RU2710215C1 - Method for aseptic organ-preserving resection of hollow organs of the digestive tract - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to oncology and surgery. Gastric or intestinal wall is resected as follows. Departing from the pathological section boundary through four opposite points, two of which are located on the line parallel to the longitudinal axis of the organ, two – on line perpendicular to its longitudinal axis, rhombically dissecting serous and muscular layers in transverse to longitudinal axis of organ direction. Suturing mucosa is sutured with suturing device to be cut off mobilized section. Seromuscular defect in the organ wall is closed with serous-muscular sutures in the direction transverse to its longitudinal axis.

EFFECT: method enables improving the results of the surgical management of the benign and malignant submucous growths (gastrointestinal stromal tumors), diverticulums of the gastrointestinal hollow organs, chronic gastric ulcers of large and giant sizes complicated by hemorrhage, in patients with high perioperative risk.

1 cl, 4 dwg

Description

The invention relates to medicine, namely to oncology and surgery, and can be used in the surgical treatment of submucosal neoplasms of a benign and malignant nature (gastrointestinal stromal tumors), diverticulums of hollow organs of the gastrointestinal tract, chronic stomach ulcers of large and gigantic sizes, complicated by bleeding in patients with high perioperative risk.

Modern approaches to the treatment of these diseases, in addition to drug therapy, include, first of all, surgical removal of the pathological area in the organ (tumor, diverticulum, chronic ulcer). The most commonly used organ-saving operations. In cases of benign and malignant submucous neoplasms (gastrointestinal stromal tumors), a part of the organ is resected with complete removal of the macroscopically visible tumor (see: Krieger, A.G. Diagnosis and tactics of surgical treatment of gastrointestinal stromal tumor / A.G. Kriger, Yu. G. Starkov, G.G. Karmazanovsky et al. // Surgery. - 2014 - No. 1 - P. 15-20), with diverticula of the small intestine, a diverticulectomy, resection or wedge-shaped excision with resection of the intestine and the formation of entero-enter oanastomosis (see: Zemlyanoy, A.G. Diverticulums of the gastrointestinal tract / A.G. Zemlyanoy: Moscow: "Medicine", 1970. - P. 206), in the absence or unsuccessful attempt of endoscopic hemostasis, high risk of recurrence of bleeding from gastric ulcers in critically ill patients — excision or flashing of the ulcer (see: National Clinical Recommendations “Ulcer gastroduodenal bleeding”: Moscow-Voronezh, 2014. - P. 7).

Open methods for removing pathological areas located in the walls of organs are proposed: a method for excising a perforated ulcer (see: Matyushin, I.F. Practical Guide to Surgical Surgery / I.F. Matyushin: Gorky: Gorky State Medical Institute named after S.M. Kirova, 1979. - P. 23), a method of surgical treatment of leiomyomas of the posterior wall of the antrum of the stomach V. Onoprieva et al. (see: Patent for invention No. 2253376, application No. 2003119395/14 dated 06.25.2003 for “A method for surgical treatment of leiomyomas of the posterior wall of the antrum”), a method for resection of Meckel’s diverticulum (see: Voilenko, V.N. Atlas of operations on abdominal wall and abdominal organs / V.N. Voilenko, A.I. Madelyan, V.M. Omelchenko: Moscow: "Medicine", 1964. - P. 313-314) and others. All of them have significant disadvantages:

1) the formation of a complete defect in the wall of a large hollow organ promotes the outflow of a significant amount of their contents into the abdominal cavity, increasing its infection and, as a result, increases the likelihood of developing purulent intra-abdominal complications in the postoperative period;

2) the development of bleeding from the edges of the formed defect in the organ wall requires measures to stop it, which increases the duration of surgery;

3) the formation of the first row of inverted sutures through all layers provokes the formation of an inflammatory shaft in the area of stitched tissues.

As an analogue, a method for excising Meckel’s diverticulum is proposed (Zemlyanoy, A.G. Diverticulums of the gastrointestinal tract / A.G. Zemlyanoy: Moscow: “Medicine”, 1970. - P. 153). Its basis is the isolation of a diverticulum from the intestinal wall, the application of a surgical clamp on the base, cutting off with subsequent stitching of the leg under the clamp with an upholstered mucous-submucosal-muscular suture, peritonization with gray-serous sutures.

