sutures are tied on the posterior semicircle of the anastomosis and the anterior semicircle of the anastomosis is formed with separate interrupted sutures. After the formation of the anastomosis, both ends of the transhepatic drainage tube are brought to the lateral surface of the abdominal wall (Pozdnyakov B.V., Fundamentals of operative surgery of the extrahepatic biliary tract: A guide for postgraduate professional training of doctors / B.V. Pozdnyakov, E.M. Trunin, V. B. Pozdnyakov - St. Petersburg: ELBI-SPb, 2011. - pp. 349-353).

The disadvantages of this method include the traumatic nature due to damage to the liver parenchyma and the walls of the bile ducts during transhepatic drainage, as well as the labor intensity and significant time costs of its implementation.

In addition, the duration of frame drainage is at least 2 years and the need to replace transhepatic drainage 3-6 times a year significantly reduces the quality of life of patients and creates conditions for the development of chronic cholangitis.

The closest in technical essence to the proposed one is a method of forming a hepaticojejunostomy, including laparotomy, revision of the hepatic hilum, isolation of the common hepatic duct and lobar ducts, bringing a loop of the small intestine to the hepatic hilum, switched off according to Roux, application of single interrupted sutures through the walls of the hepatic duct and small intestine initially along the posterior and then along the anterior wall of the anastomosis.

The known method is carried out as follows. The isolated loop of jejunum is brought along Roux to the isolated common hepatic duct, placing the “blind” end of the intestine on the left. An anastomosis is formed 4-5 cm from it with a single-row interrupted suture through all layers of the wall of the duct and intestine (without capturing its mucous membrane). The distance between the seams is 3 mm. In this case, sutures are first placed on the posterior and then on the anterior semicircle of the anastomosis (with the nodes facing outward). The intestinal wall in the anastomosis zone is additionally sutured to the scar tissue on the lower surface of the liver with interrupted sutures (Pozdnyakov B.V. Fundamentals of operative surgery of the extrahepatic biliary tract: A guide for postgraduate professional training of doctors / B.V. Pozdnyakov, E.M. Trunin, V. B. Pozdnyakov - St. Petersburg: ELBI-SPb, 2011. - pp. 344-347).

The disadvantages of this known method include its limited use in cases of high damage to the bile ducts, since the intestine, brought high to the gates of the liver, inherently interferes with the clear placement of each interrupted suture, which can cause anastomotic failure.

Also, tying a knot outside the lumen of the anastomosis, when forming its posterior wall, requires rotation of the stitched edges, which is not always possible with a short segment of the bile duct and often leads to its unnecessary trauma, as well as to the cutting of sutures.

The objective of the proposed technical solution is to develop a method for applying hepaticojejunostomy in case of damage to the extrahepatic bile ducts during cholecystectomy.

The technical result of the proposed method is to ensure reliable fixation and precision comparison of the stitched segments, simplify the formation of the posterior wall of the anastomosis, and also provide biliary decompression.

The technical result of the proposed method includes laparotomy, revision of the hepatic hilum, isolation of the common hepatic duct and lobar ducts, bringing a loop of the small intestine to the hepatic hilum, switched off according to Roux, placement of single interrupted sutures through the walls of the hepatic duct and small intestine, initially along the back, and then along the anterior wall of the anastomosis.

The main difference of the proposed method is that before forming the posterior wall of the anastomosis, “holding” sutures are applied to the side walls of the bile duct and the loops of the small intestine.

Distinctive techniques of the claimed method also lie in the fact that when forming the posterior wall of the anastomosis, single precision sutures are applied, the knots of which are tied inside the lumen. The ligatures of these sutures are cut off except for one, which is used to fix the drainage tube in the lumen of the bile duct.

The difference also lies in the fact that at a distance of 10-12 cm from the anastomosis, a hole is formed in the wall of the outlet intestine through which a drainage tube is inserted into the lumen of the bile ducts and fixed with the ends of the left ligature.

A distinctive technique of the proposed method is that the anterior wall of the anastomosis is sutured with a continuous enveloping suture, while the knot is left outside the lumen of the anastomosis, after which the “holding” sutures are removed.

