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INVENTION
Patent of the Russian Federation RU2269948

METHOD OF SURGICAL TREATMENT OF COMPLICATED ulcers of the posterior stenosis of the stomach

The name of the inventor: Novomlinets Yuri Pavlovich (RU); Antonov Andrey Evgenievich (RU); Dyachok Vladimir Vasilyevich (RU); Bogdanova Yulia Gennadievna (RU); Savelyev Vladimir Vladimirovich
The name of the patent holder: State Educational Institution of Higher Professional Education Kursk State Medical University of the Ministry of Health of the Russian Federation
Address for correspondence: 305041, Kursk, ul. K. Marx, 3, KSMU, Patent Department, Z.N. Kupriyanovoy
Date of commencement of the patent: 2004.02.03

The invention relates to medicine, surgical gastroenterology, can be used in the treatment of complicated gastric ulcer. Perform anterior gastrotomy. Stitch the back wall with ligature. They protrude the stomach wall with an ulcer into its lumen for ligature. Within the normal tissues, a gastric clamp is applied. Below the clamp, the back wall of the stomach is stitched with a trapezoidal continuous piercing suture. Cut the stomach wall under the jaws of the clamp. Stitch the same wall of the stomach in the opposite direction. After suturing the wound, the end of the ligature is associated with its beginning. Complete the formation of a two-story piercing seam. With penetrating ulcers, additional tunnel mobilization of the posterior wall of the stomach takes place. The method allows to reduce the traumatic nature of the intervention.

DESCRIPTION OF THE INVENTION

The invention relates to medicine, namely surgical gastroenterology, and can be used in performing radical or conditionally radical surgery for a complicated stomach ulcer by excising the ulcers of the posterior wall or combining it with antacid operations.

The traditional method is known when for the excision of the ulcer of the posterior wall of the stomach produces anterior gastrootomy, in order to clarify the diagnosis and create access to the posterior wall ulcer, the fringing incisions dissect the site of the posterior wall with the ulcer, stop the bleeding from the stomach wall, then suture the defect of the posterior gastric wall with piercing Sutures from the side of the stomach cavity and nodal serous-muscular sutures impose a second row of seams, for this purpose a significant part of the large curvature of the stomach is mobilized in order to provide access to its posterior wall (GE Ostroverkhov, Yu.M.Bomash, D.N. Lubotsky, Operative Surgery and Topographic Anatomy, Kursk: Academy of Sciences of the Kursk, Moscow: ZAO Litera, 1995, 720 pp.).

This traditional method of excising ulcers and suturing the posterior wall of the stomach is traumatic, since mobilization of the large curvature of the stomach is carried out for a considerable length in order to provide access to the back wall of the stomach, to superimpose the second row of serous-muscular sutures. Single-row piercing transgastral suture is not imposed because of the danger of failure of the back of the stomach.

The object of the invention is a method for transgastral excision of ulcers of the posterior wall of the stomach with a diameter of up to 4 cm in a special gastric clamp and a method for suturing the posterior wall of the stomach with a single two-story suture without mobilization of the stomach for access to its posterior wall, and for large callous penetrating ulcers, an economical mobilization of the site of a large or small Curvature and tunneling mobilization of the back wall of the stomach with ulcer to ensure its mobility.

The task is achieved by the fact that for the access to the back wall of the stomach anterior longitudinal gastrotomy is produced at the level of ulcer localization, the ulcer of the back wall of the stomach is ligated with a ligature. For ligature protrude the back of the stomach with ulcer in its lumen. On the protruded wall of the stomach within the healthy tissues, having retreated 10 mm from the ulcer, a special gastric clamp is applied in the longitudinal direction. Below the stapling clamp intragastrically with the continuous pierced trapezoidal seam of the vikril, the back wall of the stomach is stitched. At the beginning of the thread, to fix it, put a hemostatic clamp. After the end of the stitching of the stomach wall, the thread is stretched and a knot is tied at the end of this seam part. With the same thread, with the piercing seam stitching to a depth of 4 mm, the edge of the clamp of the posterior wall of the stomach in the opposite direction is cut through the fixing jaws. After suturing the entire wound, the end of the ligature is connected to its fixed in the hemostatic clamp beginning.

With callous pententric ulcers of the back wall of the stomach to ensure its mobility, a tunnel mobilization of the posterior wall of the stomach is performed. To do this, economical mobilization of the area of ​​great curvature is made and through the window in the gastrointestinal ligament, a tunnel mobilization of the posterior wall of the stomach is performed using a finger or an instrumentally blunt or acute route.

