Method of intraoperative staged decompression of small intestine through meckel's diverticulum

Abstract

FIELD: medicine; surgery.SUBSTANCE: opening is created at the apex of Meckel's diverticulum intraoperatively. A polyethylene tube is inserted through the opening at the top of Meckel's diverticulum into the small intestine along its length in the oral direction. A temporary tourniquet made from an 8 french diameter rubber urinary catheter is placed around the probe in the upper third of Meckel's diverticulum. The tourniquet is fixed with a hemostatic clamp. The contents of the small intestine are aspirated using a Janet syringe. The tourniquet is weakened. The probe is advanced in the oral direction, repeating the above-described techniques until the small intestine is decompressed at the level of the ligament of Treitz. The intestinal contents are aspirated using a Janet syringe in the aboral direction up to the ileocecal angle. Upon completion of the procedure, the probe is removed. A diverticulectomy is performed with suturing of the intestinal wall and abdominal cavity, after immersing the emptied loops of small intestine into it.EFFECT: intraoperative, step-by-step decompression of the small intestine through the Meckel diverticulum.1 cl, 2 ex

Description

[0001] This invention relates to medicine, specifically to surgical methods for small bowel decompression. The need for intraoperative small bowel emptying arises in various conditions associated with intestinal distension, such as peritonitis and intestinal obstruction, since in these situations, it is impossible to insert the distended small bowel loops into the abdominal cavity when suturing the surgical wound of the anterior abdominal wall.

[0002] Surgical methods of intestinal decompression are known [Dederer Yu.M. Intestinal intubation through a gastrostomy to eliminate postoperative paralytic ileus. Clinical surgery, 1962, no. 7, pp. 41-45]. After thoroughly emptying the stomach, a purse-string suture is placed on its anterior wall at an equal distance between the lesser and greater curvatures in the avascular zone with nylon thread. The lumen of the stomach is opened in the center of this suture. Next, the end of the tube with two lateral openings is inserted towards the pyloric sphincter. Its other end is connected to the electric suction system. The tube is passed through the pyloric sphincter and the duodenum into the jejunum. When the end of the probe is in the jejunum behind the duodenojejunal flexure, it is grasped with the fingers of the right hand and moved along the intestine by corrugating its wall, then a purse-string suture is tied with fixation of the stomach to the anterior abdominal wall [Gorsky V.A., Vypolenko A.V., Krivikhin D.V., Cherevatenko A.M.[Technical Features of Nasointestinal Decompression in Peritonitis. Practical Medicine, 2017, No. 6, pp. 27-31]. A special tube with a guide olive connected to the tube via a thinner, more flexible, yet elastic guidewire is used for intestinal decompression. The guidewire and olive are also made of heat-resistant plastic. After inserting the end of the tube into the stomach, the surgeon grasps the olive with his right hand and directs it into the antrum to pass the tube through the pylorus. The pylorus should be stabilized with the left hand. After passing the tube through the pylorus, the surgeon locates the tube with his left hand in the duodenal bulb and advances it further, while with his right hand, he directs the olive under the mesentery of the transverse colon into the lower horizontal branch of the intestine. If it is difficult to insert the tube into the jejunum, it is necessary to dissect the ligament in the area of ​​the duodenojejunal junction.Once the tube passes beyond the Treitz ligament, the surgeon continuously advances the tube in its initial section (synchronously with the anesthesiologist), and the assistant guides the tube's olive and helps it advance by straightening the intestinal loops.

[0003] The above methods have serious disadvantages:

[0004] - complexity of the procedure;

[0005] - the need for a specially designed probe;

[0006] - traumatic nature of the procedure due to corrugation of the intestine during intubation with a tube;

[0007] - long path of the probe to the small intestine and the risk of bacterial contamination of the upper gastrointestinal tract;

[0008] - risk of intraoperative complication during tissue dissection in the area of ​​the Treitz ligament;

[0009] - the need for a gastrostomy;

[0010] - need for an assistant;

[0011] - the need for a staged operation to close the gastrostomy.

[0012] The following surgical methods of intestinal decompression are also known [Aliev S.A., Aliev E.S. Device-controlled intra- and postoperative decompression and lavage of the colon in the surgical treatment of tumor obstruction. Vestnik khirurgii, 2016, No. 1, pp. 88-94]. We place a purse-string suture on the wall of the colon, in the center of which we dissect the serous-muscular layers along a free intestinal band approximately 1.5-1.8 cm long, using a single-channel tip of the aspirating tube of the device, we puncture the intestinal wall and immediately turn on the device, the operation of which is initially regulated in aspiration mode. As the intestinal contents are aspirated and the intraluminal pressure decreases, the puncture site on the colon can be expanded by 1 cm to allow free movement of the aspiration tube along the longitudinal axis of the intestine, which allows for complete decompression of the organ and maximum elimination of the intestinal contents.Next, distal to or opposite the first, we place a second purse-string suture on the wall of the colon, after which, using the method described above, we insert the tip of the irrigation tube into the intestinal lumen. The device is switched to continuous operation mode, which provides simultaneous (continuous) irrigation (pumping) and aspiration [Semenov A.V. Methods of intestinal decompression in obstructing cancer of the left colon. Abstract of a candidate of medical sciences dissertation, St. Petersburg, 2010, p. 10]. After mobilizing a section of the intestine, a prefabricated self-opening bag is secured, representing a circuit completely isolated from the external environment. The cannula of the transport system is inserted into the cecum and tightly fixed to the intestinal wall with a purse-string suture. A polymer tube with a fluid flow rate regulator is connected to the cannula. Next, saline solution is delivered from a medical bottle through the polymer tube into the cecum.During the procedure, the colon is gently massaged to ensure that large stools are washed away and can pass freely into the collection bag.