The authors of the proposed method are not aware of the use of the proposed techniques for the formation of hepaticojejunostomy in case of damage to the extrahepatic bile ducts during cholecystectomy.

A comparative analysis with the prototype showed that the proposed method differs from the known method in the above methods and, therefore, meets the “novelty” criterion of the invention.

The authors of the proposed method have established the advantages of the proposed method over the known ones, which is that:

- the application of “holding” sutures before forming the posterior wall of the anastomosis on the side walls of the bile duct and loops of the small intestine provides both ease of operation and simplification of the formation of the posterior wall of the anastomosis, as well as bringing the stitched segments closer together, their reliable fixation and precision comparison, which, in in turn, prevents the failure of the anastomosis and the formation of its stricture;

- the application of single precision interrupted sutures with knots inward when forming the posterior wall avoids rotation and additional tension of the stitched segments, which also contributes to precision comparison of layers with minimal trauma;

- by cutting the ligatures of single precision interrupted sutures along the posterior wall of the anastomosis, good visualization is achieved, the risk of tangling and piling up of threads is reduced;

- fixing the biliary drainage tube with one of the ligatures on the posterior wall of the anastomosis allows you to securely and conveniently fix it in the anastomosis area, which ensures constant decompression and reduces the load on the sutures, thereby reducing the likelihood of their cutting through, and also provides the possibility of sanitation of the bile ducts in case of cholangitis and implementation of x-ray control (according to indications);

- suturing the anterior wall of the anastomosis with a continuous encircling suture significantly simplifies the implementation of the proposed method, allowing to reduce time costs, as well as evenly distribute the load on the sutures, reducing the risk of cutting through the threads.

The above allows us to conclude that the technical solution meets the “inventive step” criterion.

The method constituting the claimed invention is intended for use in healthcare. The possibility of its implementation is confirmed by the methods described in the application. The inventive method expands the capabilities of surgical intervention techniques when performing reconstructive operations on extrahepatic bile ducts when they are damaged. From the foregoing it follows that the claimed invention meets the patentability condition of “industrial applicability”.

The inventive method of forming hepaticoenteroanastomosis is illustrated in figures 1-3, which reflect the stages of its formation.

So, in FIG. Figure 1 shows the stage of suturing when forming the posterior wall of the anastomosis; Fig. 2 - fixation of the Felker drainage to the formed posterior wall of the anastomosis, in Fig. 3 - application of a continuous suture when forming the anterior wall of the anastomosis, where: 1 - preserved proximal part of the common hepatic duct (CHD), 2 - loop of the small intestine disconnected according to Roux, 3 - “holding” sutures, 4 - posterior wall of the anastomosis, 5 - single precision interrupted sutures, 6 - single precision interrupted suture with a ligature left in place, 7 - drainage tube, 8 - anterior wall of the anastomosis, 9 - continuous wrapping suture.

The proposed method of forming hepaticoenteroanastomosis is carried out as follows: after performing laparotomy, the portal of the liver is inspected, the preserved proximal part of the common hepatic duct 1 (Fig. 1-3) and the lobar ducts are isolated. The afferent vessels of the hepatoduodenal ligament are visualized. A loop of small intestine 2, switched off according to Roux, is brought to the gate of the liver (Fig. 1-3). Then, “holding” sutures 3 are applied to the side walls of the bile duct and the antimesenteric edge of the small intestine (Fig. 1-3). Hepatico-enteroanastomosis begins to be formed from the posterior wall 4, applying single precision interrupted sutures 5. An atraumatic, monofilament absorbable thread with a diameter of 5/0-6/0 is used as the suture material, depending on the diameter of the bile duct. In this case, the ligature knots of these sutures 5 are tied inside the lumen (Fig. 1). The ends of these ligatures are cut off. Along the posterior wall of the anastomosis, the ends of one of the ligatures 6 (Fig. 2) are not cut off. Next, at a distance of 10-12 cm from the anastomosis, a hole is formed in the wall of the outlet intestine, through which a drainage tube is inserted into the lumen of the bile ducts, which is fixed with the ends of the left ligature 6 (Fig. 2). After this, the anterior wall of the anastomosis is sutured with a continuous entwining suture 9 (Fig. 3), the knot of which is tied from the outside.

