The value of mobilization of the duodenum by coher in medical terms. Kocher mobilization of the duodenum Mobilization of the duodenum 12 according to the Kocher scheme

04.06.2020

Closed, isolated trauma, tears, bruises, or wounds duodenum are rare. Often, the process is damaged together with injury to nearby tissues and organs of the peritoneum. This is due to its small size, deep localization, protection by muscles and anterior organs, the back of the vertebra. Pathology is aggravated by the density of the bottom of the intestine, the limitation of its mobility.

Damage to the duodenum is a major health hazard.

1 Reasons
2 Signs
3 Classification
- 3.1 Species
4 Degree
5 Diagnostics
6 Therapy for I, II degree
7 Therapy for grade III
8 Operation
9 After surgery
10 Diet
11 Forecast

Causes

trauma to the abdomen with a direct blow to the front wall, as a result of squeezing the body or when falling from a height;
injuries as a result of an accident or a railway accident: collision, moving, impact in the car;
stab and cut wounds;
gunshot bullet and shot wounds;
iatrogenic trauma during X-ray endoscopy of the large duodenal nipple, for example, with endopapillosphincterotomy.

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Signs

Damage to the duodenum refers to rare species injuries that are difficult to diagnose in time. Pathology is especially difficult. A large number of diagnostic errors and severe complications are not excluded. Because of this, organ injury is accompanied by high mortality.

Symptoms of isolated bowel injuries depend on the integrity of the parietal peritoneum. If there is a rupture of the appendix, in the first hours there are signs of "acute abdomen". If the retroperitoneal part of the duodenal colon is damaged, timely diagnosis is difficult due to the uncertainty of the location and strength of pain. More often the soreness is felt on the right, under the ribs, at the lower back, it is similar to the defeat of the right kidney. Later, symptoms of peritonitis appear.

Due to the growing intoxication of the peritoneum with the aggressive contents of the affected intestine and blood:

the condition is rapidly deteriorating;
the pain is getting worse;
severe weakness appears;
there is thirst with nausea;
possible vomiting mixed with blood;
the skin turns pale;
tachycardia is growing;
leukocytosis is detected.

The general symptoms of retroperitoneal injury in the first hours are similar to shock. The obvious rupture of the organ is manifested at the stage of tissue necrosis caused by the aggressive effect of the contents of the intestine. The rate and extent of the increase in symptoms is determined by:

gap size;
the fullness of the organ at the time of injury;
the speed and degree of penetration of the contents into the tissues.

The first symptoms of peritoneal inflammation appear in the time interval from 8 to 16 hours. After 18-24 hours, greenish spots appear on the skin on the right in the groin, which indicates the penetration of bile into the subcutaneous fatty tissue. A tarry stool may appear due to the ingress of blood from the hematoma into the affected intestine.

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Classification

There is a wide specific classification of duodenal trauma.

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Kinds

Closed injuries are:

isolated and shared;
intra - and external peritoneal;
with complete rupture and incomplete tearing of the walls;
with or without damage to the parietal sheets of the peritoneum.

By the nature of damage to the duodenum, hematomas are distinguished without or with impaired intestinal patency. Open injuries are:

intraperitoneal;
retroperitoneal;
front or back wall;
cross-cutting.

At the place of fixation of the duodenum, the lesions are located:

at the transition to the small intestine;
at the entrance of the channels into the pancreas;
at the gatekeeper area.

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Power

Injuries are ranked from I to V in ascending order of strength. According to this scale, all injuries are considered to be compatible with pancreatic injury.

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Diagnostics

Inspection. Symptoms and their intensity are evaluated. The following signs are visualized: abrasions; bruising.
Palpation of the abdomen. There is swelling and smoothness of the contours or swelling at the lower back with the formation of a hematoma.
Radiography. An airborne area is visualized on a plain radiograph.
Fibrogastroscopy. The method allows you to determine the presence of a wall defect.
Ultrasound. Echoes are visualized in the retroperitoneal space.
Barium contrast fluoroscopy. The intake of the substance outside the intestinal contours is visible.
Laparotomy. Allows you to see the Laffite triad, in which the peritoneum has a yellow-green tint, airy and blood-soaked areas of fiber.

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Therapy for I, II degree

The early stage of damage is characterized by a hematoma. It is detected by obstruction of the pyloric region of the stomach. On the 3rd day, bilious vomiting appears. In the absence of indications for laparotomy, the following are performed:

intravenous hydration;
nasogastric - tube aspiration.

Hematomas usually resolve spontaneously within 7-10 days. At the end of the course of treatment, a second CT scan is indicated to assess the degree of intestinal patency. Operations to remove hematoma are:

open;
drainage laparoscopic.

