Injury to the stomach. Surgical approaches to the stomach Indications for suturing a stomach wound

There are mechanical, thermal, chemical, spontaneous and other damage to the alimentary tract. The most numerous group of mechanical destruction that occurs when foreign particles get stuck, due to damage with instruments (when the throat of a girl from Miass was injured when washing from food poisoning) or jets of compressed gas, due to gunshot wounds or cuts with melee weapons. Burns occur when drinking too hot and chemically aggressive liquids. Spontaneous ruptures and fissures of the alimentary tract occur with a sudden increase in pressure within the esophagus. Scratches appear when foreign matter gets stuck.

Injuries to the esophagus pose a significant risk and interfere with normal human nutrition.

• 1 The essence of pathology
• 2 Reasons
• 3 General and local symptoms
• 4 Classification
  • 4.1 By etiology
  • 4.2 Mechanical
  • 4.3 Thermal
  • 4.4 Chemical
  • 4.5 Spontaneous
  • 4.6 By localization
  • 4.7 By depth
  • 4.8 In appearance
• 5 First aid rules
• 6 Diagnostics
• 7 Conservative treatment
• 8 Surgical intervention
• 9 Other methods
• 10 Postoperative period
• 11 Prevention
• 12 Forecast

The essence of pathology

Damage to the esophagus occurs when the integrity of the walls of the upper alimentary tract is violated. The nature of these destructions is traumatic or spontaneous. The organ can be damaged to varying degrees, such as cracks, wounds, burns, or lacerations.

Burns inflammation of the esophagus occurs due to the ingestion of corrosive chemical fluids. It is possible to damage the organ temporarily, then the defect will quickly recover. If the esophagus is scratched too deeply or if it cracks, chronic narrowing of the alimentary tract may develop, which can be corrected surgically.

If the esophagus is badly injured, the walls have ruptured, the inflammation develops rapidly and complete perforation occurs. The nearby organs of the mediastinum, trachea, and large vessels quickly become infected. The culmination of the process is death due to infection, shock, bleeding (which is what happened to the girl from Miass).

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The reasons

Most often, damage to the esophagus occurs when exposed to chemical or thermal influences. Dangerous defects if the alimentary tract is injured, for example, when washing (at the Miass hospital). Reasons for violation of the integrity of the esophageal canal:

• perforating injury by a foreign body;
• perforation with firearms or cold weapons;
• spontaneous ruptures due to increased pressure inside the tract when coughing, sneezing, severe vomiting;
• burns with hot or chemically reactive substances;
• animal bites;
• tears due to the use of tools, which happened to a girl in the city of Miass.

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General and local symptoms

The clinical picture of damage to the esophagus is diverse. Symptoms are determined by the type, location of the wound, and the rate at which inflammation develops. Symptoms are general and local. Common symptoms:

• post-traumatic shock;
• inflammation of nearby tissues;
• growing intoxication;
• worsening respiratory dysfunction;
• pneumopyothorax.

If the pharynx is damaged by a penetrating wound, the clinical picture develops in three stages:

1. initial degree (0.5-5 hours) with a sharp deterioration in the condition;
2. phase of pseudo-calm (18-36 hours) with improvement of the condition, dulling of pain. When high temperature and dehydration;
3. phase of progressive inflammation with purulent complications.

Local signs:

• pain throughout the esophagus, behind the sternum;
• hoarseness of voice;
• difficulty swallowing food or liquids;
• tissue infiltration;
• increased skin temperature;
• accumulation of air in the subcutaneous tissue of the sternum;
• accumulation of air, gases in the pleural area;
• putrid odor from the mouth.

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Classification

There is a wide classification of damage to the esophagus, depending on the causes of them, localization, type of scratches and other factors.

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By etiology

The causal classification divides damage into mechanical, thermal, chemical, spontaneous destruction. It is possible to injure the alimentary tract with instrumental trauma (the case in Miass), burns, infection, peptic ulcers, the development of oncology, disruption of integrity after radiation therapy, inflammation of the walls, spontaneous rupture (Boerhaave's syndrome), and bone scratches.

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Mechanical

Such damage to the esophagus occurs when foreign bodies get stuck, the integrity of the organ is violated by tools (like a girl from Miass), weapon wounds, closed injuries, and gas jets under pressure.

Mechanical damage to the esophagus often ends in death, even with timely medical assistance. If the esophagus is only scratched by the bone, healing occurs on its own in a short time. Injury due to bruises, crushing, and closed-type industrial injuries are rare.

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Thermal

This type of injury can be accidental or deliberate. It occurs against the background of the use of hot and cauterizing liquids. The stage of the lesion depends on the extent of the injury. When the pharynx is injured, as with chemical damage, the pathology develops in three directions:

1. destruction of the surface epithelium, for example, scratches. It is accompanied by hyperemia of the upper layer of the shell;
2. a burn with necrosis and the formation of surface erosion;
3. damage to muscle tissue with the formation of bleeding ulcers and mucosal rejection.

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Chemical

This type of damage is caused by the use of solutions of strong acids, alkalis, oxidants. Acids infect the esophagus with coagulation, necrosis and tissue crusting, accompanied by burn esophagitis (deep inflammation).

Alkalis saponify tissues, which causes large-scale tissue death without scaling. Oxidizing agents such as potassium permanganate, hydrogen peroxide solution act like acids.

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Spontaneous

Spontaneous tears are long-term injuries to the esophagus (from 40 to 80 mm). They look like a linear wall defect up to the cardiac zone of the stomach, which is provoked by powerful contractions during vomiting, a sharp jump in intra-abdominal pressure. Cracks in the alimentary tract occur with congenital thinning of this section.

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By localization

The damaged area can be located:

• in cervical spinewhen destruction occurs due to the wedging of a foreign body or when an attempt to extract it fails;
• in the chest area, which often occurs with improper bougie;
• in the abdominal cavity.

Esophageal injuries are located on one or more walls.

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By depth

• non-penetrating damage (abrasions, even ruptures of the mucous membrane, hematomas);
• penetrating injuries with perforation or through wounds;
• insulated scratches;
• combined with damage to neighboring organs.

