RU2545919C1 - Method for biliary repair in gautier's orthotopic transplantation of left lateral hepatic sector in children with separated bile duct apertures of ii and iii hepatic segments - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: biliodigestive end-to-side anastomosis are formed between the ducts of transplanted II and III hepatic segments and a recipient's Roux-excluded jejuneal loop. The transplant preserves a round ligament of liver at least 7 cm long when mobilising the left lateral donor's hepatic sector. Holes are formed in the side intestinal wall in a number equal to the number of anastomosed bile ducts. The intestinal mucosa is fixed on the periphery of each hole to a serous-muscular layer. The anastomosis are formed between the created intestinal holes and bile ducts. The intestine is fixed to the transplant at a distance on either side from the anastomosis along the anastomosis line. The round ligament of liver is placed on anterior lips of the anastomosis. A distal end of the ligament is fixed to the transplant.

EFFECT: method enables avoiding complications, prevents inconsistency and strictures of the biliodigestive anastomosis by reliable coverage of the anastomosis of the round ligament of liver, fixing the intestine additionally within the mouths eliminating suture tension, enlarging the diameter of the anastomosed site of the bile ducts by simulating it, provides the optimum blood circulation in the anastomosed intestine by selecting an area of the anastomosed holes therein.

8 cl, 1 ex

Description

The invention relates to medicine, namely to surgery and transplantology, and can be used for transplantation of the left lateral sector of the liver to children.

Liver transplantation is the only radical treatment for fatal diseases such as cirrhosis, acute hepatic cell failure, inoperable liver tumors without extraorgan metastasis, as well as some other diseases.

Various cholestatic diseases, iron accumulation diseases, liver diseases caused by malnutrition and metabolism, as well as many other diseases lead to cirrhosis in children. Among children under 2 years of age, the most common indications for liver transplantation are biliary atresia, Byler’s disease, and cirrhosis of the liver as part of Aladzhil’s syndrome.

Due to the lack of a legislative framework in Russia for performing liver transplantation from a post-mortem donor-child, the only possibility for such patients to perform a liver transplant is transplantation of a liver fragment from a living related donor or a split liver of a post-mortem donor (Split transplant). For children weighing up to 15 kg, the left lateral sector of the liver, which is most often transplanted into an orthotopic position, is most often used as a liver fragment.

The most common surgical complications in this case (according to various sources, from 10 to 40%) are biliary complications due to the failure of the biliary digestive anastomosis, which lead to the formation of incomplete external bile fistulas, bile ducts, etc., as well as strictures of biliary anastomoses.

A known method of performing transplantation of the left lateral sector of the liver to children, we have chosen as a prototype (Tanaka K, Uemoto S, Tokunaga Y, et al. Surgical techniques and innovations in living related liver transplantation. Ann Surg 1993; 217: 82-91).

The prototype method involves obtaining a graft at the donor stage by resection of the left lateral sector of the liver in conditions of preserved blood circulation with the receipt of one or more mouths of the bile ducts. After the recipient undergoes hepatectomy with preservation of the posthepatic inferior vena cava, the resulting transplant is placed in an orthotopic position. Vascular revascularization begins with the application of an anastomosis of the left hepatic vein graft with the combined mouths of the hepatic veins of the recipient or the wall of the inferior vena cava by the type of "end-to-end" or "end-to-side", respectively. The next step is the reconstruction of the portal and arterial vessels of the transplant and the recipient. After the start of blood flow and final hemostasis, biliary reconstruction is carried out as follows: the mouths of the bile ducts of the graft are anastomosed with a loop of the donor's intestine isolated by Roux (Ru) and performed end-to-end, side-by-side.

The main and most significant disadvantage of this method is the high incidence of insolvency of biliodigestive anastomoses with the formation of an incomplete externally biliary fistula and / or bile duct.

The causes of insolvency are objective anatomical conditions that make it difficult to impose these anastomoses, especially the small diameter of the bile ducts.

We set the task to develop a method of biliary reconstruction (bile duct) during transplantation of the left lateral sector of the liver to children if the transplant has separate openings of the bile ducts of the II and III segments of the liver, which ensures the consistency of the biliary digestive anastomosis.

The technical result achieved by the implementation of the proposed method consists in

1) the prevention of complications caused by the development of an incomplete external biliary fistula and / or biliary leak due to the prevention of the development of insolvency of biliodigestive anastomoses by:

- their additional sealing as a result of the original peritonization;

- increasing the diameter of the anastomosed biliary tract as a result of its modeling;

- exclusion of tension in the area of anastomoses;

- prevention of the formation of "blind" anastomoses due to the overlapping zone of biliodigestive anastomosis of the intestinal mucosa;

- ensuring optimal blood circulation in the anastomosed intestine due to the choice of the zone of formation of anastomosed holes in it;

2) the prevention of strictures of biliodigestive anastomoses by increasing the diameter of the anastomosed biliary tract as a result of its modeling.