During surgical treatment a thorough examination of the organ and nearby tissues for the presence of seroses and hematomas is performed.

The principle of treatment is to drain the hematoma, since opening it is fraught with transformation closed injury openly. After resorption of the hematoma, the wall of the duodenal process is closed with absorbable continuous suturing.

With a penetrating bowel wound, a midline laparotomy is performed, in which bleeding stops and the classical stitching technique is used. Limited stab-cut and shrapnel defects are sutured with a single-row suture if the blood supply is preserved.

Duodenotomy is performed by closing the wound with a continuous or interrupted suture along the defect to avoid tension. Sometimes it is required to suture the wound from the inside with an antimesenteric duodenotomy.

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Therapy for grade III

To eliminate defects III-V degree complex techniques are used. Large gaps require mobilization and surgical debridement wounds followed by duodenoduodenostomy if tension does not appear. The technique is not used to create an anastomosis in the descending and lower horizontal part of the duodenum, located next to the pancreas.

With a combination of damage to the duodenal process with the pancreas, the diverticulization technique is used with access to the pylorus from the inside. This requires a gastrotomy along the edge of the greater curvature of the stomach. The pylorus is sutured with a suture without resorption with the imposition of gastrojejunostomy and the suturing of the loop of the jejunum to the greater curvature. During the operation, an end fistula is formed, but it is easily treated. After diverticulization, the patient can eat orally for 14 days. The opening of the gatekeeper will take place within 6-12 weeks.

With perforation of the duodenal colon, extensive damage to nearby tissues occurs, which is typical with a firearm. With hemodynamic instability, surgical debridement, mechanical suture, drainage and plastic are required.

In case of injury to the process of the descending section located further than its ampulla, treatment is carried out by crossing the organ with the performance of a loop duodenojejunostomy through the mesentery from the transverse colon part of the intestine.

In case of damage to the lower horizontal and ascending part of the intestine, recovery is hampered by the short mesentery, which causes difficulties in mobilization and increases the risk of ischemia. In this case, resection and duodenojejunostomy are performed to the right of the mesenteric vessels.

In case of damage of the IV and V degrees, strong ruptures occur with devascularization of the descending section of the intestine with a detachment of the distal part of the bile duct or ampulla. For surgical treatment, the method of hemostasis with processing and stage-by-stage plastic is used.

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Mobilization of the duodenum according to Kocher. The peritoneum is dissected in the transitional fold of the lateral surface of the duodenum. Stupidly and sharply the duodenum moves in the medial direction. In this case, the lower hollow vein... This is the least traumatic stage of the operation. Thanks to him, it is possible to determine the mobility of the pancreas: its free separation from the anterior surface of the vena cava to the uncinate process, Treitz's ligament. The latter indicates that the operation can continue. Emphasis is placed on character lymph glands... If they are soft to the touch, have a pink color, then the possibility of metastasis in them is excluded malignant tumor (cells). In these cases, inflammatory changes are noted. Nonetheless the lymph nodes biopsy is required.

With this mobilization, the right angle of the transverse colon is shifted to the left. We have noted that a combination of large cysts with a small pseudotumorous formation practically does not happen. On the contrary, with a small cyst of the head of the pancreas, a pseudotumorous formation is rather large, bumpy. Its mobility when covered with a brush, the ability to "lift" indicates the operability of the formation. The absence of tumor invasion into the aorta and inferior vena cava is important. Otherwise, it is inappropriate to continue the radical operation.

Opening the stuffing box. It is opened through the gastro-colonic ligament and the lesser omentum. The mobility of the body of the pancreas along the upper and lower edges, the mobility of the head, the place of passage of the upper mesenteric vessels, the state of the lymphatic apparatus are determined. With good mobility of the pancreas, an attempt is carefully made to separate the isthmus of the pancreas from the fatty tissue behind the gland (Fig. 99).

Figure: 99. Pancreatoduodenal resection. Crossing the isthmus of the pancreas: a - taking on the holder; 6- crossing the isthmus or body at the border with the tail; 1 - duodenum; 2 - the head of the pancreas; 3 - isthmus; 4 - splenic artery; 5 - the tail of the pancreas; 6 - "tunnel" under the pancreas; 7 - the line of intersection of the pancreas; 8 - Wirsung duct; 9 - holders

The index finger of the right hand and the thumb with dividing movements raise the gland and form a tunnel under it. A thin gauze turunda or a vinyl chloride tube is passed into it. By lightly pulling anteriorly, the gland rises. At this point, the pancreas is incised in stages with a transverse incision so as not to damage the splenic vein and artery and preserve the function of the spleen. It is very important, after crossing the isthmus or the body at the border with the tail, to find the Wirsung duct and decide what to do with it (bandage; seal; make external drainage with a thin vinyl chloride tube; anastomose with a hollow organ).