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In appearance

They are classified as:

• stabbed or penetrating;
• cut with linear, even edges, as if damaged by tools (the case in Miass);
• lacerated wounds;
• bedsores in the form of rounded erosions with necrosis along the edges;
• spontaneous ruptures;
• scratches.

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First aid rules

1. it is forbidden to induce vomiting in the victim, gargle. These actions can additionally injure the throat;
2. the patient should not be allowed to swallow anything, since any substance, especially caustic, can burn the walls of the stomach;
3. if necessary, perform manipulations to resuscitate the patient with the restoration of breathing and heart rate;
4. call an ambulance immediately;
5. if the damage is caused by chemical burns, take the sample with you.

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Diagnostics

As a diagnostic method that allows you to identify scratches in the esophagus, the following are used:

• general x-ray of the neck, sternum, peritoneum;
• contrast x-ray of the esophagus;
• fibroesophagoscopy;
• Ultrasound of the heart, pleural cavities;
• CT of the mediastinum;
• thoracoscopy with laparoscopy.

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Conservative treatment

1. Drug treatment is based on relieving inflammation, scarring, and infection of damaged tissues. For these purposes, antibiotics are prescribed.
2. If the esophagus is severely narrowed, a flexible bougie of the appropriate size is used so that it does not scratch the esophagus (not in the case of the girl from Miass).
3. In case of dysfunction of the swallowing and chewing functions, food is administered intravenously. With the onset of the first improvements, the patient is allowed to drink, then eat liquid, chopped food so that it does not scratch the organ.
4. If there is an underlying disease, a specific set of drugs is prescribed to relieve it.

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Surgical intervention

For the purpose of prompt relief of damage to the esophagus, various techniques are used:

1. Extra cervical access. Suturing of the wound, muscle strengthening of the seams, drainage of the intervention area is performed.
2. Laparotomic access. The walls of the stomach are strengthened with sutures, fundoplication is performed, a feeding tube is inserted bypassing the esophagus, or a gastrostomy is applied if the abdominal zone is damaged.
3. Extirpation of the esophagus or plastic graft. The material is taken from the stomach or large intestine. The operation is performed a few months after the disease so that the instruments do not scratch delicate tissues.

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Other methods

Palliative or supportive measures are taken if the injury is long-standing. In this case, suturing of the esophagus is not performed, but is done:

• gastrostomy;
• the pleural cavity is drained;
• mediastinotomy;
• esophagostomy.

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Postoperative period

The severity of the postoperative course is determined by the location and type of injury. If wound closure occurred in a timely manner, then rehabilitation period will go smoothly. The patient is prescribed:

• pain relievers;
• semi-sitting position;
• sanitation of the tracheobronchial tree and oral cavity;
• complex intensive care, including the use of antibiotics, immunomodulators, infusion-transfusion and detoxification effects.

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Prevention

1. caution in performing endoscopic procedures, surgical procedures and other medical interventions to avoid scratching;
2. you can not overeat, abuse alcohol and heavy physical activity.

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Forecast

The forecast depends on the execution speed surgical treatment, severity of complications, type of concomitant pathologies, depth of esophageal scratches. Mortality rates range from 50-75%.

Stomach ulcer and surgery to remove it

Don't postpone stomach surgery or duodenum, if a drug treatment does not give the desired result. Time will be lost, the condition will worsen.

Urgent surgery for stomach ulcers is prescribed in case of exacerbation. Life may depend on the timeliness of its implementation. Planned is carried out after a thorough examination, determining the localization of the lesion. Modern medical centers have the ability to exclude the classic large dissection and limit themselves to a few punctures - to do a laparoscopy. It all depends on the patient's condition and the presence of concomitant diseases.

Stomach ulcer treatment

Gastritis and ulcers can be treated with medication. You should take 4 drugs at the same time, prescribed by your doctor. As a result:

• The inflammation is relieved.
• The number of Helicobacter Pylori is significantly reduced or bacteria are completely destroyed.
• An additional protective film is created on the walls of the stomach.
• Healing of wounds and regeneration of damaged tissues is accelerated.

The use of folk methods treatment. Acceptance of decoctions and juices should be agreed with your doctor. The funds taken should not interact and reduce the effectiveness of other substances. Be sure to follow a diet, spend time in the fresh air. See a doctor regularly.

Reasons for the operation

In the event that urgent measures need to be taken or drug therapy cannot cure a stomach ulcer, surgery is necessary. By time, operations are divided into:

• Urgent.
• Planned.

The first is carried out in the case when it is impossible to postpone surgical intervention. This is mainly the presence of a perforated stomach ulcer - the formation of a through hole in abdominal cavity with leakage of stomach contents through it, ulcers towards adjacent organs or bleeding. A perforated stomach ulcer leads to infection in the abdominal cavity, sepsis. The acid affects the tissues and causes burns of the peritoneum, destruction of the walls of blood vessels, and blood poisoning. Perforation in the direction of adjacent organs eats away at their walls, causing severe pain and spasm.

Perforated ulcer requires immediate surgical intervention... It leads to large blood loss that exceeds the permissible norms for a person. Planned operations are carried out in cases when it is necessary to remove the ulcer, but the condition is not critical:

• Drug treatment long time does not give the desired result.
• Frequent relapses, approximately every 3 months.
• Pyloric stenosis is a narrowing of the pylorus that impedes the passage of food into the intestines.
• Suspected malignancy.

The patient is assigned the date of the operation, a complete examination is carried out. In the presence of concomitant and chronic diseases, consultations of doctors specializing in various fields are held. In what cases it is necessary to postpone the operation to remove the stomach ulcer:

• The patient is sick or has just recovered from a viral infection and a cold.
• Decompensation states - recovery after treatment of other organs, severe nervousness and stress.
• General weakness of the body and the serious condition of the patient.
• The examination showed a malignant ulcer with the formation of metastases.

The operation is postponed until the time when the patient gets stronger. In case of detection malignant tumor the patient is referred to oncology for treatment.

Preparation for planned surgery

Before surgery to eliminate stomach ulcers, the patient undergoes a general medical examination. They check his reaction to sexually transmitted diseases, HIV infection, and the presence of foci of chronic diseases. If a virus is detected, the main foci of possible inflammation are checked, including the tonsils, teeth, and respiratory organs. The patient is examined by a cardiologist.

