RU2240055C1 - Method for surgical treatment of pancreonecrosis - Google Patents

Abstract

FIELD: medicine, surgical gastroenterology.

SUBSTANCE: it is necessary to provide retroperitoneal access at patient's dextral lateral position, retroperitoneal space should be lanced due to dissecting diaphragmo-colonic ligament followed by mobilizing a splenic colonic angle. Then one should lance omental bursa due to dissecting gastro-splenic ligament in vessels-free area and after removing sequestra and pathological liquid content one should puncture left-hand lumbar area to introduce a clamp there by directing it through omental bursa and lance gastro-colonic ligament by its working end, firstly, and, secondly, abdominal wall in epigastral area, through the opening developed one should capture drainage to withdraw it into the puncture in lumbar area, moreover, all manipulations should be carried out by applying videolaparoscopic technique that provides adequate lancing and drainage of all pathologically altered areas in case of pancreonecrosis under visual control and low risk for the secondary infectioning.

EFFECT: higher efficiency of therapy.

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Description

The present invention relates to medicine, in particular to surgical gastroenterology.

The relevance is due to unsatisfactory results of the treatment of pancreatic necrosis.

Inflammation of the pancreas often becomes destructive, while the inflammatory process goes beyond the pancreas and causes various inflammatory changes in the tissues surrounding the pancreas. The necrotic process is due to tissue alteration by activated proteolytic enzymes, which are found in large quantities in inflammatory exudate, which infiltrates retroperitoneal parapancreatic tissue and accumulates in the stuffing bag. All this leads to the development of omentobursitis, parapancreatic necrotic phlegmon and often retroperitoneal necrotic phlegmon, and subsequently, with inadequate treatment, they become infected and abscesses form in the pancreas itself and in various zones of the retroperitoneal space. To date, there is no unity in approaches to the surgical treatment of pancreatic necrosis, therefore, there are many different surgical techniques for the treatment of pancreatic necrosis.

An analogue is the method of laparoscopic drainage of the abdominal cavity, used for pancreatic necrosis complicated by enzymatic peritonitis. The method consists in establishing microirrigators and drains under the control of a laparoscope for peritoneal perfusion (“Acute pancreatitis”, V. S. Savelyev, V. M. Buyanov, Yu.V. Ognev, Moscow, “Medicine”, 1983, pp. 192).

A significant drawback of the operation is the lack of sanitation of the region of the omental bursa and retroperitoneal parapancreatic space.

The omentobursostomy operation developed by V.P. can serve as a prototype. Sazhin. The operation is performed as follows: a laparoscopy is performed, then pneumomentobursoperitoneum is applied by puncture with a Veress needle of the omental bursa through the gastrointestinal ligament. After this, the gastro-colonic ligament is opened in the avascular site. A 2 cm incision is made over this area on the skin, through which a constant fistula is fixed, while the gastrocolic ligament is pressed against the peritoneum of the anterior abdominal wall. Through the hole in the fistula, a manipulation laparoscope is inserted into the stuffing bag, the pancreas is examined, sequestra, pathological fluid are removed. The cavity of the stuffing bag is washed, antibiotics are administered. After completing the manipulations, a sealing insert is installed in the sleeve (“Laparoscopic diagnosis and treatment of acute pancreatitis”, V. P. Sazhin, A. L. Avdovenko, V. A. Yurishchev, A. V. Sazhin, L. E. Klimov, L. I. Karlov, “Surgery”, No. 11, 2002, p. 34-37).

The disadvantages of this operation are the inability to open and sanitize necrotic altered retroperitoneal parapancreatic fiber, as well as the fact that the operation does not provide for permanent drainage of the zone of purulent-necrotic inflammation.

The invasiveness of the operation plays a significant role in such a serious illness as pancreatic necrosis.

The tasks of surgical treatment of pancreatic necrosis are minimal trauma, simultaneous opening, rehabilitation and drainage of the entire purulent-necrotic lesion, localized in the stuffing bag and retroperitoneal space, the maximum delimitation of the surgical area from the free abdominal cavity, reducing the risk of secondary infection of the inflammatory zone.

The basis of the method that implements low-invasiveness, full visual control, simultaneous sanitation and drainage of the stuffing box and parapancreatic retroperitoneal space, reducing the risk of secondary infection, is video-laparoscopic technology produced under certain conditions of the patient’s body position.

The technical novelty of the proposal is that the opening of pancreatic necrosis is provided through retroperitoneal access in the position of the patient on the right side. The retroperitoneal space is opened by dissecting the diaphragmatic colon ligament, followed by mobilization of the splenic angle of the colon, then the omental bursa is opened by dissecting the gastro-splenic ligament in the avascular zone, and after removing sequestration and pathological fluid contents in the left lumbar region, a puncture is made through which a long clamp is inserted , carry it through the gland bag, pierce it with the working end of the gastrointestinal ligament and then the anterior abdominal wall into the epigastric of the second region, drainage is captured through the hole formed and it is taken out to a puncture of the lumbar region, and all manipulations are performed using video laparoscopic technology.

The method is as follows.

