RU2846665C1 - Method of manual oesophagoenteroanastomosis formation in laparoscopic gastrectomy - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to surgery, oncology, and may be used in treating the patients suffering gastric diseases of both malignant and other genesis. A laparoscopic clamp is inserted into the abdominal cavity and applied on the oesophagus; the oesophagus is transected below the applied clamp. A minilaparotomy is performed along the mid-line; a stomach with surrounding lymph nodes is removed; a small intestine loop is cut out according to Roux by transecting the small intestine at 40 cm from the ligament of Treitz. An extracorporeal manual single-layer continuous enteroenteroanastomosis is formed at 40 cm from an oesophagoenteroanastomosis region. A manual intracorporal two-row oesophagoenteroanastomosis is formed, and the forceps are removed.

EFFECT: method allows to form a manual oesophagoenteroanastomosis during laparoscopic gastrectomy, reduce the risk of anastomosis inconsistency and improve the functional treatment results by preventing the oesophagus migration into the mediastinum, preserving the correct orientation of the oesophageal walls, levelling the tension, thereby simplifying the procedure of creating the manual oesophageal enteroanastomosis.

1 cl, 1 dwg, 1 ex

Description

The invention relates to medicine, in particular to surgery and oncology, and can be used in the treatment of patients with stomach diseases of both malignant and other origins.

Gastric cancer is a malignant disease that ranks fifth in terms of incidence and mortality worldwide (Bray F, Laversanne M, Sung H, Ferlay J, Siegel RL, Soerjomataram I, Jemal A. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2024 Apr 4. doi: 10.3322/caac.21834. Epub ahead of print. PMID: 38572751). According to current guidelines of the Russian Society of Clinical Oncology, patients with clinically established stages I-III tumors can be considered candidates for both independent surgical treatment and combination therapy.

Surgical treatment for malignant diseases often involves performing a surgical procedure involving the complete removal of the stomach—gastrectomy. Although this type of surgery is performed not only for malignant diseases, the indications for total gastrectomy for non-oncologic reasons are decreasing every year.

The main option for reconstruction after such surgical intervention is the formation of an anastomosis between the esophagus and the small intestine - esophagoenteroanastomosis, performed in various versions.

Currently, laparoscopic approaches to performing surgical interventions are increasingly being introduced into surgical practice. They are less traumatic for the patient and allow for early activation in the postoperative period and reduce the duration of hospitalization for patients, thereby reducing the incidence of infectious complications.

With the advent of the laparoscopic approach to gastric surgery, the method for creating an esophagoenteroanastomosis has also changed. Currently, this anastomosis is rarely performed manually during laparoscopic surgery due to the technical complexity of manual anastomosis. In the vast majority of cases, esophagoenteroanastomosis is performed using linear or circular staplers. However, with this type of anastomosis, as with all cases where staplers are used, the risk of anastomotic leak increases and significant questions arise regarding the functional aspect of this anastomosis, particularly the incidence and severity of reflux esophagitis.

When attempting to perform laparoscopic esophagoenteroanastomosis manually, certain difficulties also arise due to the migration of the esophagus into the mediastinum, rotation of the esophagus, and the difficulty of performing a geometrically correct reconstruction option.

Due to the lack of skills in intracorporeal suturing among most surgeons beginning to perform laparoscopic operations, the method of forming a "Delta-Shaped" esophagoenteroanastomosis using linear stapling and cutting devices has actively come into practice. Shunichi Okushiba was one of the first to publish his experience with this technique in 2005 in Surgery Today (Shunichi Okushiba; Yo Kawarada; Toshiaki Shichinohe; Hiroto Manase; Shuji Kitashiro; Hiroyuki Katoh (2005). Esophageal Delta-Shaped Anastomosis: A New Method of Stapled Anastomosis for the Cervical Esophagus and Digestive Tract., 35(4), 341-344. doi:10.1007/s00595-004-2943-x). This method of creating an esophagoenteroanastomosis involves the use of two linear stapling and cutting devices. Initially, an opening is created in the small intestine and esophagus. One part of the stapling device is inserted into the lumen of the esophagus and the other into the lumen of the small intestine. The tissues are aligned and suturing is performed with the first device. After the first suturing, a so-called "technological opening" remains. To close this opening, a second linear device is placed and suturing is performed, creating a triangular anastomosis between the esophagus and small intestine.

