RU2523654C1 - Method for forming laparoscopic jejunostoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: mobilised enteric loop is brought out through the laparotomic incision. The brought out enteric segment is transected. A head of a circular clamping apparatus is introduced into an afferent limb. That is followed by fixing with a purse suture, and the small bowel is immersed into the abdominal cavity. The clamping apparatus is introduced in holders into the abducent segment. The abdominal cavity surrounding the apparatus is temporarily sealed. A laparoscopic technique is applied to from a mechanic end-to-side enteroenteroanastomosis. The apparatus is removed from the abducent segment. A jejunostoma is formed in the left hypochondrium.

EFFECT: method provides forming the Maydl laparoscopic jejunostoma.

2 cl, 1 ex

Description

The invention relates to medicine, namely to surgery.

Despite advances in gastrointestinal surgery, late diagnosis of cancer of the esophagus and stomach remains high. As a result, from 50% to 75% of patients admitted to the hospital for cancer of these organs need palliative surgery and enteral nutrition (W.J.Dixon, 1985; M.Shike, 1995). The most common palliative operations used for obstruction of the esophagus and stomach are gastrostomy and jejunostomy. The need for the formation of a jejunostoma occurs in patients with post-burn strictures of the stomach, inoperable cancer of the distal stomach, for nutrition [1]. General recommendations for enteral artificial nutrition are as follows: if it is required for a period of more than four weeks, then it should be carried out through a gastrostomy or juvenile nutrition [2, 3]. The need for enteral nutrition is due to the idea of the intestine as a metabolic, endocrine, immune organ, a barrier to microbial invasion, an organ that ensures the constancy of the internal environment of the body [4, 5, 6]. Currently, more than 30 methods for performing a jejunostomy and their modifications have been proposed: pendant jejunostomy, tubular, puncture, lip-shaped invagination and invagination-valvular jejunostomy (T.I. Shraer 1989; G.S. Vasiliev et al., 1993; GDBurtch 1987; QYDun et al., 1995). Such a variety of types of operations indicates surgeons' dissatisfaction with the results of this intervention.

The problem solved by the present invention is the development of methods for the formation of laparoscopic jejunostomy.

Achievable technical result is the achievement of a satisfactory result in the treatment of patients who need the formation of a jejunostoma for enteral nutrition by using the proposed methodology for the formation of a laparoscopic jejunostoma according to Maidl, the result is provided:

- thanks to the features of the proposed technology, surgical intervention is performed by the laparoscopic method, thereby reducing surgical trauma, reducing the time of surgical intervention, the time of anesthesia, which leads to a favorable course of the postoperative period and shortening the time of inpatient treatment of this group of patients;

- the implementation of this technology leads to rapid rehabilitation in the postoperative period.

The method is as follows.

An analogue of this technique is the classical Maidl method of forming a jejunostoma (Simonov N.N., Ananyev N.V., Aksenov A.V., Chartorizhsky V.D. Efficiency of the Maidlu jejunostoma in the treatment of insophobia of esophagodigestive anastomoses. Vestn. Khir., 1997 ; 1: 105-106).

The proposed technique is performed by patients who, for various reasons (the oncological process, post-burn structures), cannot receive per os nutrition, there is stenosis of the output section of the stomach, and radical surgical treatment is impossible.

Laparoscopy is performed according to the generally accepted technique. Then, using ultrasonic scissors and an electrolytic instrument, the mesentery of the small intestine is crossed as close as possible to the intestinal wall (no more than 3-5 cm) with a preservation of the vascular arcades at a distance of 40 cm from the Treitz ligament. A mobilized intestinal loop is brought to the anterior abdominal wall through an additional incision in the left hypochondrium 3-4 cm long. The extracted portion of the small intestine is crossed, a “cap” of the circular stapler, for example EEA DST 25, is inserted into the lead section of the intestine, fixed with a purse string suture and immersed in abdominal cavity. Next, the discharge section of the intestine is taken to the “holders” by forming two separate sutures on the opposite walls of the intestine, the circular stapler itself is inserted into the intestine at a distance of 15-20 cm, the intestine with the working part of the stapler is immersed in the abdominal cavity and temporary abdominal cavity sealing is created around a stapler to create pneumoperitoneum by forming temporary skin-aponeurotic seams. Next, laparoscopy is resumed, an end-to-side hardware entero-enteroanastomosis is formed between the leading and outlet sections of the small intestine at a distance of 15-20 cm from the intersection of the small intestine. After this, the cross-linking circular apparatus is removed from the abduction department of the small intestine, and a jejunostoma is formed in the left hypochondrium. To facilitate the introduction of nutrition, a Petzer catheter is inserted into the junction, which is fixed by a purse string suture to the intestinal wall. Next, sanitation, drainage and suturing of the abdominal cavity are performed according to the generally accepted technique.

