RU2802999C2 - Method of forming laparoscopic sted gastrostomy - Google Patents

Abstract

FIELD: medicine; laparoscopic gastroenterology.

SUBSTANCE: stomach is mobilized along the lesser curvature. The anterior wall of the stomach is stitched and hung out on ligatures in the proximal and distal direction of the intended stem. A gastric stalk is formed with a linear stapler, the line of the mechanical suture on the stomach is additionally covered with serous-muscular sutures. The place of removal of the stalked gastrostomy on the anterior abdominal wall is designed. An additional 12 mm port is installed. The upper edge of the formed stem is captured by the line of the mechanical suture and the carboxyperitoneum is desufflated. The 12 mm port is removed along with the formed gastric stalk. The end of the gastrostomy is opened and fixed to the skin with separate interrupted sutures, a feeding probe is inserted and fixed to the skin.

EFFECT: method allows to achieve good immediate and long-term results of surgical treatment of patients after the formation of a gastrostomy in a minimally invasive way; activate the patient as soon as possible; re-start the probe when it falls out; reduce the risk of purulent-septic complications; save a large curvature of the stomach as a reserve material for esophageal plastic surgery; form a gastrostomy in the presence of an adhesive process or a low-mobility stomach; reduce the risk of postoperative ventral hernias.

1 cl, 8 dwg, 1 ex

Description

The invention relates to medicine, namely to laparoscopic methods for forming gastrostomies and can be used in the surgical practice of medical institutions in surgical hospitals.

Correction of nutritional status and metabolic disorders is one of the main parts of complex therapy in severe patients who, for one reason or another, are not able to eat orally. Artificial nutrition is an obligatory and necessary component of treatment in this group of patients.

Experimental and clinical studies indicate that enteral nutrition (oral or tube feeding) has many beneficial effects compared to parenteral nutrition. These effects include maintaining the intestinal mucosal barrier, reducing intestinal and other infections, and improving the overall prognosis of patients on long-term artificial nutrition. Currently, the advantages of enteral nutrition in the complex treatment of cancer patients and patients with impaired swallowing function (after acute cerebrovascular accident, amyotrophic lateral sclerosis, etc.) are undeniable. The choice between parenteral nutrition, tube placement, or surgery (gastrostomy, jejunostomy) must be assessed on a case-by-case basis by a multidisciplinary team, taking into account multiple factors such as the patient's condition, clinical scenario, and the patient's risk of adverse events. According to the latest recommendations of the European Society of Gastrointestinal Endoscopy, it is recommended to consider gastro- or jejunostomy when nutritional support is needed for 4 weeks or more, since long-term enteral nutrition using an intestinal tube is not possible due to the threat of pressure ulcers, which limits the period of its presence in the lumen of the gastrointestinal tract . Today, there are a huge number of ways to form gastro- and jejunostomies.

There is a known method of forming a gastrostomy according to Witzel (atlas "Operative Surgery", A.N. Shabanov, V.I. Kushkhabiev, B.K. Veli-Zade. - M., 1977, p. 91), which consists in the fact that through an incision parallel to the left costal arch on the anterior wall of the stomach in the middle of the distance between the greater and lesser curvatures, a thick rubber tube is placed and a channel 5-6 cm long is created around the tube with separate interrupted sutures. Then a purse-string suture is placed at the end of the tube in the antrum of the stomach, in the center of which the lumen of the stomach is opened. The end of the tube is immersed in the hole, and the purse string suture is tightened. The free end of the tube remains outside, and the wall of the stomach at the entrance of the tube into the canal is sutured to the abdominal wall. The wound is sutured in layers down to the tube.

However, one of the disadvantages of this method is the absence of a direct gastrostomy channel through which it is impossible to re-pass the tube if it falls out. In addition, the presented method does not provide for isolation of subcutaneous tissue when gastric contents leak along the canal, which leads to suppuration of the wound and significantly increases the risk of developing peritonitis.

