The method of forming a compression-valve choledochoenterostomy

 

The invention relates to medicine, surgery may be used in the formation of choledochoenterostomy. Cut in the transverse direction serosa and muscle layers of the small intestine. Form a tunnel between the muscular and submucosal layers. Impose a sero-muscular sutures between choledochal and the small intestine. Cross choledoch. Stump choledochus is dipped into the tunnel. Below anastomosis cut through the small intestine. The mucosa of the small intestine in the region of the distal portion of the choledochus cut. Get through the incision the implant is in the form of staples Nickel-titanium shape memory. One round of staples placed on the rear wall of the choledochus. Another round of staples impose on the mucous together with submucosal layer of the small intestine. The front wall of the choledochus is fixed to the mucosa of the small intestine. Perform front row sero-muscular sutures. Taken in the small intestine. The method prevents the reflux of food masses in the choledoch. 10 Il.

The invention relates to medicine, specifically to surgery, and relates to methods of forming a compression-valve choledochoenterostomy various pathologies.

Known choledochoenterostomy various pathologies used with Trogo of anastomotic or geleisteten through the seam, the formation of granulomas or pathological cicatricial narrowing of the anastomosis in the long term, as well as the formation in hepaticopsida.

Known choledochoenterostomy for various diseases with the help of sewing machines (2). But they are time consuming and inconvenient, designs are bulky and unsuitable for surgery of the bile ducts. Moreover, this type of seam remained the same inherent complications that and ligature.

Known choledochoenterostomy various pathologies using bioactive glue (MK-6), which, due to its toxicity has not found wide application (3).

The most common disadvantage of all these methods is the presence of foreign bodies, as ligatures and glue, long remain in the tissues of the anastomosis and cause chronic inflammation.

A prototype of the claimed method of applying compression anastomosis is choledochoenterostomy using an implant equipped with a leader of rejection (3). The disadvantage of this method is that after the rejection of the implant remains "gaping" anastomosis, which is the gateway to throw food masses of the small intestine in the choledoch, which results in subsequent xtatic caused by what if its implementation is not formed, the flap-valve, preventing reflux of food masses in the choledoch and thereby prevent secondary inflammation of the choledochus.

The problem solved by this invention is the elimination of side effects and complications.

The problem is solved by overlaying compression-valve choledochoenterostomy by upper-middle-midline laparotomy, clipping choledochus, the summary of a section of the small intestine (Fig.1), forming a tunnel between the muscular and submucosal layers: the wall of the small intestine infiltrate 10 ml of saline using a syringe (Fig.2), then make a cut in the transverse direction of the serous and muscular layer to the submucosal and impose a number of sero-muscular sutures between choledochal and the small intestine (Fig.3), the stump of the choledochus immersed in previously established tunnel (Fig.4), 3-4 cm below the formed anastomosis in the transverse direction cut through the small intestine and its edges are bred for the thread-holders (Fig.5). The mucosa of the small intestine near the location of the distal choledochus cut through, get through the incision the implant is in the form of chilled clips of the two coils of Nickel-titanium shape memory (Fig. the second colon thus, between the turns of the staples are arranged in the rear wall of the choledochus and mucous from the submucosal layer of the small intestine (Fig.7, 8), the front wall of the choledochus is fixed to the mucosa of the small intestine by a single seams, perform front row sero-muscular sutures and anastomosis is sutured to the small intestine by a double seam (Fig.9, 10). The last stage of producing a suturing wounds.

A collection of characteristics, leading to the task is new, not known from the prior art and is not obvious to a person skilled. This method is passed clinical trials. Thus he meets the criteria of the invention: "novelty", "inventive step", "industrially applicable".

The method is as follows: perform upper-middle-median laparotomy, cut choledoch, if possible, distal, for more convenient, in the future, blending anastomosis. Cut off choledoch down to the loop of the small intestine (Fig.1). Form a tunnel between the muscular and submucosal layers: the wall of the small intestine infiltrate 10 ml of saline using a syringe (Fig.2) for separation and better differentiation of the muscular and submucosal layers of the wall of the small intestine. Then make rassekh seams between choledochal and the small intestine (Fig. 3). Stump choledochus immersed in previously established tunnel. This is necessary for forming the valve of sufficient size and keep the contents of the intestine into the lumen of the choledochus. 3-4 cm below the formed anastomosis in the transverse direction cut through the small intestine and its edges are bred for the thread-holders (this is the access to the future-side anastomosis of the bowel lumen) (Fig.4). The mucosa of the small intestine near the location of the distal choledochus cut, visualize choledoch (Fig.5). The implant is in the form of chilled clips of the two coils Nickel-titanium shape memory slid into the small intestine through the incision (Fig.6) and put one round on the back wall of the choledochus and the other on the mucous together with submucosal layer of the small intestine in such a way that between the coils of staples are arranged in the rear wall of the choledochus and mucous from the submucosal layer of the small intestine (Fig.7, 8). The front wall of the choledochus is fixed to the mucosa of the small intestine by a single seams to prevent Saakov bile. Perform front row sero-muscular sutures anastomosis (Fig. 9, 10), then the intestine is sutured by a double seam. Put in layers stitches on the wound. After 8-10 days is the rejection of a paper clip and release its natural the emer complete method: the Patient Century, 57 years, and/b 1043 hospitalized 12.10.2001 was diagnosed with pancreatic cancer stage IV with germination in the duodenum, the stomach. From the anamnesis: considers herself a patient 5.10.2001, when, after the meal came the nausea, single vomiting. The next day, the patient noted a light chair and subikterichnost sclera. Nausea and vomiting after eating continued. The patient asked for help from a therapist at the place of residence, conducted, and then sent to the hospital. When receiving a satisfactory condition. Complains of yellowness of sclera, weight loss of 2 kg per week. The physical examination revealed subikterichnost sclera. General analysis of blood from 13.10.2001, - b - 127 g/l, erythrocytes - 3,810⁹/l, leukocytes - 6,410⁹/l, platelet - 172000. Biochemical analysis of blood from 13.10.2001, bilirubin total 42,2 mmol/l, direct to 18.6 mmol/l,-amylase - 22,0. Ultrasound examination of abdominal cavity organs established that the size of the head of the pancreas is 39 mm with the structure of increased echogenicity, body, tail normal size. Data CT - head of the pancreas W is rovet the duodenum is not narrowed.