[0013] However, these methods have a number of disadvantages:

[0014] - complexity of the procedure;

[0015] - the need for a specially designed device;

[0016] - traumatic procedure due to manual massage of the intestine and application of a purse-string suture to the intestinal wall;

[0017] - cannot be used for decompression of the small intestine, including due to the short length of the probes used.

[0018] Another well-known surgical method of intestinal decompression is [Izosimov A.N. Improving the results of diagnosis and surgical treatment of acute intestinal obstruction in children. Abstract of the dissertation of a doctor of medical sciences, Ufa, 2016, p. 90]. During laparoscopy, a purse-string suture was placed on the wall of one of the loops of the small intestine, and a puncture of the intestinal wall was made in its center with a thick, long needle inserted through the trocar and connected to a suction device. The intestinal contents were evacuated using an electric suction device or a Janet syringe: the needle was removed, and the puncture site was treated with a 2% antiseptic solution. The purse-string suture on the intestine was pulled up and tied. However, this method has several disadvantages:

[0019] - complexity of the procedure;

[0020] - the need for a laparoscopic complex;

[0021] - traumatic procedure due to the application of several purse-string sutures on the wall of the small intestine for its complete decompression;

[0022] - non-obviousness of decompression of the small intestine due to the small diameter of the puncture needle used;

[0023] - risk of contamination of the abdominal cavity with intestinal contents.

[0024] Another known surgical method of intestinal decompression is [Yusupov Sh.A., Shamsiev AM, Shakhriev A.K., Yusupov Sh.Sh., Satayev V.U. Clinical rationale for small intestine decompression in widespread appendicular peritonitis in children. Experimental and clinical gastroenterology. 2022, no. 1, pp. 62-68. DOI: 10.31146 / 1682-8658-ecg-197-l-62-68]. After appendectomy on a long stump (1.5-2 cm), an endotracheal tube with a metal guidewire inserted into it was inserted into the lumen of the appendix, followed by passage of the probe through the Bauhinia valve into the small intestine. After the tip of the endotracheal tube was grasped by the assistant's fingers through the ileal wall, the metal guidewire was removed from the tube. Further tube insertion was accomplished by corrugating the intestine on the tube in an antiperistaltic direction at a distance of 70-80 cm from the ileocecal angle.Then the appendix was fixed to the probe by ligating it with catgut sutures from the outside, after which a puncture of 1-1.5 cm in length was made in the right iliac region, through which the end of the tube with the appendix was passed and the drainage was fixed to the skin.

[0025] Additionally, the dome of the cecum was fixed to the parietal peritoneum around the appendicostomy.

[0026] This method has a number of disadvantages:

[0027] - complexity of the procedure;

[0028] - the need for a non-inflamed proximal part of the appendix;

[0029] - traumatic nature of the procedure due to corrugation of the intestine during intubation with a tube;

[0030] - the need for permanent appendicostomy;

[0031] - need for an assistant;

[0032] - the need for a staged operation to close the appendicostomy.

[0033] The closest in technical essence is the method of decompression of the small intestine through the Meckel diverticulum [Sapozhkov A.Yu., Nikolsky V.I. Intestinal Decompression, 1992, Penza, pp. 103-107]. Through the Meckel diverticulum, a probe is inserted into the small intestine and fixed in it by intussusception of the end stoma with two purse-string sutures with fixation from the inside to the anterior abdominal wall with separate interrupted sutures.

[0034] This method has a number of disadvantages:

[0035] - the presence of an unchanged Meckel's diverticulum is required;

[0036] - traumatic nature of the procedure due to corrugation of the intestine during intubation with a probe;

[0037] - impossibility of advancing the probe through the small intestine due to a tightened purse-string suture on the Meckel diverticulum, sealing the lumen of the latter around the probe;

[0038] - impossibility of complete intraoperative decompression of the small intestine;

[0039] - the need for a permanent intestinal stoma;

[0040] - the need for a staged operation to close the intestinal stoma.

[0041] The aim of the invention is to improve the results of the intraoperative method of decompression of the small intestine through Meckel's diverticulum.

[0042] The stated goal is achieved by the fact that the intraoperative method of staged decompression of the small intestine through the Meckel diverticulum is carried out by periodically advancing a polyethylene probe into the small intestine at the moments of relaxation of the rubber tourniquet placed on the Meckel diverticulum on the probe, as it is decompressed, with subsequent removal of the probe, diverticulectomy with suturing of the intestinal wall and layer-by-layer suturing of the abdominal cavity after immersion of the emptied loops of the small intestine into it.