All these techniques are used in practice and in many cases depend on the techniques adopted in clinics. As for our experience, we always anastomosed the proximal end of the gland (tail) with its entire surface or with the stomach (according to M.P. Postolov, 1976) or with the loop off small intestine it's time. Some authors use an anastomosis "the end of the transected gland to the side of the small intestine." Recently, we have begun to use the technique of end-to-end anastomosis of the small intestine. All the methods used for anastomosing the stump of the proximal pancreas have their own advantages and disadvantages. Many of them are not logically justified.

Sometimes this stage is difficult to perform due to a strong pronounced adhesive process. Then the release of the pancreas begins from the site of the pancreatoduodenal ligament.

The conclusion of this stage of the operation is a complete transection of the stomach at the border of 1/2 or 2/3 parts. For this, powerful clamps are applied to the distal and proximal ends of the stomach. The stomach is crossed between them. Recently, we have crossed this area after preliminary stitching with staplers (Fig. 100).

Figure: 100. Pancreatoduodenal resection. Crossing the stomach: a - resection of 1/2 of the stomach; b - pyloric resection

This facilitates the subsequent steps of the operation. Some surgeons cross the stomach in subsequent stages of the operation (see below).

Isolation and separation of the pancreas from the hepato-duodenal ligament complex. The danger of damage to the portal vein in this situation must be clearly understood. Therefore, the process of isolating the constituent parts of the hepato-duodenal-pancreatic ligament complex is equated to the jeweler's technique using all the techniques of vascular surgery, namely, the isolation of the common bile duct and taking it on handles, taking the portal vein and its own hepatic artery onto the handles. Sometimes this requires taking on the holder and the superior mesenteric artery, splenic vein and artery (Fig. 101).

Figure: 101. The principle of forming pacreatojejunal anastomosis by end-to-end type with disconnection of the loop of the small intestine:
a - the formation of the first row of seams; b - purse string immersion seam; in - the final stage operations

The law is one for all - not to cross any formation without first taking it on hold and subsidizing. It is best to start the intersection of the complex with the common bile duct (Fig. 102). If the creation of a choledochojejunostomy is expected, then cholecystectomy is performed. Although it is better to complete this stage later. The creation of a biliodigestive anastomosis with the gallbladder is considered inappropriate due to the formation of cholelithiasis or choledocholithiasis, which impede the outflow of bile. Such anastomosis is forced.

Figure: 102. Pancreatoduodenal resection. Separation of the pancreas from the hepato-duodenal ligament complex:
and - general form the front surface after the stomach is retracted upward; b - downward; 1 - duodenum; 2 - lumen of the cut off stomach stump; 3 - gall bladder; 4 - portal vein; 5 - upper gastric artery; 6 - stomach stump; 7 - aorta; 8 - splenic artery; 9 - celiac trunk; 10 - common hepatic artery; 11 - gastroduodenal artery; 12 - pancreatoduodenal superior artery; 13 - anterior lower pancreatoduodenal artery; 14 - posterior lower pancreatoduodenal artery; 15 - common hepatic duct; 16 - cystic artery; 17 - superior mesenteric artery; 18 - right gastrosalnic artery

Isolation of the block of the pancreas and duodenum. When performing this stage of the operation, it is necessary to ligate and cross the pancreas (head) of the large arterial trunk from above - a. gastroduodenalis and two arteries extending from it - a.a. pancreatoduodenal sup. and gastroepiploica dextra. The main thing in this moment is not to cross the common or own hepatic arteries. Due to the pronounced adhesion process, movement by a cyst or pseudotumorous complex, they can be damaged or crossed.

Therefore, before ligating the arteries supplying the head of the pancreas, the holders are brought under them and the arteries are squeezed (preferably with a vascular clamp), then pulsation is checked on the hepatic arteries distal to the place of clamping, i.e. in the area of \u200b\u200bthe hepatoduodenal ligament (!). We tested next take (I.N. Grishin). After the imposition of soft clamps on these vessels in doubtful cases (or better - before transection), before performing cholecystectomy, the cystic artery is taken on the handles. She is cut. The appearance of pulsating bleeding from the cystic artery reliably indicates good blood flow through the hepatic artery.

The absence of this sign obliges you to check again if the hepatic artery is not mistakenly pinched. Failure to comply with this technique can cause the appearance of a difficult to correct complication - the development of liver ischemia. Thin-walled venous trunks pass behind these arteries, which must be ligated with great care. If these stages were passed without using hemostatic clamps, then the operation was performed at a high technical level (K.V. Lapkin et al., 1991).

