UA58374A - Technique for pyloroplasty - Google Patents

Abstract

The technique for pyloroplasty provides for dissecting the duodenal ulcer together with the affected part of the pyloric sphincter, performing the exteriorization of the ulcerous crater, and plastic surgery of the defect performed by suturing through all the layers of the wound in the stomach and the duodenum. According to the invention proposed the upper and lower ends of the pyloric sphincter on the side of the serous membrane are attaches with the separate interrupted sutures to the round ligament of the liver mobilized and sewed in the ulcerous crater employing the probe #30. Such a technique provides for the reliable hemostasis. Moreover, the point of support for the pylorus is set up providing for the reliable functioning of the sphincter and resuming the physiologic size of the gastroduodenal transition.

Description

Description of the invention

The invention relates to medicine, in particular, to surgery and can be used in the treatment of patients with 2 bleeding pyloroduodenal ulcers of the back wall.

Taking into account the role of duodenal-gastric reflux in ulcerogenesis, the development of new operations, eliminating or significantly reducing the percentage of complications, becomes an important problem of gastric surgery. The wide implementation of the operations developed up to now with the preservation of the gatekeeper function will allow to improve the rehabilitation indicators in the surgical treatment of peptic ulcer disease (see the book G.I. Dudenko, 70 V.M. Zbin - Posledstvia vagotomy, Kiev "Zdorov'ya", 1987, p. 53).

In surgical practice, many different methods are used in the treatment of patients with bleeding pyloroduodenal ulcers. The well-known method according to Judd-Horsley consists in the fact that the front wall of the gatekeeper is cut out in a rhombus along with the ulcer, after which the wall of the stomach and duodenum are sutured in the transverse direction with double-row sutures (see books by V.F. Saenko, V.V. Grubpik,

Y.V. Hrubnyk, S.G. Chetverikov "Modern methods of treatment of ulcer disease". Kyiv, "Health", 2002, p.93).

However, the known method has a significant drawback: damage to the pyloric sphincter, part of which is excised together with the ulcer. In the postoperative period, in almost all patients, reflux gastritis occurs and the portioned evacuation of food from the stomach to the duodenum (DPK) is disturbed, which leads to a worsening of the patient's condition, as well as an increased likelihood of other complications (recurrence of bleeding and ulcers, precancerous condition). .

The authors are tasked with reducing the number of complications caused by gatekeeper insufficiency during operations for bleeding ulcers of the back wall of the duodenum, as well as achieving more reliable hemostasis in the ulcer crater.

The task is solved by the fact that the upper and lower ends of the part of the pyloric sphincter (PS), which remained after the excision, are sewn with seromuscular sutures to the round ligament of the liver fixed in the ulcer crater, and the gastroduodenoanastomosis is formed by single-row knotted sutures in the transverse direction .

Due to the fact that in the presented invention, the upper and lower ends of the pyloric sphincter from the side of the serosal membrane are fixed with separate knotted sutures to the mobilized and stitched ulcer of the round ligament of the liver on the Mo30 probe, a point of support for the pyloric sphincter is created and the physiological size of the gastro-duodenal stomach is restored transition, there is a possibility of reducing the number of complications due to the insufficiency of the gatekeeper during operations for bleeding ulcers of the back wall of the DPC, and more reliable hemostasis in the ulcer crater is achieved. Gee)

The essence of the method is explained by the drawings: Fig. 3 shows excision of the ulcer with the posterior part of the PS; o in Fig. 2 - shows the filling of the ulcer crater with its tamponade by the round ligament of the liver; Fig. C3 shows the formed posterior lip of the gastroduodenal anastomosis; Fig. 4 shows fixation of the upper and lower ends of the PS to the round ligament of the liver by serous-muscular sutures; From 50 to Fig. 5 - the final view of pyloroplasty is depicted; c in Fig. 6 - shows the final view of pyloroplasty in the sagittal plane; h where: 2 1 - round ligament of the liver; 2 - duodenum;

C - ulcer crater; i-th 4 - goalkeeper;

Ge | 5 - stomach; 6 - ulcer crater, stitched with tamponade by the round ligament of the liver; at 7 - the back wall of the anastomosis is sewn; - and 20 8 - fixation of the upper end of the PS to the round ligament of the liver by sero-muscular sutures; 9 - fixation of the lower end of the PS to the round ligament of the liver by seromuscular sutures;

T" 10 - formation of the front lip of the anastomosis with single-row sutures.