A significant disadvantage of this method is through flashing of the diverticulum leg with a continuous suture, followed by its immersion in the intestinal lumen. This can lead to the formation of an inflammatory shaft with impaired blood supply in the area of stitched tissues, deformation of the lumen of the intestinal tube with impaired passage. In turn, the above consequences slow the wound process, which increases the risk of suture line failure with the development of intra-abdominal complications.

Closest to the technical nature of the proposed method is the method of surgical treatment of complicated ulcers, proposed by Yu.P. Novomlintsev et al. (See: Patent for invention No. 2261666, application No. 2004102626/14 dated January 29, 2004 for “A method for surgical treatment of complicated ulcers”), including excision of complicated ulcers of the anterior wall of the stomach, the stomach wall is protruded in the area of the ulcer, the serous is dissected and half the muscle layer of the wall of the stomach, departing from the ulcer, a clamp is applied to the protruded wall of the stomach in the deserting zone, which provides rigid and elastic fixation of the organ, on the working branches of which there are two brackets for elastic convergence of the sutured walls of the stomach, place the brackets of elastic fixation in the direction of the remaining walls of the stomach, under the brackets of elastic fixation, stitch the wall of the stomach with a continuous U-shaped seam, intersect the wall of the stomach with an ulcer between the clamping lips and the staples of the instrument in the clamp and remove the clamp, after which the stomach wall is stitched with a continuous stitch in the opposite direction, linking the beginning and end of the ligature, peritonize the piercing stitch with a continuous serous-muscular suture

There are common features of this method with the claimed:

- the method relates to organ-saving;

- the method allows you to remove part of the organ with the pathological area closed method;

- the method includes the preliminary formation of stitches-holders on the wall of the organ;

- the method provides for the mobilization of the organ wall along with the pathological site by dissecting the serous and muscle layers;

- the method allows economical resection in the direction transverse to the axis of the organ;

- the method involves layer-by-layer suturing of an organ wall wound. However, the known method is not without some drawbacks:

1) when mobilizing the resected area, half of the muscle layer of the organ wall is dissected, which subsequently leads to trauma to its second half and deformation of the lumen of the resected organ;

2) the use of one thread in the formation of a continuous suture when suturing the mucous and serous-muscular layers increases the possibility of infection of stitched tissues and the development of insolvency.

In addition, the length of the working part of the clamp used in this method does not allow you to remove fragments of hollow organs of large sizes (see: Patent for invention No. 2415650, application No. 2009133175/14 dated 09/03/2009 for “Method of excision of large and giant ulcers of small curvature stomach in patients with a high degree of operational risk and a device for its implementation ").

The technical result of the invention is the development of an aseptic organ-saving resection of the hollow organs of the digestive tract, which improves the results of surgical treatment of submucous neoplasms of a benign and malignant nature (gastrointestinal stromal tumors), diverticulums of the hollow organs of the gastrointestinal tract, chronic gastric ulcers of large and giant sizes, complicated by blood , in patients with high perioperative risk.

The technical result is achieved by the fact that in the surgical treatment of submucosal neoplasms of a benign and malignant nature (gastrointestinal stromal tumors), diverticulums of the hollow organs of the gastrointestinal tract, chronic gastric ulcers of large and gigantic sizes, complicated by bleeding, in patients with high perioperative risk, including resection the walls of the stomach or small intestine or colon, stepping back from the border of the pathological site through four opposite ki, two of which are located on a line parallel to the longitudinal axis of the organ, two - on a line perpendicular to its longitudinal axis, serous and muscle layers are diamond-shaped, in the direction transverse to the longitudinal axis of the organ the mucous membrane is sutured with a suturing device, followed by cutting off the mobilized area, sutured sero-muscular defect in the organ wall with sero-muscular sutures in the direction transverse to its longitudinal axis.

The solution to this problem is achieved by preliminary mobilization of the wall of the stomach or small intestine, or colon, together with the pathological site, its resection in a closed way, involving preliminary hardware suturing of the mucous membrane together with the submucosa, removal of the mobilized area, the formation of serous-muscular sutures.

The proposed method meets the criteria of novelty and inventive step, because allows you to:

1) to exclude the formation of a through defect in the wall of a hollow organ, which prevents infection of the abdominal cavity;

2) reduce the trauma of the wall of the resected organ and, accordingly, prevent the deformation of its lumen.