We were able to find material suitable for peritonization of biliodigestive anastomoses during reconstruction of the biliary tract during transplantation of the left lateral sector of the liver to children. It turned out that the “elongated” round liver ligament left on the graft during its formation can be successfully transferred to the area of biliodigestive anastomoses. The topographic and anatomical location of the formed round ligament of the liver transplant allows you to reliably cover her front lips of the imposed anastomoses.

We propose a set of measures that complement each other, as a result of which the prevention of insolvency of biliodigestive anastomosis is achieved.

Additional fixation of the intestine in the anastomosis zone, which excludes the tension of the sutures, in combination with peritonization allows you to get a more intimate fit of the ligament to the anastomoses front lips.

The invention consists in the following. For biliary reconstruction (restoration of biliary excretion) during orthotopic transplantation of the left lateral sector of the liver, children with separate mouths of the bile ducts of the II and III segments of the liver are placed with biliodigestive anastomoses between the bile ducts of the II and III segments of the transplant liver and the recipient’s jejunum loop disconnected according to Ru side-by-side. ” At the same time, when the left lateral sector of the liver is removed from the donor, a round liver ligament of at least 7 cm in length is left on the graft. After formation of holes in the intestinal wall, the number of anastomosed bile ducts along the edges of each hole fix the intestinal mucosa to its serous-muscular layer. Then anastomoses are formed between the created holes in the intestine and the bile ducts. After that, the intestine is fixed to the graft, departing from the area of the anastomoses on both sides along the line of the anastomoses. Lay the round ligament of the liver of the graft on the front lips of the anastomoses and fix the distal end of the ligament to the graft.

In special cases:

- before applying biliodigestive anastomoses, at least one mouth of the bile duct is dilated, for which a duct wall is cut by 2-4 mm along a bouge with a diameter of 1-1.5 mm previously inserted into the mouth;

- openings form in the mesenteric edge of the intestine;

- fixation of the mucosa to the serous-muscular layer is performed along the edges of each hole in the intestine with 3-6 separate interrupted sutures;

- biliodigestive anastomoses form separate interrupted sutures;

- for fixation of the intestine, it is sutured with the capture of the serous-muscular layer at a distance of 4-8 mm from the region of anastomoses to the capsule of the liver or connective tissue plate, in which the bile ducts of the graft pass;

- the distal end of the round ligament of the liver is fixed with one or two sutures to the capsule of the liver or connective tissue plate, in which the bile ducts of the graft pass;

- the distal end of the round ligament of the liver is fixed to the graft with suture threads that fix the intestine to the graft.

The method is as follows.

When transplanting the left lateral sector of the liver from a living (adult) related donor or from a posthumous (adult) donor (Split transplantation), anatomical resection of the left lateral sector of the liver is performed under conditions of preserved blood circulation.

Remove the recipient’s own liver while preserving the posterior hepatic region of the inferior vena cava.

The left lateral sector of the liver is implanted in an orthotopic position with restoration of the caval, portal and arterial tributaries. The restoration of bile duct transplant (biliary reconstruction) is carried out by anastomosing the bile ducts of the II and III segments of the liver of the transplant with the Roux (Roux) loop of the recipient’s jejunum, carried out end-to-end side-by-side.

At the stage of laparotomy, the donor’s round ligament is ligated and cut closer to the anterior abdominal wall so that its length is at least 7 cm.

Then, the donor mobilizes the left lobe of the liver with the release of the left hepatic vein and elements of the hepatoduodenal ligament. Selective ligation and intersection of 3 portal branches extending from the vertical branch of the portal vein to the IV segment of the liver, as well as the 1st branch to the first segment of the liver, is carried out, thus mobilizing the left branch of the portal vein.

The border of the resection passes to the right by 0.5 cm from the crescent ligament of the liver towards the gate of the liver, taking into account the mandatory preservation of the portal and arterial tributaries to the right lobe of the liver and bile duct from it.

Separation of the parenchyma in the volume of the left lateral lateral sectorectomy of the liver is performed by bipolar and monopolar coagulation in combination with irrigation of the resection area with physiological saline.

Vascular elements are ligated and dissected in the process of separation of the parenchyma in conditions of continued circulation. After dissection of the liver parenchyma in a “cold” way (using surgical instruments), the left hepatic duct is crossed with the formation of separate orifice of the bile ducts. The wall defect of the left hepatic duct on the stump of the donor liver is sutured with monofilament with a continuous upholstery.

