RU2460474C2 - Method of duodenum stump formation in case of gigantic circular complicated ulcer - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine and can be used for duodenum stump formation in case of gigantic complicated circular ulcer. Anterior wall of bulb duodenum is dissected orally to the boundary of resection, and aborally from perforation hole to stenosis line. Posterior wall of duodenum is separated in acute way 1.0 cm from distal edge of ulcer crater, penetrating into head of pancreas. Uninterrupted inverting serous-muscular-serous suture is applied, with the first stitch being made on posterior wall of intestine capturing serous-muscular layer at the distance 0.3 cm from distal edge of ulcer crater, penetrating into head of pancreas, "fixer" knot is tied up, restoring integrity of peritoneal cover of intestine wall. After that, 4-5 stitches of uninterrupted inverting serous-muscular-serous suture are applied without penetration into intestine lumen and submerging ring of ulcer stenosis inside. Last prick in is made at the distance 2.0 cm from stenotic hole. Thread is tightened until tissues contact and second "fixer" knot is formed. With the same thread in reverse direction at the distance 0.5 cm from the first line of suture the latter is submerged by means of blanket serous-serous suture, with tightening until tissues contact, and tidying up the end of thread with thread of the first "fixer" knot. At the distance 1.5 cm cranially and caudally from the line of suture two coaptation serous-serous interrupted sutures are applied. Threads of the first and second "fixer" knots are tied to each other, submerging suture line inside. After that, resection of stomach in accordance with one of modifications Bilrot-2 or Roux is performed.

EFFECT: method makes it possible to reduce risk of inflammation development, reduce risk of cutting through sutures.

3 ex, 5 dwg

Description

The invention relates to medicine, namely to surgery, and can be used to form a “difficult” stump in the treatment of a giant circular duodenal ulcer complicated by stenosis, perforation, penetration into the pancreas and hepatoduodenal ligament, spilled serous-fibrinous peritonitis.

About 200 methods are known for the formation of a duodenal stump during gastrectomy. “The choice of the method takes place in each case individually and is determined by the moments characterizing the category of difficulty in mobilizing the initial section of the duodenum, i.e. localization of the ulcer, the nature of the underlying and associated complications, and the type of upcoming resection of the stomach. "(N.A. Nikitin" Insufficiency of sutures of the duodenal stump in urgent surgery of peptic ulcer. "Kirov. 2002. P.149). Our situation belongs to the third category of complexity according to the classification proposed in 1980 by Guarneri. (Guameri A., Markolli G., Confalonieri F., Santamaria A., Caccia F. "Gastroduodenal resection in penetrating duodenal ulcer" Surg. ItaL - 1980. - Vol.10. - No. 2. - P. 92 97.)

One of the first to use a continuous suture in the formation of the stump of the duodenum Haberer in 1915. (I. N. Navrotsky “Suturing of the duodenal stump”, 1972, С-71.) “To close the duodenal stump, a continuous suture is used, serous-muscular invagination nodal sutures are used over it ... To avoid injury to the pancreas, with deep penetrating ulcers, a niche leave on the iron. "

A known method of forming the stump of the duodenum according to Yudin:

The mobilized duodenum 12 is crossed obliquely at the level of the ulcer, leaving most of the anterior wall of the intestine. Starting from the lower corner, a continuous screw-in furrow stitch is applied to the stump of the duodenum starting from the lower corner and tied at the upper corner of the stump. On the seam side, a second seam is drawn through the entire stump, forming a subsequent turn of the “cochlea”. The suture forming the “cochlea” is tightened, the “cochlea” is immersed in a penetrating ulcer, after which the suture is passed through the proximal edge of the ulcer, where it is tied. The adjacent edge of the "cochlea" is fixed to the proximal edge of the ulcer by knotted serous-muscular silk sutures.