This method allows for the formation of an esophagoenteroanastomosis without the use of manual intracorporeal suturing. However, this method has a higher rate of anastomotic leakage compared to manual suturing. Furthermore, successful formation of this anastomosis requires high mobility of the esophagus and small intestine, as well as the absence of even minimal tension. Furthermore, published data indicate the potential for rupture or perforation of the esophageal wall by a portion of the suturing device during this anastomosis, as visual inspection and control of tissue tension during formation are difficult.

Another way to consider this method analogous is the work of Oh Jeong and Young Kyu Park, published in 2009 in the journal Surgical Endoscopy (Jeong O, Park YK. Intracorporeal circular stapling esophagojejunostomy using the transorally inserted anvil (OrVil) after laparoscopic total gastrectomy. Surg Endosc. 2009 Nov;23(11):2624-30. doi: 10.1007/s00464-009-0461-z. Epub 2009 Apr 3. PMID: 19343421).

In this study, a specially designed circular stapling device, the OrVil, is used to create an esophagoenteroanastomosis. After removing the stomach, a catheter with a stapler head fixed to its proximal end is inserted through the mouth into the esophagus. The distal end is withdrawn through the esophageal opening and pulled into the abdominal cavity until a portion of the stapler head is exposed. The ligature securing the catheter to the stapler head is then cut, and the catheter is removed. A loop of small intestine is divided 30 cm from the ligament of Treitz, and the distal end of the stapler is inserted into the diverting end. The sharp tip is removed through the small intestinal wall by perforating it, and the tip is connected to the stapler head. Rotating movements then align the edges of the stapler, thereby aligning the small intestine on one side and the esophagus on the other. Next, suturing is performed and the device is removed. After the formation of a circular esophagoenteroanastomosis, the opening in the small intestine is covered using a linear suturing and cutting device.

This method allows for laparoscopic esophagoenteroanastomosis without the use of manual intracorporeal suturing. However, this method has a higher rate of anastomotic leakage compared to manual suturing. Furthermore, this method carries the risk of rupture or perforation of the esophageal wall by the head of the stapler and the small intestinal wall by the distal portion of the stapler during the anastomosis. It is also worth noting that both proposed methods are quite expensive, which further complicates their widespread implementation in clinical practice.

The objective of the proposed invention is to simplify the formation of a manual esophagoenteroanastomosis in a laparoscopic version.

The technical result of using the proposed invention is the expansion of the arsenal of technical means aimed at forming an esophagoenteroanastomosis in a laparoscopic version, as well as a reduction in the risk of anastomotic failure and an improvement in the functional results of treatment.

The technical result is achieved by the fact that during the laparoscopic gastrectomy, after complete mobilization of the stomach and lymph nodes from the surrounding tissues, a laparoscopic clamp is inserted into the abdominal cavity, applied to the esophagus before its transection, the esophagus is transected below the applied clamp, the stomach with the surrounding lymph nodes is removed, a Roux-en-Y loop of the small intestine is cut out: by transecting the small intestine 40 cm from the ligament of Treitz, an extracorporeal manual single-layer continuous interintestinal anastomosis is formed at a distance of 40 cm from the esophagoenteroanastomosis zone; then an intracorporeal double-layer elongated esophagoenteroanastomosis is formed manually, after which the clamp is removed.

The method is illustrated by figures, where Fig. 1 shows the stage of formation of esophagoenteroanastomosis.

The method is carried out as follows.