The front wall of the stomach in the gastrotomic section is sutured with two rows of nodal sutures according to the traditional method.

The invention is explained by the figures (Figs. 1-3)

1. The anterior longitudinal gastrotomy and the technique of imposing the gastric clamp on the protruded posterior gastric wall with an ulcer are demonstrated.

Fig. 2. The first stage of imposing a two-story piercing seam in the form of a continuous trapezoidal seam and fixing the knot at the end of this part of the seam is presented.

FIG. 3. The second stage of imposing a two-storeyed seam in the form of a continuous suture seam is depicted. The beginning and the end of the ligature are connected.

THE METHOD IS PROVIDED AS FOLLOWS:

Produce anterior longitudinal gastrotomy in the projection of localization of the ulcer of the posterior wall of the stomach. Stit ulcer of the back wall of the stomach with a ligature. For ligature protrude the back of the stomach with ulcer in its lumen. On the protruding wall of the stomach within the healthy tissues, having retreated by 10 mm from the ulcer, a special gastric clamp (Fig. 1) is placed longitudinally. Under the staple clamp intragastrically with the continuous pierced trapezoidal seam of the vikril, the back wall of the stomach is stitched. At the beginning of the thread, to fix it, put a hemostatic clamp. After the end of the stitching of the stomach wall, the thread is stretched and a knot is fastened at the end of the trapezoidal seam (FIG. 2). With the same thread, with the piercing seam stitching to a depth of 4 mm, the edge of the gastrocnemion clamped under the fixing jaws is stitched back in the opposite direction, while the ligature is tightened during the sewing process, and after ligating the entire wound, the end of the ligature is linked to its beginning fixed in the hemostatic clamp (Fig. .3).

In the case of callous pententric ulcers of the posterior wall of the stomach, a tunnel mobilization of its posterior wall is performed to ensure its mobility. To do this, economical mobilization of the area of ​​great curvature is made and through the window in the gastrointestinal ligament, a tunnel mobilization of the posterior wall of the stomach is made using a finger or an instrumentally blunt or acute route.

The front wall of the stomach in the gastrotomic section is sutured with two rows of nodal sutures according to the traditional method.

EXAMPLE OF EXPERIMENTAL EXECUTION

Experiments were carried out on 12 mature dogs weighing from 5 to 12 kg. In 6 dogs in an acute experiment under calypsoal anesthesia, anterior median gastro- tomia was performed, the excision of the posterior wall of the stomach with a diameter of 50 mm and its suture with a two-story suture atraumatic sutures was performed in the clamp. The same suture material is sewn up the front wall of the stomach with two rows of nodal seams. By the method of hydroporation on an isolated stomach, the mechanical strength of the stitches on the stomach was investigated. In all six animals, the nodular sutures of the anterior wall of the stomach failed. The average pressure, which caused the inconsistency of nodal sutures, was 392 ± 29 mm Hg.

In 6 dogs, the posterior wall of the stomach is cut and sewn with the same technique by a two-story suture, and the front one is sewed with two rows of nodal sutures. Three weeks after the operation, the joints of the anterior and posterior walls of the stomach were examined. The wounds of the anterior and posterior walls of the stomach were healed by primary tension. There were no cases of insolvency of the joints, but after suturing the rear wall with one two-story seam the seam line turned out to be less infiltrated, more elastic. The seam of the front wall was more coarse.

Dog P., weight 9 kg. Under calypsoal anesthesia, the upper median laparotomy, anterior median gastro- tomia, and the back wall of the stomach are ligated. For the ligature, the back wall of the stomach is protruded into its lumen. A gastric clamp is applied to the area of ​​the protruding posterior wall with a diameter of 50 mm. Below the staples of the clamp the walls of the stomach are stitched with a continuous trapezoidal suture. The beginning of the ligation is fixed in the hemostatic clamp. After tightening the seam at its second end, a knot is tied. The excision of a fragment of the back wall of the stomach under the fixing jaws of the clamp and the same ligature in the opposite direction is made by piercing the welded seam to a depth of 4 mm. After tightening the seam, the beginning and the end of the ligature are connected. Two gastroregal sutures are applied to the gastrotoemic aperture. To assess the mechanical strength of gastric stitches, a gastric gastric septum isolated in the duodenum and esophagus was examined. The inconsistency of the sutures of the anastomotic anterior wall occurred when the liquid was injected through the probe at a pressure of 415 mm Hg. The rear wall remained sealed.

