RU2834985C1 - Method of closing perforated gastric ulcer by means of minilaparotomic approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to abdominal surgery, and can be used for closure of perforated gastric ulcer. Serous-muscular-submucosal suture is applied with absorbable suture material of size 2.0-3.0 in the transverse direction within the healthy tissue at 1 cm from the edge of the perforation on the right. Needle is clamped by the needle holder and passed through the Roeder loop formed at the opposite end of the suture. Loop is tightened to form a fold covering the perforated hole. On the free ends of the tightened loop, knots are tied and the thread is cut. Symmetrical suture is applied to the left of the perforated hole. Interrupted suture is applied through the walls of the formed folds at an equidistant distance from the sutures.

EFFECT: method allows to improve the results of treating the patients with perforated gastric ulcer, to provide fast postoperative rehabilitation, to simplify the surgical intervention in the patients with the manifested adhesion of the abdominal organs and diffuse peritonitis, to reduce the risk of inconsistency and suturing by forming folds of healthy stomach tissue and using self-tightening knots.

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Description

The invention relates to surgery, namely to urgent abdominal surgery, and can be used in suturing a perforated gastric ulcer.

Among the complications of peptic ulcer disease, the most formidable is perforation, which develops in 2-10% of patients [1]. In the Russian Federation in recent years, there has been a tendency towards an increase in hospital and postoperative mortality in perforated ulcers: in 2019 - 11.40/10.77%; in 2020 13.23/12.11%; in 2021 13.91/13.08% [2]. Given the increase in mortality in perforated ulcers, it is necessary to improve existing surgical treatment methods or create new ones.

In recent years, there has been a tendency in emergency surgery to suture perforated ulcers and reduce the number of gastric resections [1-3]. Most of these interventions are attempted to be performed using videolaparoscopic access, which has a number of advantages over classical access, but, unfortunately, in addition to obvious advantages, this approach has disadvantages that limit its use in a number of cases. The literature presents various methods of suturing perforated gastric ulcers.

Oppel-Polikarpov method

A section of the omentum on a pedicle equal in thickness to the diameter of the perforation hole is isolated and sutured with a catgut thread. The free ends of the thread are passed through the perforation hole and the wall of the stomach is sutured with them from the inside out, stepping back from the edge of the hole by 2.5-2 cm. When tightening the threads, the omentum is immersed in the lumen of the stomach and tamponades the perforation hole. The thread is tied. Additional sutures are applied along the edges of the ulcerative infiltrate, capturing the omentum (V.V. Zhebrovsky, "Atlas of operations on abdominal organs", p. 33, Publishing House "Medical Information Agency", Moscow, 2009). This method has a number of disadvantages: failure of the sutures and unreliability of sealing the perforation hole, which can lead to repeated surgery and death. Stenosis of the stomach, which can develop as a result of cicatricial deformation.

The closest analogue of the method we claim is the videolaparoscopic method of suturing a perforated gastric ulcer [patent RU 2805487 C1 dated 17.10.2023 Bulletin No. 29], which was adopted as a prototype. The essence of the method lies in suturing a perforated gastric ulcer from a videolaparoscopic approach. The method involves applying sutures along the edges of the perforation (within healthy tissue) with laparoscopic instruments using atraumatic absorbable suture material, at the free end of which a self-tightening knot is formed. After applying two sutures, duplications are formed covering the perforation, then one nodal suture is applied to the formed duplications.

Among the most significant shortcomings are the following:

- the need for endovideosurgical equipment and laparoscopic instruments;

- difficulty in performing surgical intervention in case of severe adhesions of the abdominal organs;

- presence of contraindications to videolaparoscopy;

- impossibility of adequate sanitation of the abdominal cavity in case of diffuse peritonitis;

- lack of tactile sensitivity when suturing the perforation.

Due to the shortcomings of existing methods, we decided to propose a new method of suturing a perforated gastric ulcer using a minilaparotomy approach.

The technical result of the invention: to improve the results of treatment of patients with perforated gastric ulcer, to reduce the frequency of postoperative complications in the form of suture failure, cutting through sutured tissues by improving the technique of suturing perforated gastric ulcer from minilaparotomy access.

To achieve the technical result, the method is carried out as follows.

Perforated gastric ulcer is sutured through minilaparotomy access. The patient was on the operating table with the head end elevated. Upper midline minilaparotomy is used to access the abdominal cavity. After revision of the abdominal cavity and confirmation of the diagnosis of perforated gastric ulcer, exudate is aspirated. Then, a section of the stomach with a perforated opening is removed from the abdominal cavity.

Then proceed to suturing the perforation (Fig. 1). Stepping back 1 cm to the right from the edge of the perforation, apply one serous-muscular-submucosal suture in the transverse direction within the healthy tissue using absorbable suture material of size 2.0-3.0. Then, clamping the needle with a needle holder, pass it through the Raeder loop formed at the end of the thread and tighten the loop (Fig. 2), then tie several knots on the tightened loop and cut the thread. In a similar manner, apply a symmetrical suture to the left of the perforation (Fig. 3). The distance from the perforation, at which the sutures are applied, can be variable and depends on the size of the perforation and on the severity of fibroplastic and inflammatory processes in the wall of the stomach adjacent to the perforation.