2 weeks before the operation, a patient with a stomach ulcer is tested:

• Blood - a detailed clinical analysis with the simultaneous determination of the group and rhesus.
• Urine and feces for traces of bacteria and blood.
• the pH meter indicates the activity of the acid-producing glands.
• Gastric juice for the presence of Helicobacter Pylori and their amount.
• With the help of a biopsy, tissue is taken for examination for histology.

A patient with a stomach ulcer is examined:

• Contrast fluoroscopy.
• Electrogastroenterography.
• Antroduodenal manometry.
• Gastroendoscopy with biopsy of a tissue sample.

The number and list of necessary examinations is determined by the peculiarity of the patient's stomach ulcer, and the equipment of the clique preparing him for the operation.

Modern methods of eliminating gastric ulcers

During the operation, the ulcer is eliminated by suturing and resection of the stomach. The first option is used more often in urgent operations. If there is one perforated ulcer, it is sutured layer by layer, after removing the inflamed damaged edges. Then they wash the abdominal cavity with antiseptics. A probe is placed to remove the fluid entering the cavity.

When carrying out planned operations, suturing is applied to single ulcers. Such cases are rare. Most often, a significant area of \u200b\u200bthe gastric mucosa in the central part is damaged. Therefore, a resection is performed. The middle or antrum is removed, then the cardiac and pyloric sections are connected.

Gastric resection is well established and widely used in various clinics. After it, parts of the stomach are connected with special sutures. They exclude tissue contraction and scarring, as with suturing. Not only the ulcer itself is removed, but also the destroyed inflamed tissues around it, prone to the formation of erosion and new ulcers.

Traditionally, an incision for gastric ulcer surgery is performed along the entire length of the organ, from the sternum to the navel. Modern clinics have the ability to perform laparoscopic operations. To insert the instrument, several punctures are made, the largest of which can be expanded to 4 cm. With the help of manipulators and a probe with a camera, tissue is excised and sutured. Through a wide puncture, the removed fragments are removed to the outside. Then a tube is inserted, sanitation and gastric lavage is done, and the acid is neutralized. After 3 days, the drain is removed. The patient can start drinking and eating liquid jelly and other dietary products.

After laparoscopy of the stomach ulcer, the patient gets up the very next day. Tissue connection and healing is faster. Blood loss during surgery is minimal. Less pain relievers are needed because the stitches are only on the stomach. Since the cavity is not opened, there is no air ingress. This reduces the likelihood of suppuration. The patient's hospital stay is shortened.

Postoperative period and possible complications

Most patients after gastric resection find it difficult to get used to the new meal schedule. The volume of the stomach has significantly decreased, it is necessary to eat in small portions, often. Side effects may appear:

• Iron deficiency anemia.
• Bloating, rumbling.
• Constipation alternating with diarrhea.
• Adductor loop syndrome - bloating after eating, nausea, vomiting with bile.
• Adhesion formation.
• Hernias.

Food enters the intestines not completely digested, since it passes a much smaller path in the stomach. This causes dizziness, weakness, and an increased heart rate. Gastritis and stomach ulcers after surgery can form on the remaining walls of the organ. To avoid negative consequences after surgery, you can stick to a diet and undergo a medical course of postoperative therapy.

Hemorrhoids are a fairly common disease. On the initial stages condition can be adjusted conservative methods (with the help of medicines). But in more advanced cases, drug treatment rarely brings a positive result. Therefore, you have to carry out surgery.

Basic surgical treatments for hemorrhoids

There are two methods of surgical treatment for hemorrhoids. The first is Operation Longo. And secondly, Milligan-Morgan hemorrhoidectomy. The latter brings good, sustainable result, excluding the development of complications. This section is devoted to the description of this operation, it also includes a video showing the progress of the above operation. It is not recommended to watch impressionable people.

Varieties of Milligan-Morgan hemorrhoidectomy

This method of surgical treatment has a long history. This operation has been performed since 1937. Subsequently, some surgeons made their own changes and significant additions to the technique, so several varieties of this operation appeared. The differences lie in the final stage of the operation. All other moments have been preserved for many years.

The classic version of this operation is called open. This name arose because the wounds that remain after excision of the nodes are left open, they are not sutured. They heal on their own in a few days (3 - 5). For this operation, the patient is admitted to the hospital for about a week.

The operation is performed under anesthesia, which is done intravenously, sometimes using epidural anesthesia.

Since 1959, a closed hemorrhoidectomy has been performed, this option involves suturing the wounds tightly at the end of the operation. This method allows you to carry out surgery on an outpatient basis. This technique was proposed by Ferguson, Heaton. This page contains a video of closed hemorrhoidectomy.

Indications for this operation

Currently, this intervention is carried out in advanced cases:

• Stage III;
• Stage IV;
• Stage II (in the presence of large nodes).

Large nodes that cannot be removed using minimally invasive methods are recommended for removal using hemorrhoidectomy.

Operation technique

The operation has several stages. The preparatory stage includes a complete release from the hairline. It is also necessary to thoroughly cleanse the intestines from the contents, for this they drink laxatives, then do an enema. Before starting the operation, the patient should be laid on his back, his legs are widely spread and fixed on special devices. The site of operation is disinfected, a solution of iodonate and betadine is used as the main agent. Next is the operation itself.

First, local anesthesia is given. Most often, a solution of novocaine (0.25%) is injected around the anus. At the next stage, the anus is expanded using a rectal speculum. The mucous surface of the intestines is processed, dried special means... Then, using the first clamp, the doctor grabs the inner node and pulls it closer to the outer lumen.

Most often, such nodes can be located in the following places: on the mental dial it will be 3, 7, 11 hours. First, those nodes are removed that are in the 3 hour zone.

Then they begin to remove the nodes at 7 o'clock. The nodes that are localized at 11 o'clock are removed last. This course of work facilitates easy access to the nodes in need of surgery, continued bleeding will not interfere with work.

When the knot is gripped, its leg is gripped with a second clamp. In this place, the catgut is sewn up with a figure eight. This is done to prevent the ligature from slipping off the stump of the remote node.