Isolation and transection of the proper ligament of the uncinate process. Ahead of him are several small trunks of arteries from a. mesenterica sup. They are accompanied by veins that extend from the portal and superior mesenteric veins. In this situation, the principle of vascular surgery must be followed: careful selection of each branch of a small vessel, taking it under visual control on the handles (peripheral and proximal), ligating them without any tension and crossing them between the ligatures. Ligation is performed without any tension on the vessel (Fig. 103).

Figure: 103. Pancreatoduodenal resection. Careful ligation of the arterial and venous branches of the portal vein and the superior mesenteric artery along the posterior surface of the pancreas retracted to the side:
1 - duodenum; 2 - pancreas retracted to the right; 3 - portal vein; 4 - ligated branch of the portal vein; 5 - dissector with a thread, brought under the venous branch; 6 - the supplied thread under the venous branch; 7 - ligated and crossed branch of the vein; 8 - subsidized and crossed branches of the superior mesenteric artery; 9 - superior mesenteric artery

The vessels are very delicate and easily detach from the main trunks, causing bleeding. In case of such bleeding, its place is pressed with the index finger and, slowly pushing it back, the exact localization is established. The bleeding twig is taken with De Beckey's small hemostatic bulldog clamps and ligated. In extreme cases, it is very gently stitched with atraumatic needles. Sometimes ligation is performed on wall v. mesenterica or a. mesenterica sup.

Then, for execution, lateral squeezing of these vascular formations with curved tantalum clamps of the Satinsky type is used. After that, its own ligament of the uncinate process is isolated and intersected between the two supplied clamps (sometimes in portions). Better to use the Lyga-Sure apparatus. This allows you to raise the head of the pancreas and move on to the next stage of the operation - the allocation of the duodenum (Fig. 104).

Figure: 104. Pancreatoduodenal resection. Intersection of the own ligament of the uncinate process: 1 - the own ligament of the uncinate process of the pancreas; 2 - portal vein; 3 - superior mesenteric artery;
4 - clamps (or Liga-Shu apparatus); 5 - cutting line; 6 - ligature on a ligament

I.N. Grishin, V.N. Grits, S.N. Lagodich

When a gastrostomy is applied from a midline incision, the operation is performed in the same way until the last purse-string suture is tightened. Then pararectally to the left in the place of the closest adherence of the purse string suture to abdominal wall a scalpel puncture through all layers. Through this wound, a clamp is introduced into the abdominal cavity, with which the end of the rubber tube with threads from the net suture is captured and brought out.

The rubber tube and threads from the purse-string suture are pulled until the stomach wall around the tube touches the peritoneum. The stomach is fixed to the parietal peritoneum around the stoma with 2-3 sutures. One thread from the purse string suture is passed through the edge of the skin incision, the other around the rubber ring. When tying threads, the stomach is additionally fixed to the peritoneum and a rubber tube to the stoma (Fig. 3.6).

Donovan-Hagen surgery (duodenal diverticulization)

	Applied for damage twelve
	the duodenum. In order to reduce fun
	pancreas and providing
	resting duodenum produce
	subphrenic stem vagotomy, an-
	trumectomy with Roux-en-Y gastroenteroanastomosis,
	cholecysto or choledochostomy, duodenostomy
	mission. Stem vagotomy serves two purposes:
	peptic ulcer prevention and suppression
	function of the pancreas (Fig. 3.7).
	Instead of a stem vagotomy, choose
	it is better to perform selective gastric
	vagotomy, since it is, which is important,	Figure 3.7. Operation Donovan -
	does not violate parasympathetic innervation	Figure 3.7. Operation Donovan -
	does not violate parasympathetic innervation
	organs abdominal cavity... However, she both

heals quite adequate prevention of the formation of peptic ulcers, and temporarily suppress the function of the pancreas with the help of octreotide.

Suturing of stomach and duodenal wounds

For suturing a wound of the stomach or duodenum in elective surgery, it is advisable to use a single-row continuous serous-muscular-submucosal case suture or Pirogov's suture - a single-row nodular serous-muscular-submucosal suture with the location of the node on serous membrane, and in urgent surgery, preference should be given to a two-row suture.

In the latter case, the most often used are the penetrating separate nodal Mikulich suture or the continuous twisted continuous Mikulich suture in combination with the non-penetrating separate nodular serous-muscular suture of Lambert. When restoring the integrity of the wall of the stomach or duodenum, both with opening its lumen and with damage to the serous or serous-muscular membrane, preference should be given to synthetic absorbable threads with an atraumatic needle.

