RU2840047C1 - Method for hiatal hernia repair in surgical management of morbid obesity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery. First stage involves correction of hiatal hernia and posterior cruroraphy. At the second stage, a mini-gastric bypass is performed by crossing the stomach and dividing it with a stapling apparatus into two parts: a small and large stomachs with a gastroenteroanastomosis applied at 150 cm from the Treitz ligament. Third step is used to form fundoplication cuff 300° from a greater stomach with interrupted intracorporeal sutures.

EFFECT: method allows to perform hiatal hernia repair, to create an antireflux structure under conditions of mini-gastric bypass, to provide a pronounced stable effect of body weight reduction, correction of metabolic syndrome.

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Description

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of patients with obesity in combination with a hernia of the esophageal opening of the diaphragm.

Analogues

Analogue 1

A method for treating patients with obesity in combination with a hernia of the esophageal opening of the diaphragm is known (Nedelcu M., Noel P., Loureiro M. et al. Loureiro Journal of Laparoendoscopic & Advanced Surgical Techniques. - 2020; 30 (8): 907-911.), according to which a laparoscopic longitudinal resection of the stomach is performed leaving a section of the fundus of the stomach along the greater curvature in the area of the angle of His to form a Nissen fundoplication cuff. The remaining part of the fundus of the stomach in the area of the angle of His is encircled around the formed sleeve in the area of the esophageal-gastric junction and sutured together with three separate interrupted sutures to maintain its natural position.

Criticism of Analogue 1

The disadvantages of the described method are the leaving of a non-vascularized area of the fundus of the stomach in the area of the angle of His, which increases the risk of ischemia, which in turn increases the risk of developing failure of the stapler suture line in this area, the absence of a bypass component of the operation, which reduces the effectiveness of the bariatric procedure in terms of correcting comorbid diseases.

Analogue 2

A method of laparoscopic surgical treatment of obesity is known (Patent RU 2479266 C1), in which the greater curvature of the stomach is mobilized, longitudinal vertical gastroplication is performed with suturing on an esophagogastric bougie tube the edges of the fold immersed inward from the wall of the greater curvature of the stomach with the creation of the external shape of the organ in the form of a tube, characterized in that after mobilization of the greater curvature of the stomach, antireflux fundoplication is performed around the esophagus, and then the longitudinal fold of the greater curvature of the stomach is immersed inside the lumen of the organ up to the fundoplication cuff with the possibility of passing a food bolus.

Criticism of Analogue 2

The disadvantage of this method is the insufficient effectiveness of the bariatric procedure, due to the preservation of part of the fundus of the stomach, which increases the volume of the resected stomach.

Prototype

The closest to the claimed method is the method of surgical treatment of obesity and concomitant gastroesophageal reflux disease (Patent RU 2739676 C1). This method is taken as a prototype. It includes a reduction in the volume of the stomach by rolling up the mobilized greater curvature of the stomach in the form of a "roll", while before mobilizing the stomach along the greater curvature and rolling up the stomach wall in the form of a "roll", the abdominal section of the esophagus is mobilized with the formation of a "window" behind the esophagus and passing the fundus of the stomach through this "window", while the greater curvature of the stomach rolled in the form of a "roll" in the upper part is fixed to the fundus of the stomach passed through the "window" behind the abdominal section of the esophagus.

Criticism of the prototype

The disadvantages of the prototype method are the insufficient effectiveness of antireflux intervention and the insufficient effectiveness in the long term of reducing excess body weight and correcting metabolic syndrome.

Purpose of the invention

The aim of the claimed invention is to increase the effectiveness of antireflux, in case of diaphragmatic hernia plastic surgery, and bariatric, in case of morbid obesity, surgical interventions. Providing a pronounced stable effect of weight loss due to the inclusion of a malabsorptive component.

The essence of the invention

The essence of the invention is illustrated in Fig. 1, where pos. 1 is posterior cruroraphy, pos. 2 is fundoplication cuff, pos. 3 is small stomach, pos. 4 is large stomach, pos. 5 is gastroenteroanastomosis; Fig. 2; Fig. 3; Fig. 4; Fig. 5; Fig. 6; Fig. 7; Fig. 8; Fig. 9.

The essence of the invention is as follows.

The set task is achieved by laparoscopic plastic surgery of the hernia of the esophageal opening of the diaphragm (Fig. 2), posterior cruroraphy (Fig. 1 pos. 1; Fig. 3), mini-gastroshunting with the imposition of a gastroenteroanastomosis (Fig. 1 pos. 5; Fig. 6) with a small stomach (Fig. 1 pos. 3), and the formation of an antireflux fundoplication cuff 300° (Fig. 1 pos. 2; Fig. 7; Fig. 8) from a large stomach (Fig. 1 pos. 4; Fig. 7; Fig. 8).