A known method according to Rozanov:

B. S. Rozanov simplified the application of the “cochlea” by reducing the turns, which reduced the possibility of circulatory disorders in it. On the lower half of the sutured stump impose the second floor of knotted silk seams. The upper corner of the duodenum is pulled down and fixed with knotted seams of the second floor. On the upper corner of the duodenum 12 impose a marginal half-suture suture, the ends of which are drawn through the proximal edge of the penetrating ulcer and tied. Serous-muscular sutures are placed on the stump of the duodenum 12 and on the “capsule” of the pancreas.

The known method according to Krivosheev:

SV Krivosheev (1954) described the “immersion hood” method, which is a modification of the Yudin method. After cutting out the tongue-like flap from the wall of the duodenum 12 and suturing it, a “hood” is formed, which is invaginated into the intestinal lumen with a purse string suture placed on its base. The second purse string suture, seizing the edges of the ulcer, its bottom is plugged with the intestine. This method can be used for penetration into the pancreas, in the hepatoduodenal ligament, in the gall bladder, liver, cutting a flap from the opposite ulcer of the intestinal wall.

The known method according to Shalimov A.A .:

After mobilization of the stomach, the wall of the duodenum 12 is released from the ulcer crater to the lower edge of the intestine, obliquely intersecting the refreshing ulcerous edges, leaving most of the anterior wall. The wall of the duodenum is sharply separated from the distal edge of the ulcerative crater; to a depth of 0.5-0.8 cm, the catgut half-kit is placed on the weakest point of the duodenal stump, where the edges of the mucous membrane are screwed into the lumen. With the same thread, with the help of a furrier's suture, the rest of the duodenum is sutured, forming a “cochlea”, tying the ends of the thread, covering the furrowing sutures of the “cochlea”. The adjoining lateral surfaces of the “cochlea” are sutured with gray-serous sutures, and a half-mesh suture is applied to the top of the “cochlea”, with which the latter is sutured to the distal edge of the ulcer crater. For greater hermeticity, the duodenal stump with U-shaped serous-muscular sutures is sutured to the proximal edge of the ulcerative crater and pancreatic capsule. (A.A.Shalimov, V.N. Polupan “Atlas of operations on the esophagus, stomach 12 duodenal ulcer.” Moscow. Publishing house. Medicine. S.254-262)

In relation to our situation (a giant circular ulcer of the duodenum, complicated by stenosis, perforation, penetration into the pancreas and hepatoduodenal ligament, diffuse serous-fibrinous peritonitis), the disadvantages of the above methods may include:

- the impossibility of cutting out a tongue-like flap from the wall of the duodenum 12, since the ulcer is circular and all the walls of the duodenum bulb are affected, work occurs in conditions of a pronounced shortage of plastic material;

- to immerse the anterior wall of the intestine, the fibrous edge of the ulcer crater and the capsule of the pancreas are used, but the edge is often loose and the sutures erupt, and the suture through the capsule of the gland can cause postoperative pancreatitis;

- the application of the first row of sutures through all layers leads to a long-lasting inflammatory reaction.

The objective of the invention is to provide a reliable method for the formation of a duodenal stump with a giant circular ulcer of the duodenum complicated by stenosis, perforation, penetration into the pancreas and hepatoduodenal ligament, spilled serous-fibrinous peritonitis.

The problem is solved in that in the method, the front wall of the duodenal bulb is longitudinally dissected orally, to the resection border, and the duodenum is mobilized by the Kocher aborally from the perforated hole to the stenosis line, and the posterior wall of the 12 duodenal ulcer is separated sharply. 1.0 cm from the distal edge of the ulcerative crater penetrating into the head of the pancreas, a continuous screwing serous-muscular-serous suture is applied; the first stitch of the continuous suture is made on the posterior (mobilized) wall of the duodenum with the capture of the serous-muscular layer at a distance of 0.3 cm from the distal edge of the ulcerative crater, penetrating into the head of the pancreas, a knot-fixer is tied, restoring the integrity of the peritoneal cover of the intestinal wall, then 4-5 stitches of a continuous screw serous-muscular serous suture, without penetrating into the lumen of the intestine and immersing the ring of ulcerative stenosis, the last injection at a distance of 2.0 cm from the stenotic opening, the thread is tightened until the tissue touches and form the second node - "fixer". Next, the same thread in the opposite direction at a distance of 0.5 cm from the first seam line is immersed in the latter with a twisted gray-serous suture, tightened until the tissue touches and connected the end of the thread with the thread of the first “fixer” assembly. To reduce the load on the seam line at a distance of 1.5 cm cranially and caudally from the seam line, two converging gray-serous nodal sutures are applied, the threads of the first and second nodes “fixers” are connected to each other, immersing the seam line inward.