For more details on bowel suture techniques, see Part III, Chapter 2 Intestinal Suture.

Excision of the ulcer (pyloric duodenoplasty)

Figure 3.8. Barry Hill's way

Figure 3.9. Judd Tanaka's way

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Figure 3.10. Jud da horsley way

Barry - Hill (Burry - Hill) way

Method of pyloric-duodenoplasty and excision of an ulcer located on the anterior wall of the pyloroduodenal region, in combination with stenosis. Two semi-oval incisions are excised in front of the nude semicircle of the pylorus or duodenum with an ulcer. A limited semi-oval excision of the anterior wall of the stomach and duodenum is performed in the proximal and distal directions, followed by suturing the edges of the resulting defect in the transverse direction (Fig. 3.8). In this case, the perimeter of the sutured edges increases and the lumen of the plastic zone expands.

Judd - Tanaka (Judd - Tanaka) way

The method of pyloric duodenoplasty and excision of an ulcer located on the anterior wall of the pyloric or duodenal ulcer (Fig. 3.9). Two semi-oval incisions are dissected in front of the nude semicircle of the pylorus (hemipilorectomy is performed) together with the ulcer. The edges of the stomach and duodenum are sutured in the transverse direction. Thus, pyloroplasty is performed. If the ulcer is located on the wall of the duodenum in front of it, the anterior semicircle of the intestine is excised together with the ulcer. The integrity of the duodenum is restored in the transverse direction. In this case, duodenoplasty is performed.

Judd - Horsley (Judd - Horsley) way

The method of pyloric duodenoplasty and excision of an ulcer located on the anterior wall of the pylorus or duodenum (Fig. 3.10). The ulcer of the anterior wall of the pyloric (pyloroplasty) or duodenal ulcer (duodenoplasty) is excised with two limited semi-oval (or diamond-shaped) incisions in the transverse direction. The edges of the resulting defect are also stitched in the transverse direction.

Excision of gastric ulcer wedge-shaped

* After limited mobilization of the lesser curvature of the stomach in the projection of the ulcer with the help of suturing devices or long straight clamps, the lesser curvature along with the ulcer is excised in a wedge-shaped manner

(Fig. 3.11). The integrity of the stomach is restored in the transverse direction with a two-row suture, which avoids significant narrowing of the organ in this zone.

It should be remembered that it is necessary to carefully mobilize the lesser curvature of the stomach so as not to damage the gastric branches of the vagus nerve, as a result of which pylorospasm may develop. If, nevertheless, it was not possible to preserve the integrity of the gastric branches of the vagus, pyloroplasty should be performed, preferably anterior hemipilorectomy with preservation of the integrity of the mucous membrane according to Deaver - Bourdin - Shalimov.

Excision of stomach ulcers from the mucous membrane

After gastrotomy, the contents of the stomach are aspirated, a section of the stomach wall along with the ulcer is removed by hand or with the help of holders into the wound of the stomach. After that, the edges of the ulcer are excised, and the integrity of the mucous membrane is restored with a single-row suture (it is preferable to use synthetic absorbable sutures) with the obligatory capture of the submucosa (Fig. 3.12). The gastrotomic wound is sutured with a two-row suture.

Excision of an ulcer complicated by stenosis of the pyloroduodenal segment

Proximal and distal to the stenosis zone, two semi-oval flaps are cut out from the anterior wall, the tops of which are facing each other. The part of the anterior wall, located between the cut out flaps, is excised, extending the incisions to the posterior inferior and upper posterior walls of the intestine. The ulcer is excised (Fig. 3.13). The integrity of the intestine is restored in the transverse direction.

This method can be applied at any location of the ulcer and all types of stenosis with preserved motor-evacuation function of the stomach, regardless of the location of the stenosis zone. It ensures the natural passage of food and the integrity of the pylorus if the latter is not involved in scarring. The use of this method does not disrupt blood circulation in the duodenum and preserves tissue as much as possible, which helps to reduce the tension of the suture line.

Figure 3.11. Wedge-shaped excision of stomach ulcers

Figure 3.12. Excision of stomach ulcers from the mucous membrane

1 . 1" * * * * * * *

_________________ /

Figure 3.13. Excision of ulcers complicated by stenosis of the pyloric duodenal segment

Excision of ulcers located on the lateral walls of the duodenum

In the transverse direction, the anterior intestinal wall is dissected, having previously mobilized it according to Kocher. Then the incisions are extended to the upper or upper posterior, lower or posterior lower intestinal wall. The edges of the ulcer are excised (Fig. 3.14). Integral

Figure 3.14. Excision of ulcers located on the lateral walls of the duodenum

the intestine is restored in the transverse direction, starting from the upper or upper-posterior, lower or posterior-lower intestinal wall. In this case, it is possible to use a single-row suture with a frequency of 0.5 cm and a clear comparison of the serous-muscular layers. Thus, an arched duodenoplasty is formed, which in most cases allows preserving the pyloric pulp.