Clinical example. Patient 3., 46 years old, was admitted to the SRI SR with a diagnosis of gastrointestinal bleeding with severe cachexia. During the examination: according to endoscopy, there is a total tumor lesion of the stomach with a transition to the cardial part of the esophagus, decompensated stenosis of the output part of the stomach, signs of gastrointestinal bleeding. An additional examination revealed multiple metastases of the liver, lungs, skeleton bones, metastatic lesions of regional lymph nodes. Considering the impossibility of radical surgical treatment, as well as the patient’s grave condition, it was decided to create a jujunostomy according to Maidl according to the proposed technique to ensure nutrition. After additional examination and preoperative preparation under general anesthesia, the patient underwent laparoscopy according to the generally accepted technique. In the abdominal cavity pronounced carcinomatosis. A portion of the small intestine was mobilized at a distance of 40 cm from the Treitz ligament and brought to the anterior abdominal wall through an additional incision in the left hypochondrium 3-4 cm long. Next, the removed portion of the small intestine was intersected, a “head” of the circular stapler was inserted into the leading portion of the intestine. EEA DST 25, fixed with a purse string suture and immersed in the abdominal cavity. Then, a circular stapler for a length of 15-20 cm was introduced into the discharge section of the intestine, temporary sealing of the abdominal cavity around the stapler was created to create pneumoperitoneum by forming temporary skin-aponeurotic sutures. Laparoscopy was resumed, an end-to-side apparatus entero-enteroanastomosis was formed between the leading and outlet sections of the small intestine at a distance of 15-20 cm from the intersection of the small intestine. After this, the cross-linking circular apparatus is removed from the abduction department of the small intestine and a jejunostoma is formed in the left hypochondrium. To facilitate the introduction of nutrition, a Petzer catheter is inserted into the junction, which is fixed by a purse string suture to the intestinal wall. Next, sanitation, drainage and suturing of the abdominal cavity were performed according to the generally accepted technique.

Literature

1. Ionescu M., Tomulescu V., Gheorghe C., Popescu I. Post-caustic esophageal stenosis. Chirurgia (Bucur) 2000; 95: 1: 23-28.

2. Guidelines for Parenteral and Enteral Nutrition, ed. Khoroshilova. SPb., 2000

3. Kostyuchenko A.L., Kostin E.D., Kurygin A.A. "Enteral artificial nutrition in intensive care" "Special literature." St. Petersburg, 1996.

4. Luft V.M., Kostyuchenko A.L. Clinical nutrition in intensive care. St. Petersburg: Special Literature, 2002.176 p.

5. Popova TS, Shestopalov A.E., Tamazashvili T.Sh., Leiderman I.N. Nutritional support for patients in critical situations. M .: IDM-Vesti, 2002.320 s.

6. Nikoda VV, Kupriyanov K.Yu., Scherbakova G.N. et al. Early enteral nutrition after pancreatoduodenal resections // Russian Journal of Gastroenterology, Hepatology, Coloproctology. 2007. V.17, No. 4. S.73-78.

Claims (2)

1. A method for the formation of a laparoscopic jejunostomy according to Maidl, including laparoscopy, after which the small intestine is mobilized at a distance of 40 cm from the Treitz ligament and the mobilized loop is removed to the anterior abdominal wall through an additional incision in the left hypochondrium 3-4 cm long, then the inferior section of the small intestine, a “cap” of the circular stapler is inserted into the leading section of the intestine, fixed with a purse string suture and immersed in the abdominal cavity, the discharge section of the intestine is taken to miserable ”by forming two separate sutures on opposite walls of the intestine, a circular suturing device 15-20 cm long is inserted into the intestine, temporary sealing of the abdominal cavity around the suturing device is created to create pneumoperitoneum by forming temporary skin-aponeurotic sutures, then laparoscopy is resumed, hardware is formed end-to-side enteroanastomosis between the adducting and abducting portions of the small intestine at a distance of 15-20 cm from the intersection of the small intestine, after which the cross-linking app rat is removed from the discharge of the small intestine and form eyunostomu in the left upper quadrant. 2. The method according to claim 1, characterized in that in addition to facilitate the introduction of food into the jujunom, a Petzer catheter is inserted, which is fixed by a purse string suture to the intestinal wall.