The use of the claimed invention is possible in any hospital in which staplers are used in the surgical treatment of diseases of the gastrointestinal tract.

The drawings show the application of the method for resection of a portion of the small intestine with Meckel's diverticulum. In FIG. 1 schematically depicts the formation of suture-holders at four opposite points in the area of the small intestine that carries Meckel's diverticulum; in FIG. 2 - implementation of the diamond-shaped section of the serous and muscle layers of the wall of the small intestine; in FIG. 3 - submucosal-mucous stitching of a mobilized fragment of the wall of the small intestine carrying Meckel’s diverticulum with a suturing device superimposed in the direction transverse to the longitudinal axis of the organ; in FIG. 4 - intestinal wound sutured by serous-muscular sutures in the direction transverse to its longitudinal axis.

Position 1 in the figures indicates a section of the small intestine with the mesentery; position 2 - Meckel's diverticulum; 3, 4, 5, 6 - holding seams formed through points, two of which are located on a line parallel to the longitudinal axis of the organ, two - on a line perpendicular to the longitudinal axis of the organ; position 7 - diamond-shaped incision of the wall of the small intestine; position 8 - submucosal layer of the wall of the small intestine; position 9 - tweezers; position 10 — stapler; position 11 - sutured wound of the small intestine.

The method is as follows.

They make operative access to the abdominal cavity. An audit is performed to identify a pathological process in the wall of the stomach or intestines. Departing from the border of the pathological site (2.5 cm for gastrointestinal stromal tumors, 0.5-1 cm for diverticula and ulcers) at four opposite points, two of which are on a line parallel to the longitudinal axis of the organ, two on the line perpendicular to its longitudinal axis, the wall is sutured with serous-muscular sutures (Fig. 1). Suture-holders are formed, inside of which 0.5 cm a diamond-shaped incision is made of the serous and muscle layers of the wall of the hollow organ (Fig. 2). The thus mobilized fragment of the wall of the stomach or small intestine, or colon, together with the pathological site, is raised with forceps. As a result, there is a wide displacement of the serous-muscular cuff in the area of dissected tissues due to the increased mobility of the submucosa of the mucous membrane. Below, the mucous membrane together with the submucosal layer of the fragment mobilized in this way is stitched with a stapler of a standard design (UO-40, Proximate, etc.), superimposed in the direction transverse to the longitudinal axis of the organ (Fig. 3). After cutting off the drug, the integrity of the serous and muscle layers is restored. At the same time, for adequate comparison of the edges of the wound, suture-holders are used, superimposed earlier at four oppositely located points. During traction, the latches located on the line perpendicular to the longitudinal axis of the stomach or small intestine, or colon, and sero-muscular stitching at points located on the line parallel to their longitudinal axis, and subsequent tying of the ligatures, the diamond-shaped defect in the organ wall becomes linear. This technique facilitates further suturing of the wound with serous-muscular sutures in the direction transverse to the longitudinal axis of the hollow organ (Fig. 4). The operation is completed by sanitation of the abdominal cavity, drainage and suturing of the surgical wound in accordance with generally accepted principles.

The method was used in clinical practice in 9 patients. Complications in the postoperative period were not observed in any case.

Thus, the proposed method of aseptic organ-saving resection of the hollow organs of the digestive tract can be recommended in wide surgical practice.

Improving the results of surgical treatment of benign and malignant submucous neoplasms (gastrointestinal stromal tumors), diverticulums of the hollow organs of the gastrointestinal tract, chronic gastric ulcers of large and giant sizes, complicated by bleeding, in patients with high perioperative risk is the advantage and advantage of the proposed technical solution in comparison with the prototype.

Claims (1)

A method of aseptic organ-saving resection of the hollow organs of the digestive tract, including resection of the wall of the stomach or small intestine, or colon, characterized in that, departing from the border of the pathological section through four opposite points, two of which are located on a line parallel to the longitudinal axis of the organ, two on the line perpendicular to its longitudinal axis, serous and muscle layers are cut diamond-shaped in the direction transverse to the longitudinal axis of the organ, the mucous membrane is sutured with a stapler, followed by yuschim mobilized clipping portion sutured sero-muscular body wall defect in sero-muscular seams transversely to its longitudinal axis direction.

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