The proposed method is illustrated by an example of a specific implementation. Patient V., 31 years old, was hospitalized at the clinic with complaints of the presence of drainages in the right lateral area, pain in the paradrainage area and right hypochondrium, and constant flow of bile through the drainages. From the anamnesis it was established that the patient in one of the private clinics of the city a month ago underwent laparoscopic cholecystectomy for acute calculous cholecystitis. She was discharged on the second day after surgery. Two days later, the patient noted the appearance of yellowness of the skin and visible mucous membranes, darkening of the urine, which is why she returned to the hospital again, where a cholecystectomy was performed. To clarify the diagnosis, MRI cholangiopancreatography was performed, which revealed damage to the hepaticocholedochus. A week after the initial operation, the patient in the same clinic underwent a repeat subcostal laparotomy, hepaticocholedochostomy on a Kera drain, and a trap drain was installed in the subhepatic space on the right. From the first day after the operation, bile flowed through both drainages, a total of about 300-400 ml per day. On the fourth day, the patient was discharged from the clinic with drainage. For a month, the patient was observed by the operating surgeon, and dressings were performed. Given the lack of dynamics during observation and treatment, the patient went to the regional hospital.

Upon admission, the general condition is moderate, stable, consciousness is clear, the skin and visible mucous membranes are pale pink, with normal moisture. In the right hypochondrium region there is a postoperative scar of 12×0.5 cm in satisfactory condition, along the anterior axillary line there is a drainage tube (Kera drainage), through which light bile flows; Along the mid-axillary line, in the right lateral region, a silicone drainage tube with a similar discharge is also installed. On palpation, the abdomen is soft, painful in the paradrainage area and right hypochondrium.

The general blood test revealed no deviations from the reference values. When studying biochemical blood parameters, an increase in the level of AST to 175.5 IU/l, ALT to 428.5 IU/l, and alkaline phosphatase to 211.54 IU/l was revealed. To assess the vascular anatomy of the hepatobiliary zone, the condition of the bile ducts, and the location of drainage tubes, MSCT angiography and MRI cholangiopancreatography were performed.

MSCT revealed that the intrahepatic bile ducts are slightly dilated - the right lobar duct is up to 4 mm, the left one is up to 6.5 mm, and can be traced to the level of confluence. Hepaticocholedochus is not clearly visualized. In its projection there is a T-shaped drainage, the proximal branch of which reaches the level of the confluence of the lobar ducts; the second drainage tube is located under the liver. No damage to the afferent vessels of the liver was detected.

On MRI, the intrahepatic ducts were visualized to the subcortical parts of the liver, not dilated, without filling defects. The right and left hepatic ducts (lobar) merge at the porta hepatis, dilated, without filling defects. The common hepatic duct was visualized only for up to 16 mm; then a defect with a length of 18 mm was determined, after which there was an undilated common bile duct. A drainage tube is installed through the anterior wall into the hepaticocholedochus, which bends around the common hepatic duct along the anterior wall, deforming the confluence of the lobar bile ducts, and then passes along the right side wall of the right lobar duct, with its end located in the liver parenchyma. From the lower edge of the visualized part of the common hepatic duct (its length reaches 16 mm), a flow of bile into the subhepatic space was noted, where a second drainage tube was installed.

A diagnosis was made - iatrogenic damage to the extrahepatic bile ducts type I according to Bismuth or E1 according to the Strassberg classification, “+1” according to Galperin. Incomplete external biliary fistula.

After preoperative preparation, the patient underwent surgery. Access: wide combined right subcostal laparotomy with excision of the postoperative scar. There is a dense infiltrate in the right subhepatic space. When mobilizing the suspected hepaticocholedochus, a Kehr drain was identified, and it was established that the anterior wall of the duct was absent for 15 mm, the posterior wall was represented by a scar cord, and bile leakage was noted from the paradrainage; dense layers of fibrin. Both branches of the Ker drainage are firmly fixed with a non-absorbable thread to the ends of the hepaticocholedochus in such a way that it was not possible to remove the drainage without surgery.