In the presence of two ulcers of the duodenal bulb along the upper-posterior and lower-posterior walls, the pylorobulbar zone is mobilized along the upper and lower contour, as a rule, while preserving the right gastric and right gastroepiploic artery (Fig. 3.15). Then, the anterior wall of the two adolescent colon is dissected in the transverse direction with the extension of the incisions up and down and excision of both ulcers. The restoration of the lumen of the duodenum begins from the side of the posterior wall in the transverse direction with the formation of subcircular duodenoplasty.

Excision of the ulcer located on the posterior wall of the pyloroduodenal segment

In the projection of the ulcer, the anterior wall of the duodenum is dissected in the transverse direction. The wound is widened with Farabef hooks. The edges of the ulcer are excised, departing from its edge by at least 3-4 mm. The mucosal defect is sutured with a single-row suture in the transverse direction, and the wound of the anterior intestinal wall is sutured with a double-row suture.

Figure 3.16. Excision of a foamy ulcer of the posterior wall of the duodenum

howl. Then, along the perimeter, a section of the mucous membrane and muscular membrane is excised, retreating at least 3-4 mm from the edge of the ulcer. In this case, the integrity of only the upper and lower walls of the intestine is preserved. The edges of the resulting defect in the posterior wall of the duodenum (without capturing the bottom of the ulcer) are sutured with single thin synthetic absorbable sutures. In this way, the ulcer crater is removed outside the alimentary canal. The wound of the anterior wall of the duodenum is sutured with two or single stitches. This technique maximally preserves the duodenal tissue and its blood supply (Fig. 3.16).

With an ulcer that occupies almost the entire back

semicircle of the duodenum (including penetrating), after dissection of the anterior wall, it turns out that the stomach and intestines lie almost separately from each other. Stop

bleeding is carried out by careful, but at the same time, reliable imposition of a twisting, U- or Z-shaped suture around the vessel (Fig. 3.17). Then, after excision of the edges of the mucous membrane of the stomach and duodenum,

Figure 3.17. Stopping bleeding by applying a twisted and U-shaped sutures around the vessel

lying directly to the ulcer, a gastroduodeno or duodenoduodenoanastomosis is applied end-to-end with thin single nodal synthetic absorbable threads. In this case, his back lip is formed with one row of sutures, and the front one - with one or two (Fig. 3.18).

Mobilization of the duodenum

Mobilization of the duodenum according to Clermontproduced from the side of the lower floor of the abdominal cavity. The algorithm of this operative action consists of the following stages: the transverse colon together with the greater omentum is moved upward; the loops of the jejunum and ileum move down and to the right; don't stretchplica duodenalis superior and plica duodenalis inferior, the lower part of the duodenum exfoliates from the retroperitoneal tissue and shifts upward along with the head of the pancreas. When mobilized according to Clermont, it is possible

revision of only the lower parts of the duodenum. Manipulations on the posterior wall of the duodenum have to be performed near the head of the pancreas, as well as the walls of the inferior vena cava and aorta.

Mobilization of the duodenum according to Kocher performed as follows: the right lobe of the liver is lifted with a wide blunt hook; the pyloric part of the stomach is displaced downward and to the left; stretcheshepato-duodenal ligament; along the right contour of the duodenum along the transitional fold, a sheet of the paraietal peritoneum is dissected, starting from the lower edgeforamen epiploicum \\ the retroperitoneal tissue is bluntly dissected, displacing the duodenum to the left to make its posterior surface accessible for inspection; at the same time, this technique allows you to examine the retroduodenal part of the common bile duct.

Figure 3.18. Excision of an ulcer that covers almost the entire posterior wall of the duodenum