[0043] The method is carried out as follows.

[0044] Under general anesthesia, after laparotomy, abdominal examination, and detection of dilated small bowel loops and Meckel's diverticulum, a polyethylene catheter is inserted into the small bowel through the opening created at the apex of the Meckel's diverticulum, extending its entire length orally. A temporary tourniquet made from an 8-French rubber urinary catheter is placed around the catheter in the upper third of the Meckel's diverticulum. The tourniquet is secured with a hemostatic clamp. The small bowel contents are then aspirated with a Janet syringe. The tourniquet is released, and the catheter is advanced orally, repeating the above maneuvers until the small bowel is decompressed at the level of the ligament of Treitz. The intestinal contents are then aspirated with a Janet syringe in an aboral direction to the ileocecal junction. At the end of the procedure, the probe is removed and a diverticulectomy is performed with suturing of the intestinal wall and abdominal cavity, after immersing the emptied loops of small intestine into it.

[0045] Specific Application Example

[0046] 1. Patient K., 7 years old. Diagnosis: Intestinal obstruction, volvulus of the small intestine around Meckel's diverticulum. Under anesthesia, after laparotomy and revision of the abdominal organs, loops of small intestine distended to 5 cm, wrapped around Meckel's diverticulum at 720 degrees, without necrosis, were discovered. The volvulus of the small intestine was corrected, and through the created opening at the apex of Meckel's diverticulum, a 115 cm polyethylene tube was passed into the small intestine in an oral direction. A temporary tourniquet made of an 8 French rubber urinary catheter was placed around the tube in the upper third of the Meckel's diverticulum, fixed with a hemostatic clamp, after which the intestinal contents were aspirated with a Janet syringe. The tourniquet was then released and the catheter was advanced further, repeating the aforementioned small bowel decompression techniques at the level of the ligament of Treitz. The intestinal contents were then aspirated with a Janet syringe in an aboral direction to the ileocecal junction.At the end of the procedure, the probe was removed and a diverticulectomy was performed with suturing of the intestinal wall defect with a double-row suture and layer-by-layer suturing of the abdominal cavity after immersing the emptied loops of small intestine into it.

[0047] 2. Patient H., 10 years old. Diagnosis: Meckel's diverticulitis, generalized serous peritonitis, paralytic ileus. Under anesthesia, after laparotomy and revision of the abdominal organs, loops of the small intestine distended to 7 cm, and an edematous, hyperemic and fibrin-coated Meckel's diverticulum were found. Straw-yellow effusion was present in all parts of the abdominal cavity. The effusion was removed with an electric suction machine, and a 75-cm polyethylene tube was inserted into the small intestine through an opening created in the apex of the Meckel's diverticulum in an oral direction. A temporary tourniquet made of an 8 French rubber urinary catheter was placed around the tube in the upper third of the Meckel's diverticulum, fixed with a hemostatic clamp, after which the intestinal contents were aspirated with a Janet syringe. The tourniquet was then released and the tube was advanced further, repeating the above maneuvers until the small intestine was decompressed at the level of the ligament of Treitz. The intestinal contents were then suctioned abortally to the ileocecal junction.At the end of the procedure, the catheter was removed and a diverticulectomy was performed, with the intestinal wall defect closed with a double-layer suture. Drainage and layer-by-layer closure of the abdominal cavity were performed after inserting the emptied small bowel loops into the cavity.

[0048] This method was successfully used in one patient with Meckel's diverticulitis, generalized serous peritonitis, and paralytic ileus, as well as in two patients with intestinal obstruction due to intestinal volvulus around the Meckel's diverticulum. No complications were observed with this surgical method.

[0049] Significant differences of the proposed method of intraoperative staged decompression of the small intestine through Meckel's diverticulum:

[0050] - minimally invasive and easy to perform;

[0051] - no risk of intestinal injury;

[0052] - high efficiency;

[0053] - no need to involve an assistant;

[0054] - can be used even in cases of complications of Meckel's diverticulum;

[0055] - does not require the formation and closure of an intestinal stoma.

Claims

A method for intraoperative staged decompression of the small intestine through a Meckel diverticulum, including the creation of an opening in its apex, characterized in that a polyethylene probe is passed through the opening in the apex of the Meckel diverticulum into the small intestine along its length in the oral direction, a temporary tourniquet made of an 8 French rubber urinary catheter is applied around the probe in the upper third of the Meckel diverticulum, the tourniquet is fixed with a hemostatic clamp, then the contents of the small intestine are aspirated with a Janet syringe, the tourniquet is relaxed and the probe is advanced in the oral direction with a repetition of the above-described techniques until the small intestine is decompressed at the level of the ligament of Treitz, then the contents of the intestine are aspirated with a Janet syringe in the aboral direction to the ileocecal angle, upon completion of the procedure the probe is removed and a diverticulectomy is performed with suturing of the intestinal wall and abdominal cavity, after immersion of the emptied loops of the small intestine into it.