Then the knot is excised, the thread is tightly tightened. It is advisable to use an electric knife for excision. Here its ability to easily cut tissue and cauterize during cutting will work well. blood vessels... This allows you to reduce blood loss, avoid the development of severe bleeding. On the last stage the wound is sutured using catgut. The direction is radial with respect to the edge of the anus. Subsequently, other existing nodes are excised. First internal, then external.

During the operation, carefully ensure that there are gaps of the whole mucous membrane between all the sutured zones. Otherwise, the passages will narrow.

To top it off, the operated surface is treated with a disinfectant solution, everything is covered with a sterile napkin. Turunda with levomekol or levosin is introduced into the anal canal. Turunda should stand for about 6 hours.

Postoperative stage

The first day should be spent on a starvation diet, because going to the toilet is prohibited. Then you need to follow a strict diet. It involves the use of such products that will only give soft feces. Indeed, at this stage, in no case should the mucous membrane be injured.

They are on sick leave for a long time. Open hemorrhoidectomy takes 5 weeks, which will take 5 weeks for complete healing. Closed requires a little less - 3 - 4 weeks. After that, the patient can start working.

Drink plenty of fluids. The first days after surgery are accompanied by pain. Therefore, pain relievers are prescribed. Locally, it is necessary to make baths based on potassium permanganate or chamomile. Suppositories or methyluracil ointment are used.

Possible complications

Complications develop infrequently, the main manifestations are reduced to the following:

• Bleeding, which develops due to a violation of the integrity of the mucous membrane due to the passage of solid feces, can also slip the ligature from the stump from the node.
• Narrowing of the anal canal. This is a consequence of a violation of the suturing technology, in order to eliminate such a complication, you need to use an expander, in difficult cases you have to do plastic.
• Acute urinary retention. The reason for this condition is reflex, so urine is simply removed by a catheter. In most cases, men are susceptible to this complication. Insufficiency of the anal sphincter. This is a consequence of surgical damage to the muscle layer. This problem may occur due to the low qualifications of the doctor. Fortunately, this complication is extremely rare.
• Postoperative fistulas. This complication appears in this case if muscle layers were captured during suturing, resulting in the addition of an infection.
• Infectious inflammation of the wound. It can occur when the rules of asepsis have been violated.

Contraindications to hemorrhoidectomy

This surgery has a number of contraindications. These include pregnancy, oncological processes, Crohn's disease, AIDS. Contraindications, which are relative (after their elimination, the operation can be carried out) is inflammation in the anus. These processes develop in those who have discharge from the rectum. First, anti-inflammatory therapy is performed, and then the operation.

Important information about hemorrhoidectomy

The persistence of the results after this operation depends on the patient himself. He must definitely change his lifestyle, follow a diet. Operation gives good result, but not everyone can do it. Minimally invasive methods are less traumatic.

In the case of the above operation, the postoperative period is long, there are pains, discomfort, often you have to stay in the hospital for a long time.

The risk of complications during the operation and in the subsequent period makes this method of treatment imperfect. It is much easier to monitor your health, diet, and lead a normal life. If the problem has already arisen, surgery is resorted to in the most extreme cases, for example, if the nodes fall out, bleed, become inflamed. In other cases, medication can be dispensed with.

The operation should be done when conservative treatment does not work, the condition worsens. No candle, no ointment, no folk remedies do not stop the loss of nodes (after each bowel movement). In young patients, frequent bleeding quickly provokes the development of anemia. But still, before hemorrhoidectomy, they try other methods of treatment and surgical intervention with minimally invasive methods.

Middle-aged patients with seasonal nodule prolapse that does not respond to conservative treatment, it is also worth carrying out a hemorrhoidectomy. In such cases, it is very effective. At present, a lot of these operations are being done. They have already entered the category of ordinary interventions.

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Damage to the stomach is rare. Their share is 5% of the total number of abdominal injuries. Isolated trauma of the stomach is rare, in most cases it is accompanied by damage to neighboring organs (pancreas, spleen, liver, duodenum, large intestine).

Closed injury mechanism: a strong blow with a solid object in the upper anterior abdominal wall, a sharp sudden displacement of the stomach in relation to the place of fixation of the ligamentous apparatus when falling from a great height at the time of landing, compression of an organ between the spine and a traumatic object. The extent and extent of the damage to the stomach depends on the direction and force of the shock, as well as the filling of the stomach (with a full stomach, damage from hydrodynamic shock is more extensive).

Classification

The following types of closed gastric lesions are known:

• bruises and hematomas of the stomach wall;
• incomplete and complete ruptures of the stomach wall;
• separation of the cardiac part of the stomach;
• separation of the pylorus, duodenum;
• crushing of the stomach wall.

With a closed abdominal injury, rupture of the stomach wall is possible - complete and incomplete, when only the serous and / or muscle layers are damaged while maintaining the mucous membrane. In case of incomplete ruptures of the stomach wall and subserous hematomas, secondary necrosis of all layers of the wall may occur, followed by perforation and complete rupture of the stomach. With complete ruptures, damage to the anterior wall of the stomach occurs most often along the lesser curvature and in the pylorus. Less often, there are tears of the cardia and the posterior wall. When the stomach wall ruptures completely, the mucous membrane usually bleeds and protrudes. In both cases, ruptures and hematomas of the ligamentous apparatus of the stomach can be detected. When the stomach wall is bruised, only hemorrhages under the serous or mucous membrane, ruptures of the mucous membrane are observed.

Clinical signs, diagnosis

The clinical picture is determined by the nature, location of damage and the time elapsed since the moment of injury. Peritoneal symptoms in the first hours after the injury are not clearly expressed, which complicates the diagnosis, especially in shock. In most cases closed damage the stomach is found during surgery for peritonitis.