A known method of percutaneous endoscopic gastrostomy (US 5112310, May 12, 1992). The essence of this analogue method is as follows. The patient is placed on his back. The endoscope is inserted into the stomach. The assistant determines the location of the most pronounced diaphanoscopy. This place is usually located in the upper left quadrant at a distance of two thirds along the line connecting the navel and the left costal arch. After identifying this area, the skin is treated with an antiseptic. Local conduction anesthesia of the skin, subcutaneous fat and aponeurosis is performed with a lidocaine solution. A scalpel is used to make a skin incision 0.5-1 cm long. A polypectomy loop is passed through the instrumental channel of the endoscope. Its far part is located in the zone of the most pronounced diaphanoscopy. A trocar with a stylet with a diameter of 1.25 mm is used to pierce the aponeurosis and the anterior wall of the stomach through an incision on the anterior abdominal wall. The stylet is removed and a plastic-coated wire loop is inserted into the lumen of the stomach through a trocar needle. It is captured with a polypectomy loop. The endoscope and polypectomy loop are removed, dragging a wire loop behind it, which remains in the stomach, esophagus and oral cavity and is brought out. A gastrostomy tube is fixed to the end of the wire loop. The wire loop is gradually pulled out of the abdominal wall. In this case, the gastrostomy tube is slowly inserted into the mouth and pulled through the esophagus into the stomach. After the pointed part of the gastrostomy comes into contact with the anterior wall of the stomach, it is brought out onto the anterior abdominal wall with a stronger movement (piercing the anterior wall of the stomach and the anterior abdominal wall). The tube is secured from the outside with a silicone pressure disc. The gastrostomy tube is cut with scissors to the required length.

However, it is worth noting that despite the minimally invasive nature of the presented technique, as well as the absence of the need for general anesthesia of the patient, this method has its drawbacks: the impossibility of performing this technique in patients with severe stenosis of the esophagus and cardioesophageal junction, the presence of a bleeding or necrotizing tumor of the cervical localization, erosive -ulcerative lesion of the gastric mucosa in the area of the installed gastrostomy tube. Also, in the postoperative period, migration of the gastrostomy tube due to insufficient fixation in the soft tissues, or even its loss, cannot be ruled out, which inevitably leads to leakage of gastric contents into the abdominal cavity.

The closest (prototype) is the laparoscopic method of gastrostomy (Manual on clinical endoscopy, B.S. Savelyev, G.I. Lukomsky, V.M. Buyanov 1985, Page 323 of 540). After inserting the laparoscope and examining the abdominal cavity, the location on the abdominal wall for the formation of a gastrostomy is finally determined. A skin puncture is made in the intended location with a narrow scalpel. The direction of the incision is perpendicular to the midline, the length of the skin wound is no more than 8-10 mm. A laparoscopic clamp is inserted into the puncture. Find the most suitable place for removing the gastrostomy. On the stomach, the standard place for the formation of a gastrostomy is the section of the stomach wall in the area of its greatest curvature. The wall of the stomach is firmly grasped with a clamp, and 4-5 mm of tissue should be caught in the clamp, and the cone of the stomach is brought out into the puncture of the abdominal wall. The correct position of the cone should be considered when it can be moved 4-5 mm above the surface of the skin without effort. After removal of the stomach wall, laparoscopy is stopped. The wall is stitched with 3 threads and held on holders. The gastric lumen is opened. The stomach wall is sutured to the skin along its entire circumference using four to five interrupted sutures. Through the fistula, the end of a nipple rubber tube is inserted into the lumen of the stomach to a depth of 15-20 cm. The tube is fixed using two previously applied sutures. Sutures are placed on the trocar accesses.

However, the known method has certain disadvantages, namely: the impossibility of performing this technique in patients with adhesions in the upper floor of the abdominal cavity, with severe abdominal obesity, as well as an immobile stomach. Also, often due to excessive tension of the removed wall, ischemic phenomena occur, which thereby increase the risk of purulent-septic complications.

The objective of the proposed technical solution is to develop a method for forming a laparoscopic stalked gastrostomy.

This problem is solved by the fact that, just like in the known prototype, a gastrostomy is formed laparoscopically and the patient is activated in the shortest possible time.

