Method for draining omental bursa in case of destructive pancreatitis

FIELD: medicine, abdominal surgery.

SUBSTANCE: the present innovation deals with treating patients in case of destructive forms of pancreatitis. One should lance a gastro-colic ligament, mobilize splenic and hepatic angles of large intestine, tighten a middle colic artery, descend mesenteric root cross-sectionally against a colon, dissect parietal peritoneum along the upper and lower edges of pancreas to withdraw it into abdominal cavity, remove necrotized tissues. Then one should apply a rubber balloon with drainage tubes along its upper and lower edges into omental cavity: one balloon's end should be withdrawn through median wound, another one - through contra-aperture being 5 cm below a costal arch along median axillary line. The method suggested enables to form adequate access to patient's pancreas.

EFFECT: higher efficiency of drainage.

6 dwg, 1 ex

 

The invention relates to medicine, namely abdominal surgery, and can be used for the treatment of patients with destructive forms of pancreatitis.

Closest solution is the method described Belokoneva V.I. et al., patent No. 2191608 from 27.10.2002. The disadvantage of this method is the inability to adequately stage multiple rehabilitation stuffing bags with the establishment of inadequate access to pancreas slice of purulent-necrotic masses, which leads to difficulty re-access and is often accompanied by damage of hollow organs and blood vessels.

The objective of the invention is to develop a method of drainage stuffing bags with the formation of adequate access to the pancreas and prevent fragmentation of purulent-necrotic masses.

This object is achieved in that open gastrocolic ligament, mobilize the splenic and hepatic corners of the colon, tie the middle of the colon artery and relegate the root of the mesentery of the transverse colon, cut through the parietal peritoneum on the upper and lower edge of the pancreas, and then bring it into the abdominal cavity, make the removal of necrotic tissue, and into the cavity stuffing bags set rubber bottle stoppers on the ends and the location is nimi on the top and bottom edge of the cylinder drainage tubes, one end of which is brought out through the middle of the wound, and the second through contraportada 5 cm below the edge of the costal arch on the mid-axillary line.

The invention is illustrated by figures:

figure 1. Mobilization of the hepatic flexure of the colon.

figure 2. Ligation and the intersection of the middle colon artery.

figure 3. Dissection of the peritoneum over the upper edge of the pancreas.

figure 4. dissection of the peritoneum along the lower edge of the pancreas.

figure 5. The removal of the pancreas in the abdomen.

6. A device for drainage of a Packed bag.

The method is as follows. After laparotomy and revision of the abdominal cavity spend opening the gastrocolic ligament. After mobilization of the splenic and hepatic angle of the colon, bandaging average colon artery and relegated to the root of the mesentery of the transverse colon produce dissection of the parietal peritoneum in the upper and lower edge of the pancreas, and then bring it into the abdominal cavity. Make a removal of necrotic tissue, and then packing bag set device consisting of a rubber cylinder 1 tube 2 for air injection, limiters 3 at the ends of the cylinder and located at the upper and lower edge of the cylinder drainage tubes 4, in order to Polop the operating period was supported by a wide wound channel, one end of which is brought out through the middle of the wound, and the second through contraportada 5 cm below the edge of the costal arch on the mid-axillary line. This is followed by suturing laparotomic wound.

An example of a specific application.

Patient, 63 years history No. 3692-1201, was admitted to surgery. the CTD. COB on with the Kursk 05.07.01 with complaints of pain in the upper abdomen, right and left upper quadrant with radiation to the back, nausea, repeated vomiting, yellowness of the skin, the temperature increases to 39.6°C.

Considers himself ill within 24 hours, after errors in diet (taking fatty foods) appeared above complaints. The house took analgesics and antispasmodics. The condition has not improved. An ambulance delivered to the receiving COB. Hospitalized in the surgical Department.

When entering a serious condition. Skin and visible mucous jaundice. The patient is restless. The vesicular breathing, wheezing no. A/D 110/70 mm Hg, Pulse 98 beats per minute. Tongue dry, the root of white furred. Abdomen slightly swollen, participates in the act of breathing. Palpable tension in the upper sections. Liver, spleen, gall bladder is not palpated. The symptom Shchetkina-Blomberg slabopolozhitelnym in the right hypochondrium. Peristalsis is active. Gases depart. Diuresis saved.

Laboratory tests blood count er - 3,7·1012g/l, hemoglobin - 116 g/l, CP - 0,94. Leukocytes 5,8·109g/l, PAL - 12, SEG - 70, lim - 11, mon - 7, ESR 45 mm/h, coagulation - 8, shelter - 45 sec, PETIT - 105%, blood sugar 10 mmol/l Total urine: number 180,0, muddy, density - 1015, the reaction of the acidic, protein - 0,99, no glucose, leucocytes - 25-30 in the field of view. Diastasis 256. Biochemistry: urea 12,6, creatinine of € 0.195, bilirubin 141,44 mmol/l, direct 112,32, indirect 29,12, ALT-0,540, AST-0,387.