As a result of tightening the above knots, two folds are formed on the anterior wall of the stomach, covering the perforation. Then the formed folds are strengthened. Using an atraumatic needle, one interrupted suture is applied through the walls of the folds at an equal distance from the already formed sutures (the number of sutures applied to the folds can be variable and depends on the size of the ulcer defect) (Fig. 4), the thread is cut and the stomach is immersed in the abdominal cavity (Fig. 5). Then, sanitation, drainage of the abdominal cavity (if necessary) and layer-by-layer suturing of the minilaparotomy wound are performed.

The method of suturing a perforated gastric ulcer that we have developed does not require expensive endovideosurgical equipment and laparoscopic instruments, which allows this intervention to be performed in a surgical hospital using standard instruments for open interventions. It allows us to significantly simplify and make the surgical intervention safer for the surgeon, since this technique is technically easy to perform and applicable to patients with severe adhesions of the abdominal organs. The use of minilaparotomy access ensures minimal tissue trauma, which contributes to rapid postoperative rehabilitation of patients, and also allows for adequate sanitation of the abdominal cavity. It allows us to reliably suture the ulcer defect, avoid suture failure, cutting through the sutured tissues, which is ensured by forming a fold from healthy stomach tissue and using self-tightening knots (Raeder's knot).

Thus, the proposed method of suturing a perforated gastric ulcer from a minilaparotomy approach allows improving the treatment outcomes for patients with perforated gastric ulcer.

Brief description of the drawings

Fig. 1. Initial appearance of a perforated gastric ulcer.

Fig. 2. Imposition of the right suture.

Fig. 3. Application of the left suture.

Fig. 4. Application of a nodal suture to the formed folds covering the perforation hole.

Fig. 5. Sutured perforated ulcer.

Clinical examples

1. Patient M., 48 years old, was urgently admitted to the surgery department with a perforated gastric ulcer. Upon admission, she complained of epigastric pain. It is known from the anamnesis that the patient has a long history of gastric ulcer, and a history of multiple surgeries on the abdominal organs. During physical examination, peritoneal symptoms are positive. A plain radiography of the abdominal organs reveals free gas. The patient underwent minilaparotomy, and during revision of the abdominal organs, a perforated ulcer of the prepyloric part of the stomach with a diameter of 0.5 cm was found. Having retreated 1 cm to the right and left of the perforation, two sutures were applied with atraumatic suture material Vicryl 2.0, at the end of which self-tightening loops were formed. As a result of applying the sutures and tightening them, two folds were formed covering the perforation. Then a reinforcing suture was applied to the formed folds, and the abdominal cavity was sanitized and drained. No postoperative complications, including suture failure, were noted, and the patient was discharged on the 11th day after the operation.

2. Patient A., 60 years old, was admitted to the surgery department as an emergency. Complaints of “dagger-like” abdominal pain. The above complaints have been bothering the patient for several hours. It is known from the anamnesis that the patient underwent suturing of a perforated gastric ulcer twenty years ago. During the physical examination, peritoneal symptoms are positive. Free gas is determined on the plain radiography of the abdominal organs. The patient underwent minilaparotomy, suturing of the perforated gastric ulcer using the proposed method. Atraumatic suture material Polysorb 3.0 were used to form two folds covering the perforation, then a reinforcing suture was applied to the folds, sanitization and drainage of the abdominal cavity. No complications were observed in the postoperative period, the patient was discharged on the 16th day for outpatient treatment by a surgeon at the local clinic.

Bibliography:

1. Russian Society of Surgeons. Perforated ulcer. Clinical guidelines Ministry of Health of the Russian Federation. 2021;1-54.

2. Surgical care in the Russian Federation. Information and analytical collection for 2021. Revishvili A.Sh., Olovyanny V.E., Kuznetsov A.V., Shelina N.V., Ovechkin A.I.; Moscow., 2022 - 200 p.

3. Tarasenko S. V., Natalsky A. A., Panin S. I., Sazhin I. V., Yudin V. A., Sazhin V. P., Peskov O. D., Bogomolov A. Yu. Modern aspects of complex treatment of perforated ulcer of the stomach and duodenum. Surgery. Journal im. N. I. Pirogov. 2021; (1): 42-46.

Claims (1)

A method for suturing a perforated gastric ulcer through a minilaparotomy approach that includes performing an upper median minilaparotomy, characterized in that, having retreated 1 cm to the right from the edge of the perforation, a serous-muscular-submucosal suture is applied transversely within the healthy tissue using absorbable suture material of size 2.0-3.0; then, clamping the needle with a needle holder, it is passed through a Raeder loop formed at the opposite end of the thread; the loop is tightened, forming a fold covering the perforation; then knots are tied at the free ends of the tightened loop and the thread is cut; a symmetrical suture is applied to the left of the perforation; an interrupted suture is applied through the walls of the formed folds at an equidistant distance from the applied sutures.