EXAMPLE OF CLINICAL IMPLEMENTATION

Patient K., 53, a medical history of 5618/520, entered the clinic on 26.05.2000 with a diagnosis of a chronic ulcer of the body of a large stomach complicated by bleeding of the third degree. Chronic obstructive bronchitis, diffuse pneumosclerosis, CLS, II stage. An emergency FGD was made. In the stomach "coffee grounds", on the back wall of the lower third of the body of the stomach an ulcer with a diameter of 20 mm with a blood clot. After carrying out blood transfusion in a volume of 800 ml of erythrocyte mass, the patient was urgently operated. Laparotomy, antero-inferior gastrotomy, ulcer of posterior wall of stomach with a diameter of 20 mm with an infiltrative shaft up to 40 mm was detected. In the ulcer a thrombosed vessel. There are no signs of malignancy. Taking into account the severity of the patient's condition, a tunnel mobilization of the posterior wall of the stomach was made with a finger through the avascular zone of the small omentum. The back wall of the stomach with ulcers is stitched with ligature, beyond which the stomach wall with ulcer is stretched into the lumen of the stomach. In the longitudinal direction along the stomach axis a gastric clamp is placed on the back wall of the stomach, retreating 10 mm from the edge of the ulcer. Under the clamp of the clamping with the curvilinear continuous trapezoidal suture, the posterior wall of the stomach is sewn. The fixing clamp is applied to the beginning of the seam. After tightening the thread, a knot is tied at the end of the seam. The fragment of the back wall of the stomach, fixed in the clamp, is excised, and the edge of the back wall of the stomach is sewn in the opposite direction by the suture seam. The beginning and the end of the ligature are connected. Hemostasis is well-founded. Gastrotomic aperture of the anterior wall is sewn with two rows of nodal sutures according to the usual technique. Drainage of the abdominal cavity. Two days spent nasogastric aspiration. The postoperative period proceeded without complications from the gastrointestinal tract.

Endoscopic control 23.06.00 showed epithelization and elasticity of the seam region of the excised posterior wall of the stomach and deformation, infiltration of the suture of the anterior wall. According to this technique, 11 patients with different ulcer localizations on the back wall of the stomach were operated. Complications in the postoperative period, associated with the procedure of the operation, was not revealed.

Thus, the task of excising ulcers of the posterior wall of the stomach with a diameter of up to 40 mm is solved by transgastral removal of them in a special gastric clamp, carrying out, if necessary, limited tunnel mobilization of the posterior wall of the stomach to increase its mobility and transgastral suturing of the wound of the posterior gastric wall by a two-story suture in which One ligature consistently superimposed a trapezoidal, and then a suture joint. The method of imposing a trapezoidal seam provides adaptation to the serous coverings of the wound edges of the wound and, at the same time, passing predominantly in the body of the body (in comparison with the Π-shaped seam), reduces the probability of infection of the serous cover in the postoperative period during the piercing of the stomach wall, The trapezoidal configuration of the continuous seam reduces the possibility of its longitudinal extension (in comparison with the U-shaped seam), and, consequently, the adaptation and compression of tissues necessary for the healing period is provided. The stage of overlapping the welded seam increases the mechanical strength of a two-story seam. The use of a two-story seam reduces the consumption of suture material in comparison with a two-row suture. With a wound length of 25 mm - 5 times and with a wound length of 50 mm - 11 times.

CLAIM

1. A method of surgical treatment of complicated gastric ulcers of the posterior wall with a diameter of up to 40 mm by transgastral excision of ulcers, characterized by performing anterior gastrootomy at the level of the ulcer, stitching the ulcer of the posterior wall with ligature, puffing out the lining of the stomach wall with ulcer into its lumen, the bulging wall Within the healthy tissues, a gastric clamp is applied longitudinally along the longitudinal axis of the stomach, a stitch-like continuous piercing suture is sewn below the clamp, the thread is pulled and a knot is tied at the end of the seam, the gastric wall is chiseled under the jaws of the clamp and sewn with the same filament by the suturing seam of the stomach wall in the opposite direction, After suturing the wound, the end of the ligature is associated with its beginning, completing the formation of a two-story piercing seam.

2. The method of claim 1, wherein the penetrating ulcers produce an additional tunnel mobilization of the posterior wall of the stomach.

print version
Date of publication 29.03.2007gg

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