25.10.2001, operation laparotomy, revision of the abdominal cavity, the imposition of a compression-valve choledochoenterostomy.

The operation performed by the proposed method. The operating field is processed by Grossao. Under General anesthesia the upper-middle-median access made laparotomy. During inspection of the abdominal cavity revealed the presence of single metastases to peritoneum, tumor invasion of the pancreatic head in a downward Department of the duodenum, antrum, retroperitoneal space. Choledoch clipped, its distal part sutured. To overlay anastomosis to the cult of the choledochus summed loop of the small intestine. The wall of the rectum with a syringe infiltrated with 10 ml of saline. Made the cut in the transverse direction of serosal and muscular layers to submucosal and imposed a number of sero-muscular sutures between choledochal and the small intestine. The stump of the choledochus immersed in previously established tunnel between the muscular and submucosal layers of the small intestine. 4 cm below the form of anastomosis in the transverse direction cut the small intestine and its edges are bred for the thread-holders. The mucosa of the small intestine near the location of the distal choledochus dissected, wisden into the small intestine through the incision and superimposed one round to the rear wall of the choledochus, and the other on the mucous together with submucosal layer of the small intestine in such a way that between the coils of the clips are located in the rear wall of the choledochus and mucous from the submucosal layer of the small intestine. The front wall of the choledochus is fixed to the mucosa of the small intestine by a single seams to prevent Saakov bile. Performed front row sero-muscular sutures anastomosis. The small intestine is sutured by a double seam. Superimposed layers of stitches in the wound.

The postoperative period was uneventful. Total blood bilirubin decreased to 18.4 mmol/l at 3 days after surgery. Sutures were removed on the 11th day after the operation. Jaundice no. Blood from 7.11.2001, b - 125 g/l, er. - 3,610¹²/l, leukocytes - 4,5l0⁹/HP Complaints at discharge to intermittent nausea after eating.

Examination in a month. The condition is satisfactory, complaints of nausea after eating preserved, sometimes vomiting, weight loss of 1 kg During the physical examination: skin and sclera normal coloration is palpated in the epigastrium, the head of the pancreas, thick consistency.

What is new is the formation of a compression valve through the tunnel in the wall of the intestine, with katopodes prevents postoperative anastomotic stricture, thirdly, prevents hypertension in the biliary tract.

With implant of titanium nickelide the anastomosis is performed twice as fast, bloodless and eliminates the use of suture material. This type of anastomosis has high physical strength, low bacterial permeability, because you are not using the ligature, heals by type of primary tension with minimal inflammatory reaction and minor development of scar tissue. Educated valve prevents reflux of the contents of the intestine in the common bile duct than hinders the development of acute and chronic cholangitis.

The use of an implant of titanium nickelide and operation of the proposed sequence and the method prevents the formation of postoperative anastomotic stricture.

Sources of information 1. Peter C. E., Dambai, Church and other Medical materials and implants with shape memory // Tomsk, 1998, 486 S.

2. Shalimov A. A., Saenko B. C. Surgery of the gastrointestinal tract // Kiev, 1987

3. The Guibert B. K. Development and application of implants with shape memory in biliodigestive surgery // Tomsk, 1995

Claims

The method of forming a compression-clandestine it to the loop of the small intestine and the imposition of the implant between the small intestine and choledochal, the wound closure, wherein forming a tunnel between the muscular and submucosal layers: the wall of the small intestine infiltrate 10 ml of saline using a syringe, then make a cut in the transverse direction of serosal and muscular layers to submucosal and impose a number of sero-muscular sutures between choledochal and the small intestine, the stump of the choledochus immersed in previously established tunnel, 3-4 cm below the formed anastomosis in the transverse direction cut through the small intestine and its edges are bred for the thread-holders, the mucosa of the small intestine near the location of the distal choledochus cut, get through the incision the implant is in the form of chilled clips of the two coils of Nickel-titanium shape memory and put one round on the back wall of the choledochus and the other on the mucous together with submucosal layer of the small intestine in such a way that between the coils of staples are arranged in the rear wall of the choledochus and mucous from the submucosal layer of the small intestine, the front wall of the choledochus is fixed to the mucosa of the small intestine by a single seams, perform front row sero-muscular sutures and anastomosis is sutured to the small intestine by a double seam.