SU1242133A1 - Method of expanded selective proximal vagotomy - Google Patents

Description

This invention relates to medicine, namely surgery, and is intended for the treatment of hyperacid gastric and duodenal ulcers.

The aim of the invention is to reduce the complications of vagotomy by preventing gastric ischemia by maintaining the integrity of the arterial trunks and their branches.

FIG. 1 shows the general scheme of the operation; in fig. 2 - detail of opening the abdomen, opening the periarterial fascial bed and exposition of the vessel adventitia; in fig. 3 - extraction of the artery from the periarterial fascial bed (the dotted line indicates the intersection of all tissues, including the branches of the vagus and silanchnicus outside the arterial trunk).

The method is carried out in the following manner.

After laparotomy, the diagnosis and indications for vagotomy are verified. The intersection of the branches of the vagus nerves along the greater curvature near the wall of the stomach starts from the exit of the right gastrointestinal tract: the ovary artery from under the stomach wall, that is, from the point of entry of the artery into the ventricular ligament. In this way, the right and left gastroepiploic arteries are maintained. According to the line of the planned tissue section, at the junction of the ligament carrying the nerve guides to the stomach wall, the arterial trunk or its branch is isolated. A pointed clip, such as a sharpened mosquito, is punctured by the periarterial bed of the vessel and, by diluting it, the slaughter stupidly moves apart the periarterial fascia and the periarternal nerve plexuses contained in it. The depth of penetration of the clamp is the adventitia of the vessel. Then, when the tips of the clamp slide along the bare adventitia, the fascial bed begins to be taken off with a sufficient distance (1 -1.5 cm) and push it to the sides.

The presence of accidentally preserved on the adventitia of nerve fibrils is checked by a special longitudinal slip of the “mosquito” along the entire preparation vessel. Then, under the selected vessel, any turnstile, such as a filament, is carried out, and the arterial branch is removed from the fascial bed. Thereafter, all the soft tissues of the ligament, including the branches of the vagus and simpatikus, cross. In the described manner, they are treated with all arterial trunks along the large and small curvatures. Small, functionally insignificant arterial branches are crossed by a known method.

It has been experimentally and clinically proven that it is enough to leave 4--6 branches along the small curvature, but the pain is 6-8.

Similarly, they come with short gastric branches extending into the gastro-pancreatic ligament. Sites of mobilization of the stomach for pain and small curvature

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in a well-known way. In the region of the cardia 1, the stem- HOBHbie stem 1) 1 of the vagus nerves is picked up and taken on a holder. To this end, the bryupinu covering the esophagus is dissected in the transverse direction 1–2 cm below the diaphragm. The jaw is pulled up along the groove of the esophagus 1 axis, the left and right stumps of the vagus are strung like strings, they are dissected with a dessector and taken on handles to prevent accidental injury.

The onset of mobilization of the lesser curvature of the stomach reveals and maintains the main branch of the vagus, the Latarge's nerve, which goes to the antrum and the pylorus. First, nerve sprigs with small vessels located in the penis are separated and moved from the goose foot of the first Latarere up to the esophagus, then the back of M. The vessels release directly to the place of their entry into the wall of the stomach . After mobilization of a small cranial skeleton, the cardial section and abdomi} 1lL) The nuch part of the esophagus in the direction of the Hx angle, while pushing the trunks of the vagus nerves by the handles, intersects the nerves in the surrounding tissue. The esophagus is skeletal on all sides up to 4 cm from the stomach. About work) save the vessels along the lesser curvature similarly to the processing of vessels along the greater curvature.

Make a complete denervation with pH-metry after stimulation of gastric secretion by histamine. 11) Produce peritonealization of all parts of the brain (along the greater curvature and then restore the binding agent and cardia (fundoply according to Nissen) The covering of the nudalsch. 1x (part of the stomach, not covered with brewing — the point of attachment of the ligament) of the surfaces is made by turning the inside of the surface and comparing the visceral, external surface area 11). This achieves nojiiioe in the intersection of the intersected faciaea. 1.b.y.7, ozh and exclusion of their solubility jfHH at the school (: it became necessary to complete the linkage. This is necessary for the complete elimination of the reg. Nerves) of the intersecting nerves in the peri - apTe) na: njHOM fascials bed are

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The effectiveness of the previous method is concluded also in TOV; this is achieved by eliminating sscex complications that have not been developed due to the devascularization of the organ. Established. All of the a) teria of the sinus, equal to: viepc and their branches, have a peri-arterial facial cavity in their bed, in which - trophic branches of the stomach are located. It has also been established that when the peri-arterial fusion is removed, the full; It was shown by histological examination that inside the artery wall, equally its branches, go

separate nerve trunks with a vase Vasorum, i.e. with a vessel that feeds the artery wall itself. But it is these nerves that need to be preserved. They provide regulation of blood flow, rather than stimulation of the secretion of hydrochloric acid and pepsin.

The proposed method operated on 15 patients. It has been established that in all cases the periarterial fascia can be removed from the vessel with the nerve plexuses moved away from adventitia, and the vessel removed from the periarterial fascial bed. The operation is easier to do on large vessels, more difficult on small ones. It should include the main branches. The intraoperative rheographic method in combination with observations of the vascular microcirculation established that according to the proposed method, the blood supply to the stomach was improved in the first 24 hours after the operation compared with the known one from 16-42 to 76-94%.

Control of the completeness of vagotomy on the operating table is performed by pH-meter. The criteria for completeness of vagotomy were considered pH 5.5 and above.

In order to detect ischemic manifestations on the part of the gastric mucosa, endoscopic examinations were performed in patients 4-15 days later, 3-6-12 months after surgery. In the early postoperative

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At the same time, macroscopic and iimistic disorders (pallor of the mucous membranes, slight bleeding, roughness of the folds of the mucous membranes, its blueness, the presence of pinpoint hemorrhages or necrotic areas) have not been identified. The mucous membrane was pink in color, its folds were not thickened and were arranged longitudinally, in 3 patients, who had not completed a full course of conservative therapy at the time of exacerbation, the presence of perifocal inflammation was noted.

By two weeks, the ulcers flattened, cleared of necrotic masses, granulating tissue appeared, and in most patients perifocal inflammation disappeared. The endoscopic studies performed in dynamics after 3-6-12 months allowed us to state the healing of sores to 3 months from the moment of the operation; no pathological changes were detected from the gastric mucosa.

Clinical studies 6–12 months after the operation showed complete recovery of working ability, patients considered themselves to be practically healthy, and there were no disorders in the function of the digestive organs. Most of them did not follow the diet, diet. The method is recommended for use in clinical practice.

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Claims (1)

METHOD FOR ADVANCED SELECTIVE PROXIMAL VAGOTOMY, including intersection of the ligamentous apparatus of the stomach, esophagofundoplication and restoration of the ligamentous apparatus, characterized in that, in order to reduce complications by preventing ischemia of the stomach, large arterial branches are first isolated from the fascial bed at the entrance, and then the ligament is crossed while maintaining the selected vessels. FIG. 7