RU2277863C2 - Method for unilaterally portalizing suprarenal and renal blood - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves creating splenorenal venous end-to-end anastomosis without ligating splenic artery. Then, renoportal anastomosis is created by suturing autotransplant end into splenic vein into exit zone, the other end being end-to-end connected to renal vein end.

EFFECT: enhanced effectiveness of treatment; retained unrestricted blood circulation from pancreas and spleen; reduced risk of postoperative complications.

4 dwg, 1 tbl

Description

The invention relates to medicine, namely to surgery.

The prototype is a method of unilateral portalization of the adrenal and renal blood (A.S. 673271) by creating an anastomosis between the renal vein and the portal vein inflow, ligation of the renal vein, splenic artery and vein inflows and adrenalectomy on the right (Fig. 1). The method is used to treat arterial hypertension (2), chronic hepatitis (3, 5), diabetes mellitus (4).

The disadvantages of the prototype are created by ligation of the splenic vessels obstruction of blood flow from the pancreas and spleen, splenic vein thrombosis and the risk of developing postoperative pancreatitis.

The aim of the present invention is to maintain unhindered blood flow from the pancreas and spleen and to reduce postoperative complications.

This goal is achieved in that the proximal end of the splenic vein is connected to the distal end of the renal vein end-to-end without ligation of the splenic artery.

The method is as follows.

The abdominal cavity is opened by the upper median access (or transverse access above the umbilicus), the parietal peritoneum of the posterior wall of the abdominal cavity above the aorta is dissected in the projection of the renal vessels, continuing to the lower edge of the pancreas. The latter is displaced upward, and the small intestine to the right, dissect the ligament of Treitz. The mouth of the lower and upper mesenteric, splenic and the beginning of the portal vein are distinguished. Then, the left renal vein with its tributaries is isolated. Turnstiles are brought under the left renal and, through a window in the gastrointestinal ligament, under the splenic artery.

In the inguinal region, the mouth of the great saphenous vein is exposed, it is crossed at a distance of 4 cm from the mouth, mobilized for 20 cm by tunneling and cut off to create an autograft insert. 5 thousand units of heparin are administered intravenously. Cross the splenic vein at the mouth, and the renal distal to the adrenal vein. The proximal end of the splenic vein is connected with the distal end of the renal end-to-end, while the excess width of the renal vein, if necessary, is eliminated by truncating its lower edge by cone and stitching. For the period of the creation of the anastomosis, blood flow from the kidney is shunted at the mouth of the large saphenous vein.

The length of the required autovenous graft is determined, it is formed by longitudinal section of the vein (Fig.2b) and stitching of the edges of the transverse sections (A.C. 627823, Fig.2d) or the edges of the longitudinal sections of the vein in a spiral shape (A.C. 860750, Fig. 2d). One end of the autograft is sutured into the area of the mouth of the splenic vein, and the other end is connected to the proximal end of the renal vein end-to-end (Fig. 3).

When forming anastomoses, a continuous twisting seam with synthetic threads is used. After completion of the anastomoses, the peritoneum of the posterior wall of the abdominal cavity and the opening in the gastrointestinal ligament are sutured with rare interrupted sutures; produce, according to indications, an adrenalectomy on the right; the abdominal cavity is sutured in layers tightly. The distal end of the great saphenous vein of the thigh, after ligation at the mouth, is cut off and the wound in the inguinal region is sutured.

In the proposed method, unobstructed bleeding from the pancreas and spleen is achieved and the inevitability of splenic vein thrombosis and other complications is excluded. The operation is applicable for diseases with impaired liver, pancreas, adrenal glands and kidneys.

The possibility of carrying out the invention shown by the authors in anatomical and surgical studies. On 111 corpses of adults of both sexes, anatomical preparation of blood vessels (root inflows of the portal vein and renal vein with its tributaries), measurement of their width and full-size sketch and practical implementation of splenorenal and renoportal venous anastomoses were performed. In 26 studies performed x-ray, showing the relative position of the splenic and renal veins (figure 4). The operation was feasible in 52.1% of cases. The very low or very high location of the renal vein trunk relative to the splenic vein, the mismatch between the width of the splenic and renal veins of more than 0.5 cm, obesity, a number of vein anomalies were an obstacle to the operation. The feasibility of anastomoses was influenced by body type and portal vein formation options. So, more often anastomoses were feasible with the mesomorphic type of physique (59.3%) than with dolichomorphic (52.6%, p <0.01) and brachymorphic (50%, p <0.02). An even greater dependence of the feasibility of anastomoses was established on the options for the formation of the portal vein: in cases of inflow of the inferior mesenteric vein into the spleen, the operability was 68.6%, if it flowed into the superior mesenteric near the splenic, anastomoses were feasible in 41.2% (p <0.001 ) and lower than the splenic, forming the mesenteric trunk, in 26.1% (p <0.001).

The feasibility of end-to-end splenorenal anastomosis directly depends on the comparability of the width of the connected veins. After studying and comparing the width of the veins in each case, we obtained the real frequency of feasibility of the end-to-end splenorenal venous anastomosis (Table 1) only by this parameter.

Table 1 Comparability of the left renal vein with portal inflows in width Veins Indicator The difference in the width of the veins in mm 0 one 2 3 four 5 more The common trunk sat. and lower mesentery. veins abs. 7
8.4 fourteen
16.9 19
22.9 9
10.8 6
7.2 four
4.8 24
29th % Splenic abs. one
0.8 2
1.7 5
4.1 5
4.1 10
8.3 twenty
16.5 78
64.5 %

The table shows that end-to-end splenorenal venous anastomosis is feasible in 71% of cases if the splenic and inferior mesenteric veins form a common trunk, and in 35.5% of cases if the splenic trunk is to be connected to the renal vein (both options are acceptable, if the width of the renal vein exceeds the width of the vein connected to it by no more than 0.5 cm).

Information sources

1. Torgunakov A.P. A.C. No. 673271.

2. Torgunakov A.P. Venous blood diversion from the adrenal gland and kidney to the portal system in the treatment of malignant arterial hypertension // Herald of Surgery. - 1979. - No. 2. - p. 8-11.

3. Torgunakov A.P., Krivov Yu.I., Ponomarev V.N. A new opportunity for the surgical treatment of chronic hepatitis // Bulletin of surgery. - 1984. - No. 12. - p. 45-47.

4. Torgunakov A.P., Torgunakov S.A., Orlovskaya S.I. New approaches to the surgical treatment of diabetes mellitus // Bulletin of Surgery. - 1990. - No. 4. - p. 27-30.

5. Torgunakov A.P., Krivov Yu.I., Kuznetsova N.N. et al. Experience of unilateral portalization of adrenal and renal blood in chronic hepatitis // Herald of surgery. - 1992. - No. 1. - p. 9-12.

Claims (1)

1. The method of unilateral portalization of the adrenal and renal blood, characterized in that they form a splenorenal venous anastomosis of the end-to-end type without ligation of the splenic artery, and then form a reno-portal anastomosis by suturing into the mouth area of the splenic vein of the end of the autograft, the other end of which connected to the end of the renal vein type "end to end".

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