RU2352268C1 - Method of surgical treatment of external fistula of duodenum - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: duodenal fistula is exsected. Thus after supramedian laparotomy, having receded for 0.5 cm from edges of an external fistulous aperture, bordering cut of a skin and subject tissues to fascia is made. Surgery field restriction by sterile napkins is erformed. Fistulous course is painted with a methylene dark blue. Tissues surrounding to the fistulous course to an internal aperture of a fistula of a duodenum are dissected. A duodenum is mobilised according Koecher. The intestine is stitched on border of the janitor and an upper-horizontal duodenum department. Tissues are dissected between mechanical seams. With the help of a purse-string suture the mechanical seam is immersed in the duodenum. Grey-serous Z-shaped seam is imposed. Mechanical seam of a stomach is immersed using applying of separate noose sutures. The internal fistulous aperture is diagnosed. Having receded from it on 0.5 cm, duodenal fistula is exsected together with a duodenum wall. Preparation of a fistulous course with a dermal flap and duodenal tissues is removed. Edges of the duodenal wound are processed by a spirituous chlorhexidine solution. Noose sutures are imposed on a wound in a cross-section direction. Having receded 1 cm from a lateral noose suture, the second row of nodal grey-serous seams in longitudinal direction to perpendicularly first row of seams is imposed. The distance between second row seams makes 0.5 cm. The length of the second row of seams is peer to length of the first row. Having receded from the second longitudinal seam more lateral than 0.5 cm applying of the third grey-serous number of seams in length 1.5 cm is more than length of the previous is made, turning duodenum walls. The subhepatic space is drained. Surgical wounds are taken in layer by layer.

EFFECT: way provides preventive maintenance of purulent-septic complications in an abdominal cavity and in retroperitoneal space, reliable hermetic sealing of an intestine, is less traumatic, is simple in execution.

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Description

The invention relates to medicine, namely to surgery.

Surgical treatment of fistula of the digestive tract is the most difficult section of purulent surgery. The danger of this pathology is associated with a progressive loss of digestive juices, which contain a variety of proteins and electrolytes, the loss of which leads to progressive intoxication, serious disturbances in homeostasis and a change in digestion processes, and, consequently, to a progressive deterioration of the patient's body as a whole and a decrease in its compensatory capabilities.

Particularly difficult situations are associated with the development of duodenal fistula, characterized by abundant loss of bile, pancreatic and gastric juices. With duodenal fistula, due to the physiological characteristics of the duodenum, the patient is in a serious condition and extremely high mortality rates, reaching 98%. Over the past decade, there has been an increase in duodenal fistula, which is caused by a trauma of the duodenum and a large number of distal resections of the stomach due to its various diseases, such as cancer and gastric ulcer. The very presence of an external duodenal fistula causes purulent complications, such as a paraduodenal abscess, peritonitis, and retroperitoneal phlegmon, which determine the surgeon's desire to perform reconstructive surgery on the formed duodenal fistula to avoid the occurrence of such formidable complications mentioned above.

The prototype of the method, the authors propose a method for circular resection of the intestine of the duodenum with external duodenal fistula according to the Billroth method. Around the fistulous opening, departing from the edges of the intestinal mucosa 2-3 cm, preferably within healthy skin, make two bordering incisions to the aponeurosis. The edges of the skin flaps formed are sewn over the fistula with silk ligatures, which ensures aseptic treatment for the subsequent stages of the surgical intervention. The aponeurosis, muscles and peritoneum are gradually excised, pulling the silk sutures into the wound, the block leads to the fistula area, which leads and leads loops, and splits are separated. Especially carefully should examine the outlet section of the intestine, straighten it and eliminate excesses. Fence swabs are inserted into the abdominal cavity and a conventional small bowel resection is performed along with a fistula. Anastomosis form “end to end” or “side to side”, the wound of the abdominal wall is closed layer by layer tightly (A. Bogdanov - Digestive tract fistulas in the practice of a general surgeon. - Moscow. - 2001. - P.111).

The disadvantages of the method are.

