SU1242126A1 - Method of setting transduodenal papillosphincteroplasty - Google Patents

Description

The invention relates to medicine, in particular to surgery, and can be used in operations on the large duodenal papilla (OBD).

The purpose of the invention is to reduce postoperative complications by reducing the injury to the duodenum during the operation and to preventing infection of the abdominal cavity by using the LDP fixator without mobilizing the intestine.

FIG. Figure 1 shows a multi-tip probe to determine the degree of narrowing of the incision size and the OBD plasty; in fig. 2 --- BDS retainer.

The method is carried out as follows.

The abdominal cavity is opened with one of the known incisions, along with an elongation of the incision to the middle axial line. This opens up sufficient access to the duodenum. After that, the choledoch is mobilized, opened, a multi-leaf probe is inserted, which represents rod 1 with handle 2, on which olives 3 are planted. Moreover, 1-olive, located at the end of the probe, has an initial diameter of 1 mm, which is chosen on the basis of that the tool is used for narrowing the nipple, and only with this end diameter it is possible to pass the narrowed nipple area, thereby determining its location for the next nj.ero to open the 12-pointed, nipple protruding into the incision and plastics it. The final olive, located in the middle of the probe, is made with a diameter of 8 mm. This size is selected from the conditions for obtaining a maximum choledoch lumen equal to 8 mm in diameter, which does not exceed the normal dimensions of the width of the common bile duct. Between the initial and final olives are located several more olives, which are located at a distance of 10-30 mm from each other, which makes it possible to protrude the area of each subsequent olive, which are performed with gradually increasing dimensions. Each o; 1iva has a cone-shaped form in the initial part, which smoothly transforms into a spherical one.

Usually, each subsequent olive is different in diameter from the corresponding section diameter of the previous olive by 1-2 mm.

The sequential arrangement of the olives, differing from each other in diameter by 1 mm, makes it possible to determine the size of the nipple constriction, dissect it step by step under the control of the width of the dissected nipple, hold the plate under conditions convenient for the surgeon and, if necessary, bougie the constricted area. Under the control of the finger, a rod with an end olive is held through the narrowed nipple and, guided by it, transversely dissect the anterior wall of the duodenum. Cut length mm. After this, the multi-tip probe is pulled through the constricted

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SOSOK until one of the olives fixes it. the passage of olives is determined by the size of the constriction of the large duodenal papilla.

The fixation is performed using a probe and a special instrument - a fixator of the large duodenal nipple and 12 duodenal ulcer (Fig. 2), which is a hinged branch 4 with semicircular working jaws 5 with an internal diameter of 8-10 mm bent at an angle of fx: 150-170 ° and covered with an elastic material, with a regulating screw 6 handles with a slat lock 7.

The presence of working sponges with an elastic coating allows the duodenal nipple to be well and softly fixed and to press to it and the posterior wall of the duodenum the wound of its anterior wall and to create a good tightness of the lumen of the duodenum in the area of its incision. Angle a equal to 150-1 ° -70 ° is chosen based on the convenience of the operation. It is selected experimentally. The inner diameter of the semicircular sponges (8 --- 10 mm) was chosen based on the minimum size of the nipple.

The latch works as follows.

Using a adjusting screw (5, set the working jaws so that the inner diameter matches the diameter of the nipple, divorce them with the jaws 5, feed them to the cutter, press the branches, pressing the front wall of the duodenum to the nipple and its back, simultaneously removal of the intestinal mucosa from the nipple, closing the scarf lock 7, in addition to fixing the nipple in a predetermined position. Thus, it is not necessary to use traumatic clamps or suture holders, a tuff to remove the treatment mucosa and, moreover, amponirovat lumen of 12 duodenal ulcer or prizhi.mat its tuferami.

After fixing the nipple using the appropriate tool, cut the nipple on the uro15 11 h across the dial, put knotted stitches on the wound edges, using a thin atraumatic needle or other known material. At the same time, the condition of the mouth of the pancreatic duct is checked. Following this, the probe is advanced until the nipple is fixed to the next olive and the previous operation is repeated. This is repeated until the narrowing is eliminated, i.e. until the last olive passes by an 8 mm diameter. The probe is sealed for P1BOV, the probe is removed retrogradely through the choledoch, the wound on the anterior wall of the duodenal ulcer is sutured with two-stitch knotted sutures. Drain and seal the choledoch. The subhepatic region is drained and the abdominal wound is sutured in layers tightly.

Clinical example. Sick E., 54 g. Diagnosis: stenosis of the large duodenal papilla IH - TV degree, cholangitis, pancreatitis.

mechanical jaundice. Was operated in this way. Narrowing of the nipple reached 1 mm. A probe with six olives was used, a narrowed section of 3-4 mm incisions was cut in stages, the total length of the incision was 10 mm, and the resulting clearance was 8 mm. The diameter of the jaws of the clamp set with the help of the adjusting screw size of 15 mm, which corresponded to the size of the nipple. During the operation, the gallbladder with a lot of stones was removed, stones were also removed from the choledochus, the choledoch was washed with antibiotics and drained according to Vishnevsky. The drainage of the abdominal cavity is performed, the abdominal wall is sutured tightly. After 16 days, the patient was discharged in good condition.

Transduodenal papillophincteroplasty using special tools allows you to perform an operation without large mobilization and traumatization of the duodenum and large duodenal nipple through a small cross-section (not more than 1.5 cm long) of the anterior wall of the duodenum, which prevents deformity and narrowing of the intestine during closure, step by step under the strict control of the nipple lumen until its constriction is completely eliminated and dissection should be performed and with good surgical

put a step-by-step good suture on the edges of the incision of the terminal part of the choledochus and the mucous membrane of the duodenum and carefully seal the wound, isolate the abdominal cavity well from leakage of the duodenum and bile contents and thereby prevent infection of the abdominal cavity, inconsistency of the duodenal sutures and the development of retroperitoneal phlegmon and peritonitis. The method reduces the incidence of left and viewed stones in the choledochus, as in the process of pulling the multi-leaf probe, each olive in the process of passing through the enlarged nipple pushes the existing stones in the choledochus, while avoiding leaving a gap in the upper corner of the incision between the long-lasting papillosphincteroplasty and the duodenal wall and prevent duodenal contents from flowing into the retroduodenal space. The operation usually takes place without trauma to the pancreas, which is important for the prevention of postoperative pancreatitis, the complete elimination of stenosis is also the prevention of postoperative ascending cholangitis.

5 The proposed method is applied in practice in 59 patients with good immediate and long-term results.

Compiled by T. Shakhmatova

Editor A. KozorizTechred I. VeresKorrektor, 4. Pojo

Order 3637/7 Circulation 660 Subscription

VNIIPI USSR State Committee

for inventions and discoveries

113035, Moscow, Zh-35, Raushsk nab. 4/5

Branch PPP "Patent, Uzhgorod, st. Project, 4

FIG. 2

Claims (1)

METHOD OF transduodenalnym PAPILLOSFINKTEROPLASTIKI comprising holedohoto- ¹ Mia transverse duodenotomiyu holding bougie passed olive-guide with a large duodenal papilla (BNS), wherein, f that, in order to reduce postoperative complications by reducing injury 12perstnoy intestine during surgery and the prevention of infection of the abdominal cavity, a probe with several olives increasing in diameter is carried out in the BDS, bougienage and dissection of the BDS are carried out in stages, while the BDS is fixed with simultaneous sealing th intestinal lumen. Bf Bf bf I