The proposed method for the formation of a duodenal stump with a giant circular ulcer of the duodenum complicated by stenosis, perforation, penetration into the pancreas and hepatoduodenal ligament, diffused serous-fibrinous peritonitis, is illustrated by figures 1-5.

Figure 1 shows the stage of longitudinal dissection of the anterior wall of the bulb of the duodenum 12 orally to the border of the resection and aborally from the perforated opening to the line of stenosis;

figure 2 shows a view of organs after mobilization of the duodenum according to Kocher, separation by the acute way of the posterior wall of the duodenum by 1.0 cm from the distal edge of the ulcerative crater, penetrating into the head of the pancreas, applying continuous screw serous-muscular-serous seam;

figure 3 shows the step of applying a second level of continuous twisting gray-serous suture;

figure 4 shows the step of applying two bringing together gray-serous interrupted sutures, cranial and caudal from the suture line, as well as a view of the main line of the suture;

figure 5 shows a completed view of the formed duodenal stump with a continuous two-level suture, where: 1 - stomach, 2 - pancreas, 3 - hepatoduodenal ligament, 4 - stenotic enlarged, affected ulcer of the duodenum, 5 - perforated hole, 6 - ulcerative crater, penetrating into the hepatoduodenal ligament, 7 - ulcerative crater, penetrating into the head of the pancreas, 8 - line stenosis of the post-bulbar part of the duodenum, 9 - lines of longitudinal dissection (yelled nno and aborally) of the anterior wall of the bulb of the duodenum 12, 10 - the border of the resection of the stomach (distal to the pylorus), 11 - cicatricial-ulcerative stenosis of the lumen of the post-bulbar part of the duodenum, 12 - the first node is a "fixer", 13 - back wall 12 of the duodenum, not covered by the peritoneum, 14 - the first level of a continuous suture, screwing serous-muscular-serous, 15 - the second node is a “fixer”, 16 - the second level of a continuous suture, twisting serous-serous, 17 - bringing together gray-serous nodular seams.

The method is as follows.

The formation of a duodenal stump with a giant circular ulcer of the duodenum complicated by stenosis, perforation, penetration into the pancreas and the hepatoduodenal ligament, diffuse serous-fibrinous peritonitis, is performed after upper-median rhizome and laparotomy. A longitudinal dissection of the anterior wall of the bulb of the duodenum 12 is performed 9 orally, to the border of the resection 10, and more aborally of the perforated hole 5, to the line of stenosis 8, excision of the remains (islets) of the mucous bulb of the duodenum 2 and treatment of ulcerative craters 6 and 7 with iodine solution, mobilization of the duodenum according to Kocher, acute separation of the posterior wall of the duodenum 13 by 1.0 cm from the distal edge of the ulcerative crater 7, penetrating into the head of the pancreas, the imposition of a continuous screw serous-muscular-serous va 14. The first stitch of a continuous suture is made on the posterior (mobilized) wall of the duodenum 13 with the capture of the serous-muscular layer at a distance of 0.3 cm from the distal edge of the ulcerative crater 7, penetrating into the head of the pancreas, a knot is fixed; 12, restoring the integrity of the peritoneal cover of the intestinal wall, then 4-5 stitches of a continuous screwing serous-muscular-serous suture 14 are imposed, without penetrating into the intestinal lumen and immersing the ulcer stenosis ring 11, the last injection at a distance of 2.0 cm from stenotic about the hole 11, the thread is tightened until the tissue touches and the second “fixer” assembly 15 is formed. Then, the same thread in the opposite direction at a distance of 0.5 cm from the first seam line is immersed with the last serous-gray serous suture 16, tightened until the tissue touches and linking the end of the thread with the thread of the first node, the “latch” 12. To reduce the load on the seam line at a distance of 1.5 cm cranially and caudally from the seam line impose two converging gray-serous nodal seam 17, the threads of the first 12 and second 15 knots- clamps "bind together, pogru pressing the seam line inward. Next, a stomach is resected according to one of the modifications of Billroth-2 or Ru, with the extraterritorialization of ulcerative craters.