A feature of the technical solution is that after performing a video revision, the anterior wall of the stomach is sutured and hung on ligatures in the proximal and distal direction of the intended stalk, and a stalked gastrostomy is formed closer to the lesser curvature of the stomach for the purpose of possible subsequent use of the greater curvature of the stomach for plasty of the esophagus, then a linear stapler is used to form a gastric stalk 8 cm long, the mechanical suture line on the stomach is additionally covered with serous-muscular sutures and the location of the gastrostomy stalk is designed on the anterior abdominal wall, then an additional 12 mm port is installed, the upper edge of the formed stalk is grabbed by the mechanical suture line with a soft laparoscopic with a clamp and desufflation of the carboxyperitoneum is performed, after which the 12 mm port is removed along with the formed gastric stalk, the end of the gastrostomy is opened and fixed to the skin with separate interrupted sutures, a feeding tube is inserted and fixed to the skin.

The invention is illustrated by a detailed description, a clinical example and illustrations, which show:

Fig. 1 – Scheme of mobilization along the lesser curvature of the stomach.

Fig. 2 – Scheme of the formation of a stem from the lesser curvature of the stomach.

Fig. 3 – Photo illustration during the operation: placement of trocars (the arrow points to the trocar for removing the gastrostomy).

Fig. 4 – Photo illustration during the operation: hanging the stomach on ligatures in the proximal and distal direction of the intended stem.

Fig.5 – Photo illustration during the operation: formation of the gastric stalk with two strokes of a linear stapler.

Fig.6 – Photo illustration during surgery: removal of the gastric stalk through an additional 12 mm port.

Fig. 7 – Photo illustration during surgery: an additional 12 mm port is removed along with the formed gastric stalk.

Fig.8 – Photo illustration during surgery: final view of the formed gastrostomy.

The method of forming a laparoscopic stalked gastrostomy is performed in the following way.

The patient is placed on the operating table lying on his back, with his lower limbs apart. The first 12 mm port under the camera is installed in the periumbilical region. In order to exclude iatrogenic injury, the first port under the camera is installed in an open manner, according to Hassen. Carboxyperitoneum up to 12 mm Hg is applied in the abdominal cavity. To perform manipulations in the abdominal cavity, the surgeon installs an 11 or 12 mm port in the right lateral region along the midclavicular line, as well as a 5 mm port under the right costal arch. The assistant's working ports are installed on the left side: a 12 mm port along the midclavicular line in the left lateral region and a 5 mm port in the left hypochondrium along the anterior axillary line. A stalked gastrostomy is formed closer to the lesser curvature of the stomach for the purpose of possible subsequent use of the greater curvature of the stomach for esophageal plastic surgery.

The stomach is mobilized along the lesser curvature (Fig. 1). The size of the stomach is assessed, the anterior wall is sutured and hung on ligatures in the proximal and distal direction of the intended stem. Then, with two strokes of a linear stapler, a gastric stalk 8 cm long is formed (Fig. 2). The mechanical suture line on the stomach is additionally covered with seromuscular sutures. Next, the site for the intended removal of the stalked gastrostomy on the anterior abdominal wall is designed. An additional 12 mm port is installed in this location. The upper edge of the formed stem is grasped behind the mechanical suture line with a soft laparoscopic clamp. The carboxyperitoneum is desufflated, the 12 mm port is removed along with the formed gastric stalk. The end of the gastrostomy is opened and fixed to the skin with separate interrupted sutures. The feeding tube is inserted and fixed to the skin. All remaining trocars are removed, and the wounds are sutured layer by layer.

Clinical example.

Patient A., 55 years old, considers himself sick since May 2022, when he was observed with a sore throat by an ENT doctor at his place of residence. An examination and conservative therapy were carried out - without effect. At the end of August, he went to the clinic at his place of residence. Oropharyngeal cancer was suspected, and therefore he was sent for a consultation with an oncologist at the oncology clinic. A tumor formation in the left oropharynx was detected, a biopsy was performed, according to the morphological examination: squamous cell carcinoma without keratinization, G2. I contacted the MNIOI named after. P.A. Herzen for consultation, where a comprehensive further examination was carried out, the real diagnosis was established: C10.2 Cancer of the oropharynx on the left, (p16+), cT4N1M0, stage III.