The left hepatic artery is ligated and transected. Two vascular clamps are applied to the left branch of the portal vein. The mouth of the left hepatic vein is squeezed by a vascular clamp. The left branch of the portal vein and the left hepatic vein are sequentially cut off. Perform cold preservation of the left lateral sector by perfusion of the preservation solution through the portal vein.

The next step is to perform a hepatectomy in the recipient with preservation of the inferior vena cava, the maximum length of the portal vein fragments and the hepatic artery proper. Having removed the liver, the defects of the inferior vena cava are sutured in the area of the mouths of the median and left hepatic veins, as well as the communicative veins from the VI-VIII segments of the liver.

Then the mouth of the recipient’s left hepatic vein is excised, the mouth of the hepatic veins is combined to form an oval “window” and a hepaticocaval anastomosis is formed. Then a portal anastomosis is formed, after which the transplant is reperfused.

Then an arterial anastomosis is applied. Having completed the final hemostasis, they proceed to the formation of bile duct (biliary or biliary reconstruction).

By the Roux technique (according to Ru), a loop of the jejunum is formed 30-40 cm long at a distance of 30-40 cm from the ligament of Treitz. The loop of the intestine is carried out posteriorly and laid in such a way as to avoid twisting and bending of its mesentery.

The coagulator forms openings in the anti-mesenteric edge of the selected intestine in accordance with the diameters of the anastomosed bile ducts of the II and III segments of the liver.

Separate, nodal 3-6 sutures, depending on the size of the opening in the intestinal wall, fix the intestinal mucosa to its serous-muscular layer along the edges of each formed opening in the intestine. Then, anastomoses between the bile ducts and the intestine of the end-to-side type are formed by separate interrupted sutures.

In the particular case, before applying biliodigestive anastomoses, at least one mouth of the bile duct is dilated, for which a duct wall is cut by 2-4 mm, and the direction of dissection is determined by the bougie with a diameter of 1-1.5 mm previously inserted into the mouth.

Dissection of the ducts is carried out by increasing their initial small diameter, which allows you to create a wider anastomosis and is the prevention of anastomotic strictures.

A thin bougie (1-1.5 mm in diameter) allows you to determine the optimal direction of dissection of the duct wall and parenchyma above it, that is, to choose a duct wall for dissection, which is located more superficially.

After the formation of anastomoses, a loop of the intestine with individual nodular serous-muscular sutures is fixed to the graft, departing in both directions from the line of anastomoses (on each side). For example, the intestine is sutured with separate nodular sero-muscular sutures to the connective tissue plate in which the bile ducts of the transplant pass, or to the liver capsule at a distance of 4-8 mm from the anastomotic region with individual nodular sutures.

The portal or connective tissue plate in which the bile ducts pass is described in detail in Art .: Anatomy of the hepatic hilar area: the plate system. Kawarada Y, Das BC, Taoka H. J Hepatobiliary Pancreat Surg. 2000; 7 (6): 580-6.

Anatomically, the circular ligament is located in such a way that moving it to the region of anastomoses, it is possible to peritonize their anterior semicircles. Pre-applied fixing sutures allow you to avoid tension in the area of anastomoses.

A round ligament of the liver of the graft is placed on the front lips of the biliodigestive anastomoses along them and the distal end of the ligament is fixed in this position with one or two sutures to the graft. The round ligament of the liver is laid in such a way that it intimately fits in the area of anastomoses to the intestine and transplant.

The distal end of the ligament can be fixed to the capsule of the liver or connective tissue plate, in which the bile ducts of the graft pass. The distal end of the liver ligament can be fixed, for example, with suture threads that fix the intestine to the graft.

The round ligament of the liver effectively peritonizes the anterior semicircles of biliodigestive anastomoses, which are most prone to the development of insolvency.

The intestine is additionally fixed with 2-3 separate nodular serous-muscular sutures in the “window” of the mesentery of the transverse colon.

Then the abdominal cavity is drained, the surgical wound is sutured and closed with an aseptic dressing.

To prove the possibility of realizing the claimed purpose and achieving the specified technical result, we provide the following data.

Clinical example

Patient A., 5 months., And. 1438 / 13C.