In a patient undergoing laparoscopic gastrectomy, after complete mobilization of the stomach and lymph nodes from surrounding tissues before transecting the esophagus into the abdominal cavity through a separate incision, a laparoscopic clamp (Fig. 1, pos. 1) is inserted and applied to the esophagus above the intended site of esophagojejunostomy. After clamp application, the esophagus below the clamp site is transected, a minilaparotomy is performed, and the stomach and surrounding lymph nodes are removed. A Roux-en-Y loop of small intestine is created: the small intestine is transected 40 cm from the ligament of Treitz, and an extracorporeal manual single-layer continuous interintestinal anastomosis is created 40 cm from the esophagojejunostomy site. The diverting portion of the small intestine is then advanced to the upper abdominal cavity toward the esophagus. A manual double-row esophagojejunostomy is performed: the outer row is stitched with interrupted sutures, and the inner row is stitched with interrupted sutures. Then, an intracorporeal double-row esophagojejunostomy is performed manually, and the esophageal clamp is released and removed from the abdominal cavity. Finally, trap drains are placed and the wounds are closed layer by layer.

Clinical example

Patient S., 57, was examined for epigastric pain and diagnosed with a malignant gastric disease, T3N1M0. Given the stage of the disease, diagnostic laparoscopy was the first step. No evidence of dissemination was obtained, and the patient was referred for preoperative chemotherapy. The patient underwent 4 courses of polychemotherapy according to the FLOT regimen. Follow-up examinations were performed after the treatment. The patient's response to treatment was assessed as stabilization. Subsequently, the patient was referred for radical surgery. Given his complexion, age, and the extent of the disease, he was selected as a candidate for laparoscopic surgery. Under general anesthesia, the patient underwent complete mobilization of the stomach and surrounding lymph nodes via a laparoscopic approach. Before transecting the esophagus, a laparoscopic clamp was inserted into the abdominal cavity through a separate incision. A clamp was applied to the esophagus 3 cm above the gastroesophageal junction. The esophagus was transected 1 cm above the gastroesophageal junction. The stomach and lymph nodes were placed in an endobag. A midline minilaparotomy was performed. The endobag was removed. A Roux-en-Y small bowel loop was dissected: the small bowel loop was transected 40 cm from the ligament of Treitz using a cutting and stapling device, and the ends were immersed in purse-string sutures. An extracorporeal manual single-layer continuous interintestinal anastomosis was created using 3/0 PDS suture at a distance of 40 cm from the esophagoenteroanastomosis. A membrane was placed on the minilaparotomy area, and the surgery was continued laparoscopically. The diverting loop of small bowel was transferred to the upper abdominal cavity through the formed opening in the mesocolon. An intracorporeal double-layer curtain esophagoenteroanastomosis was created manually using the proposed method: the outer row was sutured with continuous 3/0 PDS thread, and the inner row was sutured with interrupted 4/0 PDS thread. The clamp was removed from the esophagus and removed from the abdominal cavity. Visual inspection revealed no evidence of anastomotic leakage. An abdominal exploration revealed no evidence of bleeding or foreign bodies. Two drainage tubes were inserted into the abdominal cavity. The minilaparotomy membrane was removed. Layer-by-layer suturing of the postoperative wounds was performed. The surgery was completed. No complications arose in the early postoperative period. The patient was discharged home on the 7th postoperative day. The patient did not require rehospitalization, and no postoperative complications were observed. During follow-up 6 months after surgery, the patient was alive; no data on reflux esophagitis were obtained based on the results of FGDS.

The proposed method allows for an expansion of the arsenal of technical means aimed at forming an esophagoenteroanastomosis in a laparoscopic version, while reducing the risk of anastomotic failure and improving functional results by preventing esophageal migration into the mediastinum, maintaining the correct orientation of the esophageal walls, leveling tension, thereby simplifying the procedure for forming a manual esophagoenteroanastomosis in a laparoscopic version.

Claims (1)

A method for forming a manual esophagoenteroanastomosis during laparoscopic gastrectomy, including mobilization of the stomach and lymph nodes from the surrounding tissues, characterized in that a laparoscopic clamp is inserted into the abdominal cavity and applied to the esophagus, the esophagus is transected below the applied clamp, a minilaparotomy is performed along the midline, the stomach with the surrounding lymph nodes is removed, a Roux-en-Y loop of small intestine is cut out, transecting the small intestine 40 cm from the ligament of Treitz, an extracorporeal manual single-layer continuous interintestinal anastomosis is formed at a distance of 40 cm from the esophagoenteroanastomosis zone; then a manual intracorporeal double-layer elongated esophagoenteroanastomosis is formed, and then the clamp is removed.