1. The method is traumatic.

2. Promotes the additional formation of duodenal fistula.

3. Requires a lot of technical skill when applying a duodenal anastomosis.

4. An extremely high risk of purulent complications due to the failure of the sutures of the anastomosis.

The authors propose their own method of surgical treatment of the external duodenal fistula. Verkhnesomedinaya laparotomy is performed. Then, departing 0.5 cm from the edges of the external fistulous foramen, a fringing incision is made of the skin and then the underlying tissues to the aponeurosis. After that, the surgical field is demarcated with sterile napkins and the fistula is stained with methylene blue to determine the topographic and anatomical distribution of the fistula, then the tissues surrounding the fistula are dissected to the internal opening of the duodenal fistula. Then they begin to mobilize the duodenum according to Kocher. At the border of the pylorus and the upper horizontal section of the duodenum, flashing with the UO-60 apparatus is performed to turn off the duodenum (Fig. 1). Then, between the mechanical joints, tissue is dissected. This achieves the stage of "turning off the duodenum." Then, with the help of a purse string suture, the mechanical suture is immersed in the duodenum. After this, a gray-serous Z-shaped suture is imposed, thereby preventing the failure of the duodenal stump. The mechanical suture of the stomach is immersed by applying individual nodal sutures. Having diagnosed the internal fistulous opening and departing from it 0.5 cm, the duodenal fistula is excised together with the duodenal wall. The fistulous course preparation with a skin flap and duodenal tissues is removed. Then the edges of the duodenal wound are treated with an alcohol solution of chlorhexidine, after which in the transverse direction separate nodal sutures are applied to the duodenal wound (figure 2). 1 cm away from the first (lateral) nodal suture, a second row of nodular gray-serous duodenal sutures is applied in the longitudinal direction, i.e. perpendicular to the first duodenal suture (figure 3). The distance between the seams of the second row is 0.5 cm, and its length is equal to the length of the first row of seams. Then, departing from the second longitudinal suture lateral than 0.5 cm, a third gray-serous row of sutures is applied, 1.5 cm longer than the previous one (Fig. 4). This ensures the immersion of the pathological section of the wall of the duodenum, and hence the strengthening of its hermeticity. The operation is completed by drainage of the subhepatic space by tubular drainage. Surgical wounds are sutured in layers.

The method of surgical treatment of the external duodenal fistula proposed by the authors has several advantages:

1. Promotes the prevention of purulent-septic complications in the abdominal cavity and in the retroperitoneal space.

2. The specified method is less traumatic.

3. Provides reliable sealing.

4. Easy to execute.

5. Reduces the patient’s hospital stay.

The authors operated on 4 people according to the method described above.

Clinical example: case history No. 431, patient A.V., 37 years old, was admitted to the surgical department with a duodenal post-traumatic fistula. The patient was operated on as described above. The postoperative course is smooth. On the 17th day, the patient in satisfactory condition was discharged home.

Claims (1)

A method of surgical treatment of the external duodenal fistula, including excision of the duodenal fistula, characterized in that after the upper median laparotomy, departing 0.5 cm from the edges of the external fistulous opening, border the incision of the skin and underlying tissues to the aponeurosis, limit the surgical field with sterile wipes and stain of the fistulous passage with methylene blue, the tissues surrounding the fistulous passage of the tissue are dissected to the internal opening of the duodenal fistula and proceed to of the duodenal ulcer according to Kocher, on the border of the pylorus and the upper horizontal section of the duodenum, it is stitched, tissue is dissected between the mechanical sutures, the mechanical suture is immersed in the duodenum using a purse string suture, after which a gray-serous Z-shaped suture is applied, the stomach is immersed by applying separate nodal sutures, diagnosing the internal fistulous opening and departing from it 0.5 cm, excising the duodenal c looking together with the wall of the duodenum, the fistulous preparation with a skin flap and duodenal tissues is removed, then the edges of the duodenal wound are treated with an alcohol solution of chlorhexidine and individual nodal sutures are applied in the transverse direction, then, departing 1 cm from the lateral nodal suture, the second a number of nodular gray-serous duodenal sutures in the longitudinal direction perpendicular to the first duodenal suture, the distance between the seams of the second row is 0.5 cm, and its length is equal to the length of the first row of sutures, then, departing from the second longitudinal suture lateral than 0.5 cm, the third gray-serous row of sutures is applied 1.5 cm longer than the previous one, wrapping the walls of the duodenum, draining the subhepatic space with tubular drainage and suturing surgical wounds in layers .

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