The clinical picture was discussed at the oncology council dated October 31, 2022: 2-3 courses of induction chemotherapy according to the TPF regimen were recommended (Docetaxel 75 mg/m2 on day 1 + cisplatin 75 mg/m2 on day 1 + fluorouracil 1000 mg /m2 on days 1-4; cycle 21 days) followed by resolving the issue of CRT. The patient underwent 3 courses of PCT according to the TPF regimen. According to the control survey from February 2023, stabilization. On February 17, 2023, an oncology consultation was held: Considering the prevalence of the tumor process and stabilization during chemotherapy, it was decided to attempt CRT using a radical program. However, given the prevalence of the tumor and the presence of severe dysphagia, before starting treatment it is necessary to form a gastrostomy and tracheostomy.

On March 29, 2023, the patient underwent surgical treatment using the method we proposed.

After triple treatment, a 3.0 cm long incision was made in the skin of the lower third of the neck along the anterior surface along the midline from the level of the cricoid cartilage downward. The skin-fat flaps were mobilized and separated. The anterior neck muscles were pulled apart. The trachea was opened between 2 and 3 half rings. The edges of the tracheostomy were formed by placing separate interrupted sutures between the skin and the tracheal half-rings. Reintubation with tracheostomy tube No. 7.5.

After three times treatment of the surgical field under the umbilical ring along the midline, access to the abdominal cavity was made according to Hassen. A carboxyperitoneum of 12 mmHg was imposed. Additionally, 2 12 mm trocars were installed along the midclavicular line at the level of the navel and 2 5 mm trocars in the right and left hypochondrium (Figure 3). The stomach is of medium size, no pathological changes were detected. The stomach is mobilized along the lesser curvature. Using two strokes of the EndoReach 45 mm apparatus (green cassette), a gastric stalk 8 cm long was formed from the lesser curvature of the stomach (Fig. 4,5). The mechanical suture was additionally covered with seromuscular sutures. An additional 12 mm port was installed in the left hypochondrium along the pararectal line, and the end of the gastric stalk was brought out through it (Fig. 6,7). The latter was fixed to the skin with separate interrupted sutures. An 18 Fr feeding tube was inserted into the stomach, the tube was fixed to the skin, and the patency of the tube was checked. Hemostasis – dry, instruments and napkins counted. The trocar holes are sutured in layers (Fig. 8). Aseptic dressings.

The patient is currently undergoing chemoradiotherapy according to a radical program, and his condition is satisfactory. During the observation period, no early or late postoperative complications were identified.

The proposed method in clinical practice allows: to achieve good immediate and long-term results of surgical treatment of patients after the formation of a gastrostomy using a minimally invasive method; activate the patient as soon as possible; re-insert the probe if it falls out; reduce the risk of purulent-septic complications; preserve the greater curvature of the stomach as a reserve material for plasty of the esophagus; form gastrostomy tubes in the presence of adhesions or an immobile stomach; reduce the risk of postoperative ventral hernia formation.

Claims (1)

A method for forming a laparoscopic stalked gastrostomy, including laparoscopy with removal of the stomach to the anterior abdominal wall and the formation of a gastrostomy, characterized in that after performing video revision, a stalked gastrostomy is formed along the lesser curvature of the stomach, for which the stomach is mobilized along the lesser curvature, the anterior wall of the stomach is sutured and hung on ligatures in the proximal and distal direction of the intended stalk, after which a gastric stalk 8 cm long is formed using a linear stapler, the line of the mechanical suture on the stomach is additionally covered with seromuscular sutures and the location of the stalked gastrostomy is designed on the anterior abdominal wall, then an additional 12 mm port is installed, upper the edge of the formed stalk is grabbed by the line of the mechanical suture with a soft laparoscopic clamp and the carboxyperitoneum is desufflated, after which the 12 mm port is removed along with the formed gastric stalk, the end of the gastrostomy is opened and fixed to the skin with separate interrupted sutures, a feeding tube is inserted and fixed to the skin.