The proposed method for the formation of a duodenal stump with a giant circular ulcer of the duodenum complicated by stenosis, perforation, penetration into the pancreas and hepatoduodenal ligament, diffused serous-fibrin peritonitis, in contrast to the classical methods, has the following advantages:

- longitudinal section of the anterior wall of the bulb of the duodenum 12, affected by a circular ulcerative process, allows you to determine the degree of ulcerative stenosis, to perform the extraterritorialization of ulcerative craters with excision of the remnants (islands) of the mucosa of the duodenal bulb;

- the use of stenotically modified postbulbar part of the duodenum 12 as a frame in the formation of the stump;

- only the intestinal wall is used in the formation of the stump, which prevents injury to neighboring organs (pancreas);

- the use of a two-level continuous suture that does not penetrate the intestinal lumen, reduces the likelihood of infection and increases the contact area of the serous membranes of the stitched walls and, therefore, the mechanical strength of the suturing site;

- reduced trauma of the intestinal wall due to the use of absorbable atraumatic suture material.

According to this method, the stump of the duodenum was closed in three patients, stump failure, postoperative pancreatitis and other complications were not noted.

Patient V., 36 years old, case history No. 10955, was admitted and operated on in BSMP-2 in Omsk on 08/18/09., Was discharged on the 16th day, with recovery.

Patient N., 63 years old, case history No. 4557, was admitted and operated on in BSMP-2 in Omsk on 03/29/10, was discharged on the 14th day, with recovery.

Patient V., 61 years old, case history No. 16816, was admitted and operated on at the BSMP-2 in Omsk on 09.11.10., Was discharged on the 17th day, with recovery.

Claims (1)

A method of forming a stump of the duodenum with a giant complicated circular ulcer, comprising applying a continuous two-level suture, characterized in that the front wall of the duodenal bulb is longitudinally dissected orally to the resection border and aborally from the perforated opening to the stenosis line, the posterior wall of the duodenum is separated , 0 cm from the distal edge of the ulcerative crater penetrating into the head of the pancreas, impose a continuous screw serous-muscular o-serous suture, and the first stitch of the suture is made on the posterior wall of the intestine with the capture of the serous-muscular layer at a distance of 0.3 cm from the distal edge of the ulcerative crater, penetrating into the head of the pancreas, a knot is fixed, restoring the integrity of the peritoneal wall intestines, then impose 4-5 stitches of a continuous screwing serous-muscular-serous suture, without penetrating into the lumen of the intestine and immersing the ring of ulcerative stenosis, make the last injection at a distance of 2.0 cm from the stenotic opening, the tightening thread they are wound until the fabrics come into contact and a second knot is formed, the fixer, with the same thread in the opposite direction at a distance of 0.5 cm from the first seam line, immerse the last with a twisted gray-serous suture, tightening it until the fabrics come into contact and tying the end of the thread with the thread of the first “Clamps”, at a distance of 1.5 cm cranially and caudally from the suture line, two converging gray-serous nodal sutures are applied, the threads of the first and second nodes “fixers” are connected to each other, immersing the suture line inward, then the stomach is resected according to one of modifications Billroth-2 or Ru.

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