In case of incomplete ruptures and hematomas of the stomach wall, varying intensity of pain in the epigastric region is observed, vomiting with an admixture of blood is possible. Symptoms of peritoneal irritation are mild. The classic symptoms of an acute abdomen are detected only after the patient is removed from a serious condition. In cases where there is no complete rupture of the stomach wall, but there are only ruptures of the serous membrane, subserous hematomas, hematomas of the ligamentous apparatus, the clinical picture of intra-abdominal bleeding prevails. In case of bruises, tears of the stomach wall, subserous hematomas, three periods are distinguished: shock, imaginary well-being and secondary necrosis (peritonitis). In the first period, severe shock may develop. After removing the patient from shock, a period of relatively satisfactory condition begins. The patient is worried about only moderate pain in the epigastric region. The third period may end with cicatricial stenosis or, as mentioned above, secondary necrosis of the gastric wall and perforation.

A complete rupture of the stomach wall is manifested by "dagger" pain, characteristic of perforation of the hollow abdominal organ. The rupture of the posterior wall of the stomach is accompanied by sharp, burning pains in the abdominal cavity radiating to the back.

When the stomach wall ruptures, peritonitis develops rather quickly. Diagnosis of perforation of the stomach wall is facilitated by X-ray examination, which reveals free gas in the abdominal region, the disappearance of the air bubble of the stomach or its deformation. However, X-ray examination is not always possible due to the severity of the patient's condition. Due to the fact that it is often quite difficult to diagnose a stomach injury based on clinical data only, especially with multiple and associated injuries, it is advisable to use even with minimal suspicion of a "catastrophe" in the stomach instrumental methods research (laparocentesis, laparoscopy).

Treatment

Is it suspected for clinical research damage to the stomach or the diagnosis is established during laparoscopy, regardless of the nature of the damage (tear of the serous membrane, subserous hematoma), the surgical tactics is unambiguous - urgent laparotomy.

After revision of the anterior and posterior walls of the stomach, when a complete rupture is detected, the operation is reduced to removing blood clots, economically excising the edges of the stomach wound and suturing it in the transverse direction with respect to the stomach axis with a double-row suture, followed by covering the sutured defect with an omentum on the leg (Fig. 53- 8).

Figure: 53-8. Stages of suturing a stomach wound: a - excision of the edges of the stomach wound; b - suturing in the transverse direction with respect to the axis of the stomach.

With extensive ruptures of the walls of the stomach and its ruptures in the pyloric or cardiac section, which is observed quite rarely, one should also limit ourselves to suturing. Indications for gastric resection should be limited. In exceptional cases, if wound closure can lead to severe deformation of the stomach, the volume of surgery can be expanded. If the wound is localized on the lesser curvature, near the cardiac part it is necessary to dissect the hepato-gastric ligament in an avascular place, to bandage and mobilize the gastric artery, which makes it possible to isolate the stomach wall, and suture the wall damage with a two-row suture. For any injury to the anterior wall of the stomach, duodenum, or pancreas, the gastro-colon ligament should be widely dissected and the posterior stomach wall, pancreas, and duodenum examined. If the wound is localized in the area of \u200b\u200bthe fundus of the stomach, the gastro-splenic ligament should also be dissected to revise the posterior wall. The bleeding vessels of the submucosal layer are bandaged and the wound is sutured in the transverse direction with double-row sutures. The wound can be peritonized with a pedicle omentum.

Special attention should be paid to subserous hematomas of the stomach wall and its ligaments, which can cause circulatory disturbances with the development of secondary necrosis and perforation. Hematomas of the stomach wall and its ligamentous apparatus must be removed, the bleeding is reliably stopped, the wound of the stomach wall is sutured with a double-row suture. The operation is completed by introducing drains and irrigators into the abdominal cavity through additional punctures of the abdominal wall. A nasogastric tube is left in the stomach.

Predicting outcomes after surgery for gastric injury is difficult. The prognosis for bruises and tears of the stomach wall is favorable. With complete ruptures of the stomach wall, the outcome depends on the amount of damage, the timing of surgery, concomitant damage to neighboring organs, and the presence of associated injuries. For operations performed 6 hours or more after injury, the mortality rate, according to various sources, ranges from 18 to 45%. The high mortality rate is due to the fact that stomach trauma is rarely isolated. Multiple injuries of the abdominal and retroperitoneal organs, combined trauma significantly worsen the prognosis.

A.S. Ermolov

Conditions under which surgical treatment of perforated gastric ulcer by resection is preferable:

Time after perforation is not more than 6 hours.

The patient's age is not more than 50 years.

There are few gastric contents in the abdominal cavity.

An experienced surgeon is available.

There are appropriate conditions in the clinic.

Methods for suturing a perforated ulcer -

Suturing with your own stomach wall.

Suturing by adjacent organs (great omentum).

Combined types of gastric resection:

Billroth 1 - gastroduodenoanastamosis.

Billroth 2 - gastrojejunostamosis.

91 Stem and selective proximal vagotomy

Denervation of the stomach when crossing the branches or trunks of the vagus with non-resection. (organosharp, treatment of ulcers and duodenal ulcers, which eliminates the effect of parosympathes ns on gastrin formation - reducing acidity and healing ulcers)

Stem - the intersection of the vagus trunks (along the entire circumference of the esophagus for at least 6 cm above the discharge of the hepatic and celiac branches). It leads to persistent narrowing of the pylorus and impaired gastric motility, therefore, it is used with pylorus plastic.

Selective - (Hart) the intersection of the small branches of the gastric nerve, the innervir-x body and fornix of the stomach, while the distal branches are preserved - there is no spasmoplasty and pyloroplasty is not required.

92 Determination of the size of the removed part of the stomach

93 Understanding gastric resection

Along the greater and lesser curvature of the stomach with multiple anastomoses transversely ..

Typical levels of gastric resection.

Subtotal ..

Total.

Determination of the level of gastric resection; Major and minor curvatures are divided into 3 parts:

Types of gastric resection:

Billroth 1 - gastroduodenoanastamosis + Ridiger 1, Ridiger 2.

Billroth 2 - gastrojejunostamosis + Polia-Reichel.

Hofmeister-Finsterer.top. Wednesday incision. Mobilize. g-ka (dissect lig.hepatogastricum in avascular places), ligate a.gastr.sin. & dex. in 2 places and cross. Find fl.duodenojejun. and bring to the Zh-ku. Apply pulp on 12pc and cross, sew, cover the pouch. seam. Suck it out of the liquid, apply a pulp and a clamp. Cut on the press, sew on the clamp continuously. seam. Remove w-k. On the remaining hole, put a loop of skinny k-ki (as you did). Fixation drive. loops. Stitching.