Suturing the bleeding veins of the stomach and esophagus

Gastrotomy with esophageal vein ligation

and stomach (Fig. 3.19). After the upper midline laparotomy, the stomach is pulled down to the limit. Between provisional ligatures, an oblique incision 10-12 cm long from the bottom of the stomach to the lesser curvature is dissected through the anterior wall of the stomach in the cardiac section and the bleeding vessels of the edges of the stomach wound are carefully bandaged. After that, they suck off and remove the clot

ki of blood from the stomach cavity. However, sometimes
manages to see the bleeding vein that
stitched through the mucous membrane covering it
shell.
The veins of the car are stitched in the same way.
dialal section around the esophagus from
versts, more along the lesser curvature of the stomach.
It should be noted that from a puncture with a needle
there is significant bleeding, which after
blowing stop additional flashing
eat. Thickened folds of the mucous membrane
on a small curvature, where they mainly pass
dilated branches of the coronary vein, about
sew with separate interrupted seams in check
dull order. After that, go to pro
suturing the veins of the esophagus.
For portal hypertension, the sphincter	Figure 3.19. Pen gastrotomy
the esophagus usually gapes. Concerning	viscous veins of the esophagus and stomach

the entrance to the esophagus is significantly enlarged, due to which the varicose veins of the esophagus are clearly visible. Pressing the mucous membrane of the lesser curvature with a tupfer, the veins protruding into the lumen of the distal esophagus are stitched with several ligatures for 4-5 cm. As a rule, there are 3-4 trunks.

Ligatures should not be applied through the sphincter to avoid esophageal stenosis. This intervention is often complemented by devascularization of the cardiac stomach and abdominal esophagus, which requires fundoplication (restoration of the His angle). Further, hemostasis is controlled. The wound of the stomach is sutured with a two-row suture, and the wound of the abdominal wall is closed in layers.

Circular stitching of the cardia: after the upper midline laparotomy, gastrotomy is performed in the subcardial region in the transverse direction between two rows of sutures. Once a bleeding vein is found, it is sutured. Then put on1-2 suture in the area of \u200b\u200bthe cardioesophageal transition from the side of the lesser and greater curvature of the stomach. When pulling on these threads, the esophagus invaginates into the stomach. ThenU-shaped

Figure 3.20. Circular stitching of the cardia

sutures, suture to suture, circularly, through all layers, suture the esophagus to the stomach (Fig. 3.20). As a result

fundoplication is obtained from the mucous membranes of the esophagus and stomach, which reliably stops bleeding and at the same time prevents refluxesophagitis. This operation is performed in the presence of a thick gastric tube in the stomach, which prevents suturing of the walls.

esophagus and its narrowing.

Figure 3.21. Scheme for determining the size of the removed part of the stomach (according to A.A. Shalimov): 1 - antrumectomy; 2 - 1/2 stomach resection; 3 - resection of 2/3 of the stomach; 4 - resection of 3/4 of the stomach; 5 - subtotal gastrectomy

Stomach resection

Borders of distal gastric resection

Antrumectomy. In most cases, the proximal border of the antrum is located 5–6 cm from the gatekeeper of both the lesser and greater curvatures. Others \\ anatomical sign of the border n< малой кривизне является проксимальна) ветвь нерва Lataijet в виде гусиной лапки,; по большой кривизне граница совпадает точкой соединения обеих желудочно-саль никовых артерий.

1/2 stomach resection (according to A.A. Shalimov). Resection from the duodenum to the line crossing the stomach p

Figure 3.22. Billroth gastric resection- Peanu

the lesser curvature, 4 cm away from the esophagus towards the lesser curvature, and along the midline along the greater curvature.

Resection of 2/3 of the stomach (according to A.A. Shalimov). Removal of part of the stomach along the line intersecting the lesser curvature, retreating to2-3 cm from the esophagus, and a greater curvature, departing to the left of the midline by6-8 cm, that is, to the right of the discharge of the vascular branches to the bottom of the stomach from the leftgastroepiploic arteries.

Resection of 3/4 of the stomach (according to A.A. Shalimov). The line of intersection of the stomach runs along the lesser curvature on1-1,5 cm from the esophagus and along the greater curvature - at the lower pole of the spleen, when the short gastric arteries remain, coming from the vascular arcade at the gate of the spleen,

Resection of 4/5 stomach (according to A.A. Shalimov) - subtotal resection of the stomach. The line of intersection of the stomach goes along the lesser curvature at the esophagus itself (departing from it only by0,5-0,8 cm), along the greater curvature - at the lower pole of the spleen with the intersection of one short gastric artery running from the arcade at the lower pole of the spleen to the fundus of the stomach.

Billroth - Peana (Billroth - Reap) method (fig. 3.22)

This method of operation is the most common classical method of gastric resection according to Billroth I and can be used for peptic ulcer disease of both the stomach and duodenum (cited by A.A. Shalimov and V.F.Saenko).

After specifying the volume of the resection, the stomach and transverse colon are removed into the wound. The non-vascular area with a stretched gastro-colonic ligament is dissected. The gastro-colic ligament is clamped in parts and transected. In the corner between the head of the pancreas and the duodenum, the gastroepiploic artery is inserted and, together with the gastro-colonic ligament, it is crossed between two clamps and ligated. Under the control of a finger passed through the small omentum, grip with clamps, cross and bandage

hut the right gastric artery.