The method is implemented as follows (Fig. 1, Fig. 2, Fig. 3, Fig. 4, Fig. 5, Fig. b): after laparotomy and mobilization of the DPK 2 according to Kocher, a transverse duodenotomy is performed in the projection of the ulcer. The ulcer of the back wall 29 is excised within healthy tissues together with the affected part of the PS, externalized. Mobilize, v. bandage and cross the round ligament of the liver 1. Suture the ulcer crater C with tamponade from its part of the round ligament of the liver b. The back wall of the gastroduodenoanastomosis 7 is formed by single-row knotted sutures. From the side of the serous membrane, the upper and lower ends of PS 4 are fixed by serosal-muscular sutures to the round ligament of the liver on the probe Mo30 - 8, 9. The formation of the anterior lip 60 of the anastomosis between DPK 2 and the stomach with 5 single-row knotted seams 10.

The use of precision technology and thin atraumatic suture material 6/0-5/0 allows you to accurately adapt the junction of the anatomical structures of the same name, which prevents the development of coarse stenosing scars in the future.

The following example can be used as evidence of the effectiveness of this method, which was tested in the Kyiv City Clinical Hospital for Emergency Medical Care (KMKLSHMD).

Patient P. A. P., 24 years old, medical history Mo30370, was admitted to the KMKLSHMD clinic on October 19, 2002 with a diagnosis of duodenal ulcer complicated by moderate bleeding. During EGD, an ulcer with a diameter of 2 cm was found on the back wall of the DPC with a transition to the gatekeeper, at the bottom of the ulcer - a thrombosed vessel with a diameter of 1.5 mm. Due to the high risk of recurrence of bleeding after preoperative preparation, an operation was performed: upper-middle laparotomy. Given the patient's stable condition and the fact that bleeding had stopped at the time of surgery, a selective proximal vagotomy was performed. DPK is mobilized along Kocher.

Transverse duodenotomy in the ulcer projection. The ulcer of the back wall was excised within healthy tissues together with the affected part of the PS, externalized. The round ligament of the liver was mobilized, tied and cut. 7/0 The crater of the ulcer was sutured from a tampon with its part of the round ligament of the liver. The back wall of the gastroduodenal anastomosis was formed with single-row knotted sutures. From the side of the serous membrane, the upper and lower ends of the PS were fixed with erosive-muscular sutures to the round ligament of the liver on the Mo30 probe. The front lip of the anastomosis is formed by single-row knotted sutures. Drainage under the liver. Layered sutures on the laparotomy wound.

The postoperative period was uneventful. Peristalsis appeared on the third day. On the fifth day, the drain was removed from the abdominal cavity. On the tenth day, the patient underwent EGD and X-ray of the stomach.

Evacuation from the stomach to the duodenum is portioned, timely, there is no duodenogastric reflux.

On the eleventh day after the operation, the patient was discharged home in satisfactory condition. Inspected after a month - no complaints.

Thus, the proposed method of pyloroplasty reduces the number of complications caused by the insufficiency of the gatekeeper during operations for bleeding ulcers of the back wall of the duodenum, ensuring timely and portioned evacuation from the stomach, prevents the development of reflux gastritis, and also increases the reliability of hemostasis in the ulcer crater.

Claims (1)

The formula of the invention "Method of pyloroplasty". which involves excision of the duodenal ulcer together with the damaged part of the pyloric sphincter, exteriorization of the ulcer crater and closure of the defect by suturing through all layers of the edges of the wound of the stomach and duodenum, which differs in that the upper and lower ends of the pyloric sphincter from the side of the serous membrane are fixed with separate nodal sutures to the mobilized and stitched ulcer of the round ligament of the liver on the Mo3Z0 probe, which achieves reliable hemostasis, v. a point of support for the pyloric sphincter is created, which enables it to function, and the physiological size of the gastroduodenal transition is restored. (ee) And c) - . and? 1 (ee) (95) - and p» 60 b5