BillrothI. cut the ligaments, the stomach, then collect the stump in folds and make gastroenterostomosis end to end.

BillrothII sutured the duodenum with a two-row suture, the entire stomach was sutured. The loop of the large intestine is anastomosed from the gall to the side. But there are many incisions and sutures on the gland, the duodenum is not functioning correctly. Then the loop of the jejunum is pulled up to the previous seam - a spur is formed, preventing food from being thrown into the duodenum. And the stoma is superimposed between the side of the skinny tee of the lower part of the stomach in the region of the greater curvature

94 Gastrostomy temporary gastrostomy

An operation to create an artificial entrance to the stomach. produced for feeding the patient and carrying out other therapeutic measures for obstruction of the esophagus.

Temporary (tubular) - if it is possible to restore the patency of the esophagus -. injury, cicatricial stenosis, atresia.

Temporary: spontaneously overgrow after tube removal.

Strain-Kader through the upper midline laparotomy or left transrectal incision. 3 purse-string sutures (serous-muscular) are applied in the avascular zone of the stomach. with a diameter of 2, 3.5, 5 cm in the center of the inner pouch, cut and insert a tube with a diameter of at least 1.5 cm. tighten the inner pouch. immerse the tube in the stomach and tighten the second pouch over the first one. immerse inside and over the second, tighten the triple pouch. Gastropexy before inserting the tube into the wound. - fixation with serous-muscular sutures around the tube. the anterior wall of the stomach to the parietal peritoneum - prevention of peritonitis. it is better to lead the tube into the adjacent incision. fixation - sew with 1-2 stitches per sleeve ..

Vitzel. - a tube is applied along the stomach in the middle. which is immersed in the anterior abdominal wall with 6-8 serous-muscular sutures. at the pyloric section, the stomach wall is dissected,. through the incision, the end of the tube is immersed in the lumen of the stomach. then tighten the half-belt in the center of which the incision is made ..

Holotopy: the left hypochondrium, the actual epigastric region.

Skeletotopy:

1.cardiac foramen - to the left of Th XI (behind the cartilage of 7 ribs);

2. bottom - Th10 (5th rib on the left midclavicular line);

3. gatekeeper - L1 (8 right rib along the median line).

Syntopy:

1.top - aperture and left lobe liver

2.behind and left - pancreas, left kidney, adrenal gland and spleen, in front - abdominal wall

3. below - the transverse colon and its mesentery.

Ligaments of the stomach:

1. Hepato-gastric ligament - between the gate of the liver and the lesser curvature of the stomach; contains the left and right gastric arteries, veins, branches of the vagus trunks, lymphatic vessels and nodes.

2. Diaphragmatic-esophageal ligament - between the diaphragm, esophagus and the cardiac part of the stomach; contains a branch of the left gastric artery.

3. The gastrophrenic ligament is formed as a result of the transition of the parietal peritoneum from the diaphragm to the anterior wall of the fundus and partially to the cardiac part of the stomach.

4. Gastro-splenic ligament - between the spleen and the greater curvature of the stomach; contains short arteries and veins of the stomach.

5. Gastro-colon ligament - between the greater curvature of the stomach and the transverse colon; contains the right and left gastroepiploic arteries.

6. The gastro-pancreatic ligament is formed when the peritoneum passes from the upper edge of the pancreas to the posterior wall of the body, cardia and fundus of the stomach; contains the left gastric artery.

The blood supply to the stomach is provided by the celiac trunk system.

1. The left gastric artery is divided into the ascending esophageal and descending branches, which, passing along the lesser curvature of the stomach from left to right, give up the anterior and posterior branches.

2. The right gastric artery starts from the own hepatic artery. As part of the hepato-duodenal ligament, the artery reaches the pyloric part of the stomach and between the leaves of the lesser omentum along the lesser curvature is directed to the left towards the left gastric artery, forming an arterial arch of the lesser curvature of the stomach.

3. The left gastroepiploic artery is a branch of the splenic artery and is located between the sheets of the gastro-splenic and gastro-colonic ligaments along the greater curvature of the stomach.

4. The right gastroepiploic artery starts from the gastro-duodenal artery and goes from right to left along the greater curvature of the stomach towards the left gastroepiploic artery, forming a second arterial arch along the greater curvature of the stomach.

5. Short gastric arteries in the number of 2-7 branches depart from the splenic artery and, passing in the gastro-splenic ligament, reach the bottom along the greater curvature of the stomach.

The veins of the stomach accompany the arteries of the same name and flow into the portal vein or into one of its roots.

Lymphatic drainage. The discharge lymphatic vessels of the stomach flow into the lymph nodes of the first order, located in the lesser omentum, located along the greater curvature, at the gate of the spleen, along the tail and the body of the pancreas, in the pyloric and superior mesenteric lymph nodes. The diverting vessels from all of the listed first-order lymph nodes are directed to the second-order lymph nodes, which are located near the celiac trunk. From them, the lymph flows into the lumbar lymph nodes.

The innervation of the stomach is provided by the sympathetic and parasympathetic parts of the autonomic nervous system... Basic sympathetic nerve fibers are sent to the stomach from the celiac plexus, enter and spread in the organ along the extra- and intraorgan vessels. Parasympathetic nerve fibers in the stomach come from the right and left vagus nerves, which below the diaphragm form the middle and posterior vagus trunks.

Suturing a perforated stomach ulcer and duodenum

With a perforated gastric ulcer, it is possible to perform two types of urgent surgical interventions: suturing of a perforated ulcer or resection of the stomach together with an ulcer.

Indications for suturing a perforated ulcer:

1. sick in childhood and young age;

2. in persons with a short history of ulcers;

3.in elderly people with concomitant pathology (cardiovascular insufficiency, diabetes and etc.);

4. if more than 6 hours have passed since the moment of perforation;

5. with insufficient experience of the surgeon.

When suturing a perforation, you must adhere to the following rules:

1.The defect in the wall of the stomach or duodenum is usually sutured with two rows of Lambert serous-muscular sutures;

2. the suture line should be directed perpendicular to the longitudinal axis of the organ (in order to avoid stenosis of the lumen of the stomach or duodenum); it is recommended to additionally peritonize the suture line with a flap of the greater omentum.