Under endotracheal anesthesia (ETA), a laparoscopic approach is performed through an incision in the paraumbilical region; additionally, manipulation trocars are installed under optical control. The abdominal cavity is inspected, followed by an assessment of the esophageal opening of the diaphragm and the condition of the esophageal-gastric junction. The first stage involves correction of the hernia of the esophageal opening (Fig. 2) and posterior cruroraphy (Fig. 1 pos. 1; Fig. 3). For this purpose, the abdominal part of the esophagus, diaphragmatic crura, cardia, and fundus of the stomach are mobilized (Fig. 2). Then, the crura of the diaphragm are sutured behind the esophagus with intracorporeal single interrupted sutures using non-absorbable suture material (Fig. 3). The second stage involves mini-gastrosurgery by transecting the stomach and dividing it into two parts with a suturing apparatus (Fig. 4; Fig. 5): the small stomach (Fig. 1 pos. 3; Fig. 5) and the large stomach (Fig. 1 pos. 4; Fig. 5). The small stomach (Fig. 1 pos. 3) is formed in the form of a 23 cm tube along the lesser curvature on a 39 Fr calibrated orogastric tube. Then, a gastroenteroanastomosis is formed with the latter (Fig. 1 pos. 5; Fig. 6), retreating 150 cm from the Treitz ligament, using a suturing apparatus and subsequent manual suturing of the defect. In the third stage, a 300° fundoplication cuff (Fig. 1 pos. 2; Fig. 7; Fig. 8) is formed from the large stomach (Fig. 1 pos. 4) using intracorporeal interrupted sutures with non-absorbable suture material. After hemostasis control (Fig. 9) and anastomosis leakage test, the orogastric tube is removed. Desufflation is performed, trocars are removed, and wounds are sutured.

Summarizing the essence of the proposed method, it can be noted that the first stage involves plastic surgery of the esophageal hernia and posterior cruroraphy, the second stage involves mini-gastroshunting with the imposition of a gastroenteroanastomosis at a distance of 150 cm from the Treitz ligament, and the third stage involves forming a 300° fundoplication cuff from the large stomach using interrupted intracorporeal sutures.

The invention is illustrated by specific examples of the method implementation.

Example 1.

Patient Sh., 60 years old, complained of heartburn, belching, a feeling of a lump and periodic pain behind the breastbone, bradycardia, shortness of breath during physical exertion, and the ineffectiveness of conservative methods of weight loss. She considers herself ill for a long time when she began to notice heartburn, belching, and a feeling of a lump behind the breastbone. She had been independently taking antisecretory, antacid, and gastroprotective drugs for a long time - with a short-term partial positive effect. Subsequently, she noted the addition of pain behind the breastbone, shortness of breath, and bradycardia. During an outpatient examination, signs of hiatal hernia complicated by reflux esophagitis were detected. At the time of surgery, BMI was 44.7 kg/m ² .

After additional examination and preoperative preparation for ETN, a 10 mm trocar was inserted through an incision in the paraumbilical region above the umbilicus, an inevmoperitoneum of 12 mm Hg was formed, and a laparoscope was inserted. During revision: no iatrogenic damage to internal organs, visceral obesity is determined. The liver is not enlarged, the surface is smooth, no focal changes are revealed. The stomach and visible areas of the duodenum are unchanged. Dilation of the esophageal opening of the diaphragm with dislocation of the cardiofundal complex to the posterior mediastinum is determined. The loops of the small and large intestines are not dilated, peristalsis is traced. Additionally, under the control of the laparoscope, a 10 mm trocar was inserted in the epigastric region, a 14 mm trocar in the right mesogastric region and two 5 mm trocars in the left mesogastric region and in the left hypochondrium. With technical difficulties, mobilization of the abdominal esophagus and fundus of the stomach was performed using the LigaSure device. A hernial sac with a posterior mediastinal lipoma was isolated. The latter were removed through a 14 mm trocar. Posterior cruroraphy was performed by applying intracorporeal interrupted sutures with non-absorbable suture material (Ethibond Excel 2/0) to the crura of the diaphragm. The stomach was mobilized along the greater curvature, starting from the antral section to the fundus of the stomach with transection of the ligamentous apparatus. Mini-gastrostomy was performed using the Echelon Flex Ethicon 60 mm device with formation of a small stomach in the form of a 23 cm tube with subsequent application of anastomosis between the latter and the jejunum at a distance of 150 cm from the Treitz ligament (single-anastomosis bypass) using 2 yellow, 2 green, 1 blue cassettes. Next, a 300° fundoplication cuff was formed from the large stomach using interrupted intracorporeal sutures with non-absorbable suture material (Ethibond Excel 2/0). Hemostasis control - dry. Anastomosis tightness test - tight. The orogastric tube was removed. A drainage tube was inserted into the surgical area through a trocar in the left hypochondrium. The trocars were removed in stages. The aponeurosis defect was sutured with interrupted sutures. Desufflation. Sutures on the skin. As. dressings.