Ultrasound: Liver slightly enlarged. Intrahepatic ducts extended. The parenchyma is homogeneous, normal echogenicity. Gallbladder significantly increased 113 55 mm, wall thickness up to 3,5 mm, homogeneous structure, sometimes with indistinct contours. The common bile duct up to 12 mm, choledoch up to 16 mm in diameter. In the lumen of the bladder multiple small concrements 5-7 mm in diameter. In accessible areas of the choledochus number of concrements are not clearly defined. Distal choledochus is not rendered because of an enlarged pancreas. The gland tissue is not homogeneous in the head with areas of high and low echogenicity. The contours of the tail blurred, fabric hypoechogenic. In the pelvis a small amount of free fluid. The structure of the right kidney without features. Left not visualized clearly.

Diagnosis: Acute biliary pancreatitis, obstructive jaundice, JCB, acute cholecystitis, enzymatic peritonitis.

P is after removing the patient from shock in the ICU and held conservative therapy the patient is taken to the operating room. At laparotomy found: in all departments of the abdominal cavity to 500 ml of turbid effusion mixed with bile and fibrin. Gall bladder 15 to 6 cm, phlegmons changed tense. Hepatoduodenal link edematous, hyperemic. Choledoch to 15 mm Pancreas increased in volume by head, green-black color. The root of the mesentery of the small intestine is swollen.

Opened stuffing a bag that is up to 150-200 ml pussy liquid with an unpleasant odor.

Produced by the puncture of the gallbladder at the bottom. Removed to 120 ml fetid bile. Dedicated cystic duct is opened. Bile from the choledochus is not received. Mobilized duodenum by Kocher. On palpation of the audit is determined by the concrement to 0.8 cm in diameter. Made choledochotomy on the concrement in supraduodenal part of the choledochus. Calculus removed. Allocated " putty-like " bile. The ducts washed with furatsilina. Bougie No. 3 passes freely into the lumen of the duodenum. Made drainage choledochus by Vishnevskaya. Choledocholithiasis hole stitched.

After mobilization of the splenic and hepatic angle of the colon, bandaging average colon artery and relegated to the root of the mesentery of the transverse colon was abdominal pancreas. Made necrsequestrectomy: rubber balloon limiters n the ends and positioned on the upper and lower edge of the cylinder drainage tubes, one end of which is gated through the middle of the wound, and the second through contraportada.

The abdominal cavity sanitized and drained glove-tube drainage in the pelvis. The wound is sutured in layers.

In the postoperative period the patient received complex conservative therapy. Every day was spent washing stuffing bags with antiseptic solutions. The patient was conducted stage necrsequestrectomy, during which there were widespread access to the bed of the pancreas.

Thus, the task is achieved due to the fact that reveal the gastrocolic ligament, mobilize the splenic and hepatic corners of the colon, tie the middle of the colon artery and relegate the root of the mesentery of the transverse colon, cut through the parietal peritoneum on the upper and lower edge of the pancreas, and then bring it into the abdominal cavity, make the removal of necrotic tissue, and into the cavity stuffing bags set rubber bottle stoppers on the ends and positioned on the top and bottom of the tank drain tubes, one end of which is brought out through the middle of the wound, and the second through contraportada.

Application of the developed method drainage stuffing bags allows you to solve a number of problems:

1. To create adequate access to the pancreas, Thu which facilitates abdominal and the subsequent stage of rehabilitation and sequestrectomy.

2. To create conditions for maintaining a single cavity in a sealing bag.

3. To prevent self-closing omentectomy and maintain a wide wound channel with the aim of safe conduct stage necrsequestrectomy.

4. To produce postoperative rehabilitation stuffing bags.

5. To bring drugs to the bed of the pancreas.

6. Remove the pathological exudate from stuffing bags.

The method of drainage stuffing bags with destructive pancreatitis, characterized in that the open gastrocolic ligament, mobilize the splenic and hepatic corners of the colon, tie the middle of the colon artery and relegate the root of the mesentery of the transverse colon, cut through the parietal peritoneum on the upper and lower edge of the pancreas, and then bring it into the abdominal cavity, make the removal of necrotic tissue, and into the cavity stuffing bags set rubber bottle stoppers on the ends and positioned on the top and bottom of the tank drain tubes, one end of which is brought out through the middle of the wound, and the second through contraportada 5 cm below the edge of the costal arch on the mid-axillary line.



 

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