89. Types of gastroenteroanastomoses. Provide a diagram of the operation in the sagittal plane. Advantages and disadvantages of one or another gastroenteroanastomosis .

Indications: inoperable cancer of the pyloric stomach, cicatricial narrowing of the pylorus in a severely weakened patient.

Anterior anterior colon gastroenteroanastomosis (according to Bellefleur).

A large omentum with a transverse colon is taken in the left hand and taken out into the wound. The right hand is inserted into the abdominal cavity along the mesentery of the transverse colon to the spine, slide from the latter to the left and grab the first loop lying here jejunum... The intestinal loop is brought to the anterior wall of the stomach in front of the greater omentum and the transverse colon. The leading loop (small loop) is fixed with a silk suture at the lesser curvature closer to the cardiac region, the abducting loop (large loop) - at the greater curvature, closer to the pyloric region of the stomach, after which the posterior row of serous-muscular sutures is applied. The threads are cut, with the exception of the two extreme ones. The stomach is opened first, and then small intestine departing from the serous-muscular suture by 0.75 cm. The contents of the stomach are aspirated and the intestinal lumen is drained. A continuous catgut suture is applied through all layers to the posterior edges of the anastomosis, and then to the anterior edges.

Formation of enteroenteroanastomosis according to Brown.

An additional anastomosis is applied between the adductor and discharge loops of the jejunum in a side-to-side manner at a distance of 10-15 cm downward from the imposed gastroenteroanastomosis. The posterior and then the front edges of the interintestinal fistula are sewn with two rows of sutures. The width of the anastomosis should be slightly larger than the diameter of the intestine. Enteroenteroanastomosis is applied in order to prevent the development of a vicious circle.

A vicious circle is understood as a violation of the movement of food masses from the stomach, as a result of which food does not enter the intestine, but is retained in the stomach, duodenum and the adductor knee of the jejunum, causing them to stretch. The disease that develops in this case is called the adductor loop syndrome: the adductor loop is stretched, squeezes the discharge loop, disrupting the function of the anastomosis; food in it decomposes and, getting into the stomach, causes belching, vomiting.

Posterior colon gastroenteroanastomosis according to Gacker - Petersen. For anastomosis, a long jejunal loop is taken. The mesocolon transversum is dissected in the vertical direction, below the Riolan arch, in the avascular zone. The left hand, located on the anterior wall of the stomach, protrudes the posterior wall of the stomach through the opening in the mesocolon transversum. The bowel loop is fixed to the stomach with two silk sutures in the vertical direction with respect to the stomach axis. To prevent a vicious circle, the leading loop should be sutured to the stomach wall above the anastomosis with 2-3 interrupted sutures. The edges of the opening in the mesocolon transversum are fixed with several interrupted sutures to the stomach wall above the anastomosis.

90. Blood supply and lymph drainage of the stomach. Methods of gastrostomy surgery according to Witzel .

From the lesser curvature and adjacent parts of the cardia and body, the lymphatic vessels of the stomach carry lymph to the left and right gastric nodes located along the left and right gastric arteries. From the fundus of the stomach, lymph flows along the short arteries of the stomach into the splenic nodes. They also receive lymph, coming from the greater curvature to the left gastroepiploic nodes. Through the right gastroepiploic lymph nodes, lymph enters the pyloric nodes. All of these nodes are regional nodes of the first stage of lymph outflow. From them, lymph enters the main lymph nodes of the second stage - celiac nodes, nodi coeliaci. Lymph from the hepatic, splenic and pancreatic nodes also flows into them. From the celiac nodes, lymph flows into the aortic and caval lymph nodes, and then into the thoracic duct.

To expose the stomach, various abdominal incisions are proposed: median, transverse, transrectal and combined (Fig. 167). The choice of one or another incision of the abdominal wall depends on the type of surgical intervention and the degree of spread of the pathological process.

167. Incisions of the anterior abdominal wall during operations on the stomach.

1 - right transrectal incision; 2 - upper midline section; 3 - cross section; 4 - combined upper midline section; 5 is a combined cross section.

The best incision of the abdominal wall for operations on the stomach is a longitudinal incision along the midline of the abdomen from the xiphoid process to the navel. This cut provides good access to the stomach and does not damage the nerves, blood vessels and muscles. If necessary, this incision can be extended downward, bypassing the navel on the left. With subtotal gastrectomy and gastrectomy, the xiphoid process is sometimes dissected - this allows the wound to be lengthened by 2-3 cm.

A transrectal incision is used during gastrostomy to create a muscle pulp. This incision is made in the epigastric region vertically in the middle of the left rectus abdominis muscle.

A transverse incision of the Sprengel is performed above the navel with the intersection of both rectus abdominis muscles. This cut is less common than the longitudinal cut.

In cases where the exposure of the stomach from a midline or transverse incision is insufficient, combined incisions are used. They are T-shaped and angular. If the abdominal cavity is opened by the upper midline incision, then an additional transverse incision is made to the right or left. The latter can be performed at various levels of the midline incision, depending on the conditions of the operation. This incision is most often used for gastrectomy with simultaneous splenectomy. When dissecting the anterior abdominal wall with a transverse incision, an incision is sometimes added to it along the midline up to the xiphoid process.

CUTTING THE STOMACH (GASTROTOMIA)

Gastrotomy is performed to remove foreign bodies from the stomach, for diagnostic purposes - to examine the mucous membrane, for retrograde bougienage and probing of the esophagus, etc.

The operation is performed under general anesthesia or local anesthesia.

An upper midline laparotomy is used to expose the stomach.

Operation technique. The incision of the skin and subcutaneous tissue is carried out from the xiphoid process to the navel. Throughout the incision, the white line of the abdomen is dissected (Fig. 168). Two anatomical forceps grasp the peritoneum along with the preperitoneal tissue and, slightly lifting it, dissect with a scalpel (Fig. 169). Scissors are inserted into the formed hole and, under the control of the fingers, the peritoneum is cut along the length of the wound (Fig. 170). The latter, as it is dissected, is grasped with Mikulich clamps and fixed to napkins. The abdominal cavity is fenced off with three gauze napkins introduced into the right and left hypochondria, as well as into the lower corner of the wound.