Pneumoperitoneum is applied in a typical place above the navel, after which a port is inserted into the abdominal cavity through which the video laparoscopic system is inserted. Then the patient is turned on the right side, which allows you to see the diaphragmatic colonic ligament. The second port is introduced in the left hypochondrium. The diaphragmatic-colon ligament and the parietal peritoneum are cut along the proximal part of the descending part of the colon, the splenic corner of the colon is mobilized and the left retroperitoneal space is exposed, if there is an accumulation of pathological fluid or sequestration, they are evacuated. For the convenience of manipulation, an additional port with a manipulator is introduced in the left hypochondrium. After this, the gastro-splenic ligament is exposed and opened in the avascular zone, after which the cavity of the omental bursa is examined, sequestrectomy and evacuation of the accumulation of pathological fluid are performed. After that, a puncture is made in the left lumbar region, through which a long clamp (50 cm) is inserted, it is passed through an omental bursa, the gastrocolic ligament is pierced with its working end, and then the anterior abdominal wall is in the epigastric region. Through the hole formed, drainage is captured and brought out to a puncture of the lumbar region. If necessary, up to 4-5 drains are thus performed. After turning the patient on his back, the mobilized splenic angle of the colon is put in place and thus covers the area of operation and drainage from the free abdominal cavity. Immediately after the end of the operation, continuous flow-suction drainage is carried out through the drains until full rehabilitation is achieved.

The method was tested on 12 patients.

Patient X., 44 years old, East. disease number 4420, was received 05.11.02, with severe pain in the abdomen, accompanied by repeated vomiting and bloating. The patient was immediately hospitalized in the intensive care unit for intensive care with a diagnosis of pancreatic necrosis, which was subsequently confirmed by ultrasound and computed tomography. The severity of the condition was evaluated on the Apach-2 scale and amounted to 8 points. Despite intensive conservative treatment, an increase in endotoxemia was noted by the 5th day, and according to computed tomography, there were pronounced necrotic changes in the pancreas, parapancreatic fiber, extending to the lower pole of the left kidney, and accumulation of pathological fluid in the stuffing bag. 11.11.02, an urgent operation was performed: opening and drainage of the stuffing box and retroperitoneal space under video-laparoscopic control. Pneumoperitoneum was applied at a typical location above the navel and a video laparoscope was inserted through the port at that location. Then the patient was laid on his right side - the left diaphragmatic-colonic ligament was exposed. Then, in the left hypochondrium, two ports for manipulators were introduced, with the help of which the diaragal-colon ligament with the parietal peritoneum section was cut along the descending part of the colon and the splenic corner of the colon was mobilized, while the necrotic altered retroperitoneal space of black-gray color was revealed, which was bluntly opened. Then the tense gastro-splenic ligament in the avascular zone was dissected and the stuffing bag was opened - up to 400 ml of odorless brown turbid liquid was aspirated. The cavity of the omental bursa was examined, while a necrotic altered pancreas of dirty gray color was found throughout and the same changes in parapancreatic fiber in the region of the mesentery root were revealed. Free-lying sequestration is not identified. Then, a puncture was made in the left lumbar region, through which a long clamp (50 cm) was inserted, carried out retroperitoneally and through the gland sac, after which the gastrocolic ligament and the anterior abdominal wall in the epigastric region were sequentially punctured with its working end. Through the hole formed, drainage is captured, passed through the stuffing bag and removed through a puncture in the left lumbar region. In the same way and in the same sequence, three more drainages were carried out nearby, the fifth drainage was installed with the end in the lower part of the left retroperitoneal space. Immediately after the end of the operation, continuous flow-suction drainage was started through the drains. After surgery, the effects of endotoxemia significantly decreased on day 3, and subsequently sequestered tissues were actively washed out. Treatment was monitored by computed tomography on 11/18/02, 11/25/02, 12/03/02, 12/20/02, with positive dynamics. The patient was discharged 58 days after surgery. Inspected 05/20/03 No complaints.

The technical result of the invention is low-invasiveness, adequate opening and drainage of all pathologically altered areas with pancreatic necrosis under visual control, minimal risk of infection of the abdominal cavity, minimal risk of secondary infection, reduced level of pain in the postoperative period, reduced time of onset of a positive effect during the disease. The method does not require additional material costs and is recommended for widespread use in practical health care.

Claims (1)

A method of surgical treatment of pancreatic necrosis, including the removal of sequestration, pathological fluid contents and drainage, characterized in that they provide retroperitoneal access in the patient’s position on the right side, the retroperitoneal space is opened by dissecting the diaphragmatic colon ligament, followed by mobilization of the splenic corner of the colon, then the omental gland is opened bag by dissecting the gastro-splenic ligament in the avascular zone and after removing sequestration and pathological fluid of the abdominis, a puncture is made in the left lumbar region, through which a clamp is inserted, it is passed through the stuffing bag, the gastrointestinal ligament is pierced with its working end and then the anterior abdominal wall in the epigastric region, through which the drainage is captured and brought out into the lumbar puncture, moreover, all manipulations are carried out using video laparoscopic technology.