The threads were removed, the drainage was evacuated, after which an abundant flow of bile from the proximal parts of the common hepatic duct was noted. The scarred posterior wall of the common bile duct is excised. The distal stump of the common bile duct is stitched and bandaged. The walls of the right and left lobar ducts in the area of their confluence were gradually isolated from the scars; the posterior wall of the confluence was preserved.

During control instrumental revision, the right and left lobar ducts are freely passable. The loop of the small intestine is disconnected according to Roux, a hepaticojejunostomy is formed at 80 cm according to the proposed method, i.e. “holding” sutures were placed on the side walls of the bile duct and the antimesenteric edge of the small intestine, the posterior wall of the anastomosis was formed with single precision interrupted sutures with an atraumatic, monofilament absorbable thread, 5/0 in diameter, with knots tied inward. The ends of these ligatures are cut off, except for one. Next, at a distance of 10-12 cm from the anastomosis, a hole was formed in the wall of the outlet intestine, through which a drainage tube was passed into the lumen of the bile ducts, which was fixed with the ends of the preserved ligature. Then, the anterior wall of the anastomosis was formed with a continuous enveloping suture. A trapping silicone drainage was installed in the subhepatic space.

The early postoperative period proceeded without complications; the catching drain was removed on the fourth day after the intervention. On the sixth day, a control fistulography was performed, which revealed: the right and left lobar ducts and the common hepatic duct are filled; the hepaticojejunostomy is freely passable, the contrast freely enters the small intestine; No contrast material leaks were detected during the study.

On the 8th day, the patient was discharged in satisfactory condition with the Felker drainage blocked near the skin under the supervision of a surgeon at her place of residence. The patient was examined 2 months after surgery, the drainage was freely removed from the bile ducts.

To date, 18 patients have been operated on using the claimed method. In 14 observations, complications associated with evasion of bile from the hepaticojejunostomosis area, intra-abdominal bleeding, abdominal abscesses, and peritonitis were not noted. In 2 cases, bile leakage was detected through the catching drainage, which self-limited by the 8th day after the intervention. In the 1st observation, suppuration of the postoperative wound was detected, and one patient developed intra-abdominal bleeding, requiring emergency relaparotomy.

The advantages of the proposed method compared to the known ones are that:

1. more convenient in technical design;

2. application of “stay sutures” allows you to securely fix the intestinal loop to the bile duct, thereby reducing the load on the first sutures of the anastomosis;

3. provides reliable fixation and precision comparison of stitched segments;

4. the formation of nodes inside the lumen makes it possible to avoid rotation of the remaining duct stump and, thereby, reduce its trauma and the likelihood of cutting sutures;

5. the formation of the posterior wall of the anastomosis is simplified;

6. provides biliary decompression;

7. improves the quality of life of patients due to the absence of the need for long-term frame drainage.

Thus, the proposed method for forming hepaticojejunostomy expands the capabilities of surgical intervention techniques when performing reconstructive operations on extrahepatic bile ducts when they are damaged.

Claims (1)

A method for forming a hepaticojejunostomy, including laparotomy, revision of the hepatic hilum, isolation of the common hepatic duct and lobar ducts, bringing a loop of the small intestine to the hepatic hilum, switched off according to Roux, placement of single interrupted sutures through the walls of the hepatic duct and small intestine, initially along the back, and then along the anterior the wall of the anastomosis, characterized in that before the formation of the posterior wall of the anastomosis, “holding” sutures are applied to the side walls of the bile duct and the loops of the small intestine; when forming the posterior wall of the anastomosis, single precision interrupted sutures are applied, the knots of which are tied inside the lumen, the ligatures are cut off except for one, then at a distance of 10-12 cm from the anastomosis, a hole is formed in the wall of the outlet intestine through which a drainage tube is inserted into the lumen of the bile ducts and fixed. ends of the left ligature, and the anterior wall of the anastomosis is sutured with a continuous wrapping suture, while the knot is left outside the lumen of the anastomosis, after which the “holding” sutures are removed.