168. Upper midline incision of the anterior abdominal wall. Dissection of the aponeurosis.

169. Upper midline incision of the anterior abdominal wall. Dissection of the peritoneum between two forceps.

170. Upper midline incision of the anterior abdominal wall. Dissection of the peritoneum on the fingers brought under it.

The anterior wall of the stomach is taken out into the operating wound, fixed with two sutures, and cut between them in the longitudinal or transverse direction, depending on the purpose of the operation. If a wide opening of the stomach is necessary, for example, to find a bleeding ulcer, a longitudinal incision is used. A small cross-section is usually sufficient to remove foreign bodies. A longitudinal incision is made along the axis of the stomach in the middle of the distance between the greater and lesser curvature, the transverse - approximately in the middle of the distance between the cardia and the pyloric part of the stomach. First, the serous and muscular membranes of the stomach are dissected and the bleeding vessels are tied up (Fig. 171), then the mucous membrane is grasped with two forceps, lifted in the form of a cone and dissected with a scalpel or scissors for 1-1.5 cm (Fig. 172). From this incision, the contents of the stomach are aspirated and the mucous membrane is cut with scissors to the size of the wound of the serous and muscular membrane. Foreign body grasp with forceps or forceps and remove (Fig. 173).

171. Gastrotomy. Dissection of the serous and muscular membranes of the stomach.

172. Gastrotomy. Dissection of the gastric mucosa.

173. Gastrotomy. Removal of a foreign body.

With diagnostic gastrotomy, the state of the mucous membrane can be examined with a finger inserted into the lumen of the stomach. To examine the mucous membrane of the posterior wall of the stomach, it is protruded into the wound with a hand inserted into the cavity of the omental bursa through the dissected gastro-colonic ligament.

The wound of the anterior wall of the stomach is sutured with a two-row suture. First, a furrier suture is applied (Fig. 174), and then nodal serous-muscular sutures. The technique of applying a furrier suture is as follows. At the corner of the incision, both edges of the stomach wound are stitched through all layers and the first stitch of the seam is tied. Subsequent injections of the needle are made all the time from the side of the mucous membrane, first through one, and then through the other edge of the wound. The assistant tightens the stitches of the seam, while the edges of the incision are screwed into the lumen of the stomach. The last loop of the seam is tied to the end of the thread. When applying a suture, the distance between the injections of the needle should not exceed 1 cm. Very often sutures should not be applied, as nutrition of the edges of the sutured wound may be disturbed.

174. Gastrotomy. Suturing the incision of the stomach wall. Overlay furrier suture.

After the furrier suture is applied, napkins and tools are changed, hands are washed and a second row of interrupted silk serous-muscular sutures is applied (Fig. 175).

175. Gastrotomy. Suturing the incision of the stomach wall. The imposition of serous-muscular interrupted sutures.

PILOROTOMY

The operation consists in dissecting the serous-muscular membrane of the pyloric region of the stomach to the mucous membrane.

The indication for surgery is congenital pyloric stenosis in children.

Anesthesia: ether-oxygen anesthesia or local infiltration anesthesia.

Fredet-Weber-Bamstedt method. The abdominal cavity is opened layer by layer with the upper median or right pararectal incision 3-5 cm long. The liver is pulled upward and to the right with a blunt hook and the hypertrophied pylorus is removed. Having fixed it with the fingers of the left hand, the serous and muscular membranes of the pylorus are dissected in the longitudinal direction closer to the lesser curvature (Fig. 179). After that, along the edges of the incision with tweezers and a grooved probe, carefully peel off the mucous membrane until it bulges into the wound (Fig. 180).

179. Pylorotomy. The Frede-Weber-Ramstedt way. Dissection of the serous and muscular membranes of the pylorus.

180. Pylorotomy. The Frede - Weber - Ramstedt way. Exfoliation of the mucous membrane.

This point in the operation should be done carefully to avoid injury to the mucosa. If damage to the mucous membrane occurs, which can be seen by the release of gas bubbles or duodenal contents, then the wound is carefully sutured.

The operation ends with layer-by-layer stitching of the abdominal wall incision.

SEAM OF THE STOMACH (GASTRORRAPHIA)

• Suturing stomach wounds

Stomach suture as an independent operation is used for wounds and perforated ulcers.

• Suturing stomach wounds
• Suturing of perforated gastric and duodenal ulcers

SEWING THE WOUNDS OF THE STOMACH

Distinguish between closed and open stomach wounds. They can be isolated or combined with damage to other organs.

Stomach wounds are more often located in the area of \u200b\u200bthe body and fundus, less often in the area of \u200b\u200bthe pylorus and cardiac part.

Since isolated lesions of the stomach are rare, a thorough examination of other abdominal organs must be performed during the operation.

Operation technique. The abdominal cavity is opened layer-by-layer with the upper midline incision, the accumulated blood and overflowing stomach contents are removed. Examine the stomach and other abdominal organs.

The most difficult to find wounds in the area of \u200b\u200bligament attachment. Such wounds are often accompanied by extensive subserous hematomas. To find them you need to cut serous membrane, remove the hematoma and bandage the bleeding vessels.

If the wound is localized along the lesser curvature near the cardiac part, it is necessary to dissect the hepato-gastric ligament in the avascular site, which allows the stomach to be pulled down and to approach the wound site.

When the wound is localized in the bottom area, the gastro-splenic ligament should be dissected.

Suspecting a perforating wound of the stomach, the gastro-colonic ligament is dissected in the avascular area and the posterior wall of the stomach is examined.

Small puncture wounds are sutured with a purse-string suture, over which several serous-muscular interrupted sutures are applied. Often stomach injuries are accompanied by prolapse of the mucous membrane. In these cases, the crushed edges of the wound and the prolapsed mucous membrane are excised, the bleeding vessels of the submucosal layer are tied up and the wound is sutured in the transverse direction with a two- or three-row suture. The suture technique is shown in Fig. 174, 175. For better tightness, sometimes an omentum on the leg is sutured to the sutured wound of the stomach.