The abdominal cavity was opened in layers with a bisubcostal incision. The liver is enlarged, dense. Splenomegaly is moderate. Mobilization of both lobes of the liver and inferior vena cava (IVC) under the diaphragm and under the liver. Bypass of the inferior vena cava above and below. As part of the hepatoduodenal ligament, its own hepatic artery was discovered, dichotomously dividing into the left and right lobar branches. The gastro-duodenal artery is ligated, crossed. Skeletal portal vein, having a diameter of 4.5 mm. The portal vein is pinched and cut off from the liver in the bifurcation region. The IVC is pinched by vascular clamps under the diaphragm and above the mouth of the renal veins. The liver was removed, defects in the HUB wall were sutured, an oval window was formed from the mouths of the hepatic veins. The graft is placed in the position of the left lateral sector of the liver. The opening of the hepatic vein of the graft is expanded to 3.0 cm and anastomosed with an oval opening in the HUB (PDS 4/0). In the process of applying a cava-caval anastomosis, the portal system of the graft is perfused with 100 ml of 10% albumin solution. An anastomosis was placed between the portal vein of the transplant and the portal vein of the recipient "end-to-end" with a twisted suture (PDS 6/0). The start of portal blood flow. The filling of the transplant with blood is uniform, timely. Anastomoses are tight. 2-3 minutes after the start of portal blood flow, bile began to secrete from the mouths of the hepatic ducts of the graft. For arterial revascularization, it was decided to use the trunk of its own hepatic artery. The internal diameter of the transplant artery is 2 mm. The diameter of the recipient's own hepatic artery is 1.8 mm. Anastomosis is applied end-to-end (Prolene 7/0) with a continuous suture. Start arterial blood flow. Artery ripple is satisfactory.

At a distance of 40 cm from the Treitz ligament, a loop of a jejunum 40 cm long is turned off along Ru. An end-to-side enteroanastomosis is applied with a single-row suture with Prolene 5/0 thread. In the anti-mesenteric region of the intestine at a distance of 6 mm from each other, which corresponds to the distance between the ducts on the graft, two holes with a diameter of 3 mm are formed in accordance with the diameters of the anastomosed bile ducts. At the edges of each hole 4 nodal sutures were applied, fixing the intestinal mucosa to the serous-muscular layer with PDS 6/0 thread. Further, two transplant ducts are sequentially anastomosed with two holes of the intestinal loop turned off according to Ru (PDS 5/0) end-to-side with separate interrupted sutures. Above the distal biliodigestal anastomosis and below the proximal anastomosis at a distance of 5 mm from the corners of the extreme anastomoses (that is, departing from the region of the anastomoses on both sides along the line of anastomoses of 5 mm), nodal sutures are fixed that fix the intestine to the transplant. Anastomoses are sealed with a round ligament of a liver transplant 9 cm long according to the proposed method, the ligament is fixed with a PDS 5/0 nodal suture to the graft above biliodigestive anastomoses. Two drains into the right subphrenic space, between the graft and stomach and into the pelvis. Layered closure of the wound of the anterior abdominal wall. Aseptic wound dressing. The postoperative period is smooth. The transplant function is satisfactory. The patient was discharged from the hospital.

The proposed method was successfully implemented in 9 patients with transplantation of the left lateral sector of the liver to children, the development of insolvency, strictures imposed by the proposed method biliodigestive anastomoses were not observed.

Claims (8)

1. The method of biliary reconstruction during orthotopic transplantation of the left lateral sector of the liver in children with separate mouths of the bile ducts of the II and III segments of the liver, including the application of biliodigestive anastomoses "end-to-side" between the bile ducts of the II and III segments of the transplant liver and a loop disconnected along the Ru jejunum of the recipient, characterized in that when mobilizing the donor of the left lateral sector of the liver, a round liver ligament of at least 7 cm in length is left on the transplant after formation in the lateral the intestinal wall of the holes according to the number of anastomosed bile ducts along the edges of each hole fix the mucosa to the serous-muscular layer, then anastomoses form between the created holes in the intestine and the bile ducts, after which the intestine is fixed to the graft, departing from the region of anastomoses on both sides along the line of anastomoses, then a round ligament of the liver is placed on the front lips of the anastomoses and the distal end of the ligament is fixed to the graft. 2. The method according to claim 1, characterized in that before applying the biliodigestive anastomoses, at least one mouth of the bile duct is dilated, for which a duct wall is cut by 2-4 mm along a bouge with a diameter of 1-1.5 mm previously inserted into the mouth. 3. The method according to claim 1, characterized in that the holes are formed in the anti-mesenteric edge of the intestine. 4. The method according to claim 1, characterized in that the fixation of the mucosa to the serous-muscular layer is performed along the edges of each hole in the intestine with 3-6 separate interrupted sutures. 5. The method according to claim 1, characterized in that biliodigestive anastomoses form separate interrupted sutures. 6. The method according to claim 1, characterized in that for fixation of the intestine it is sutured with the capture of the serous-muscular layer at a distance of 4-8 mm from the region of anastomoses to the capsule of the liver or connective tissue plate, in which the bile ducts of the graft pass. 7. The method according to claim 1, characterized in that the distal end of the round ligament of the liver is fixed with one or two sutures to the capsule of the liver or connective tissue plate, in which the bile ducts of the graft pass. 8. The method according to claim 1, characterized in that the distal end of the round ligament of the liver is fixed to the graft with suture threads that fix the intestine to the graft.