The postoperative period was uneventful. The immediate and remote results of surgical treatment were satisfactory. In the early postoperative period, after 1 month, at control visits to the surgeon, no complications were observed, a decrease in body weight and an improvement in the quality of life were recorded.

Example 2.

Patient G., 52 years old, complained of heartburn, belching, a feeling of heaviness behind the breastbone, bradycardia, episodes of increased blood pressure, shortness of breath during physical exertion, psychological and physical discomfort from excess weight, and the ineffectiveness of conservative methods of weight loss. She considers herself ill for 10 years, when she began to notice heartburn, belching, and a feeling of a lump behind the breastbone. She had been independently taking antisecretory, antacid, and gastroprotective drugs for a long time - with a positive effect during the period of intake and a return of the clinical picture during the withdrawal period. Against the background of weight gain (BMI = 39.44 kg/m ² ), she noted an increase in the clinical picture, the addition of shortness of breath and bradycardia, and episodes of increased blood pressure. During an outpatient examination, signs of hiatal hernia complicated by reflux esophagitis were revealed.

After additional examination and preoperative preparation for ETN, a 10 mm trocar was inserted through an incision in the paraumbilical region above the umbilicus, a pneumoperitoneum of 12 mm Hg was formed, and a laparoscope was inserted. During revision: no iatrogenic damage to internal organs, visceral obesity is determined. The liver is enlarged mainly due to the left lobe, the surface is smooth, focal changes are not revealed. The stomach, visible areas of the duodenum are unchanged. The loops of the small and large intestine are not dilated, peristalsis is traced. An additional 5 mm trocar was inserted in the left mesogastric region. During further revision, a significantly dilated esophageal opening of the diaphragm with dislocation of the cardiofundal complex to the posterior mediastinum is determined. Additionally, under laparoscopic control, a 10 mm trocar was installed in the epigastric region, a 14 mm trocar in the right mesogastric region, and a 5 mm trocar in the left hypochondrium. A 39 Fr orogastric tube was installed under laparoscopic control. The right and left crura of the diaphragm, abdominal esophagus, and fundus of the stomach were mobilized using the LigaSure device. Posterior cruroraphy was performed by applying intracorporeal interrupted sutures with non-absorbable suture material (Ethibond Excel 2/0) to the crura of the diaphragm. The stomach was mobilized along the greater curvature, starting from the antral section to the fundus of the stomach with intersection of the ligamentous apparatus. Mini gastrosurgical bypass was performed using the Echelon Flex Ethicon 60 mm apparatus with formation of a small stomach in the form of a 23 cm tube, followed by the application of a hardware gastroenteroanastomosis between the latter and the jejunum at a distance of 150 cm from the Treitz ligament (single-anastomosis bypass). Then, a 300° fundoplication cuff was formed from the large stomach with interrupted intracorporeal sutures using non-absorbable suture material (Ethibond Excel 2/0). Hemostasis control - dry. Anastomosis tightness test - tight. Orogastric tube removed. A drainage tube was inserted into the surgical area through a trocar in the left hypochondrium. The trocars were removed in stages. The aponeurosis defect was sutured with interrupted sutures. Desufflation. Sutures on the skin. As. dressings.

The operation lasted 2 hours. The postoperative period was uneventful. The immediate and remote results of the surgical treatment were satisfactory. In the early postoperative period, after 1 month, no complications were observed at the control visits to the surgeon, a decrease in body weight and an improvement in the quality of life were recorded.

Features of an invention that distinguish it from a prototype

The features of this method, which are distinctive from the prototype, are: the first stage involves plastic surgery of the esophageal hernia and posterior cruroraphy, the second stage involves mini-gastroshunting with the imposition of a gastroenteroanastomosis at a distance of 150 cm from the Treitz ligament, and the third stage involves forming a 300° fundoplication cuff from the large stomach using interrupted intracorporeal sutures.

The positive effect obtained from the use of the invention

The method allows performing plastic surgery of the esophageal opening of the diaphragm, creating an antireflux structure under mini-gastroshunting conditions. The result of using the invention is an increase in the effectiveness of antireflux, in plastic surgery of the esophageal opening of the diaphragm, and bariatric, in morbid obesity, surgical interventions. Providing a pronounced stable effect of weight loss, correction of metabolic syndrome due to the inclusion of a malabsorptive component.

Information taken into account

Patent RU 2739676 C1 – prototype.

Claims (1)

A method for plastic surgery of a hernia of the esophageal opening of the diaphragm in the surgical treatment of morbid obesity, characterized by the fact that the first stage involves plastic surgery of the hernia of the esophageal opening and posterior cruroraphy, the second stage involves mini-gastroshunting by transecting the stomach and dividing it with a suturing device into two parts: the small and large stomachs with the imposition of a gastroenteroanastomosis, retreating from the Treitz ligament by 150 cm, and the third stage involves forming a 300° fundoplication cuff from the large stomach with interrupted intracorporeal sutures.