The lesser omentum is dissected to the cardiac part of the stomach. It should be noted that vessels from the left gastric artery to the liver often pass here. It is necessary to check whether there is a hepatic artery among them. Ligation of the main trunk of the hepatic artery, which abnormally extends from the left gastric artery, threatens liver necrosis. Above the place of division of the left gastric artery, an incision is made in the serous membrane at the lesser curvature of the stomach. A clamp is made into the incision along the stomach wall towards the finger drawn to the posterior surface of the stomach at the lesser curvature.

The left ventricular artery separated from the stomach is clamped, transected, and tied. The boundaries of gastric resection are finally determined and, if necessary, their expansion is additionally mobilized to a greater curvature. The duodenum is grasped with a clamp closer

to the gatekeeper, the second clamp is placed on the stomach at the gatekeeper. Between the clamps, the stomach is cut off along the duodenum.

In cases where the ulcer is located in the duodenum, the latter is crossed below the ulcer if mobilization of the intestine allows, since on the posterior medial wall of it, at a distance of 2-8 cm from the gatekeeper, there is a large duodenal papilla.

On the side of the greater curvature, a clamp is applied, the length of the branch of which is approximately equal to the lumen of the duodenum. A small curvature is formed using a stapler and a second row of interrupted gray-gray sutures is applied. In the absence of a device for the formation of a small curvature, you can use a continuous overlap or immersion seam, furrier seam or Connel seam. Coarse clamps are applied to the removed part of the stomach and cut off.

The unsecured part of the stomach stump and the duodenum are brought together. From stepping 0.5 cm from the edge of the incision, nodular serous-muscular sutures are applied to the posterior lips. The back and front lips of the anastomosis are sutured with one of the types of through suture (single interrupted or continuous suture). On the front lip of the anastomosis, a second row of serous-muscular sutures is applied, strengthening the corners with U-shaped serous-muscular sutures. When anastomosis is applied,

Figure 3.23. Scheme of gastric resection according to Billroth I in case of duodenal ulcer: 1 - cutting off the proximal part of the stomach from the ulcer; 2 - the formation of the posterior wall of the anastomosis; 3 - the final view of the lines of sutures imposed on the anterior (P) and posterior (3) walls of the anastomosis

610 Part III. Surgical operations on the organs of the chest and abdominal cavity

reading should be given with synthetic absorbable threads with an atraumatic needle.

The greater omentum, and in its absence, the mesentery of the transverse colon is sutured to the stomach and duodenum at the entrance to the omentum bag, eliminating the entrance to the latter.

The described method of classical Billroth I gastric resection is not always applicable, especially for giant, penetrating ulcers located on the posterior and upper posterior wall of the duodenum, etc. In such situations, the following technique can be applied (Figure 3.23). After cutting off the stomach and forming a lesser curvature, starting from the upper edge of the ulcer, nodal serous-muscular sutures are placed between the posterior wall of the stomach, retreating 0.8-1 cm from the proposed anastomosis zone, and the scar tissue of the distal edge of the ulcer. Then, an inner row of single interrupted sutures is applied, capturing the stomach wall and the mucous-muscular layer of the duodenum. The anterior lip of the anastomosis is formed with through single nodal (inner row) and serous-muscular (outer row) sutures. The corners of the anastomosis are strengthened with U-shaped sutures. For anastomosis, thin synthetic absorbable sutures and atraumatic needles are used.

Roux (Roux) method (fig. 3.24)

This operation refers to modifications of the gastric resection according to the Bill Roth II method. It is more often used for peptic ulcers of the anastomosis (as a rule, in combination with vagotomy). The stomach is mobilized depending on the expected volume of resection. The stomach is resected, the duodenal stump is sutured tightly. Having retreated 40-80 cm from Treyz's ligament, the jejunum is crossed across with an incision of the mesentery. The aboral end of the transected intestine is passed through a window in the mesentery of the transverse colon and anastomosed end-to-end with the stomach stump (from the side of the greater curvature). The oral end of the transected intestine is sewn into the side of the discharge (from the anastomosis) intestine. Thus, a gastroenterostomy with a Y-shaped loop of the jejunum is created.

Tomoda (Tomoda) way

This operation refers to modifications of gastric resection according to the Billroth I method. It is more often used in case of duodenal ulcer.

The classic way.After resection of the stomach, its stump is sutured from the side of the greater curvature, leaving an opening for the fistula at the lesser curvature. The opening of the duodenum is enlarged by an oblique incision of the anterior wall and anastomosed with the unsecured part of the gastric stump at the lesser curvature. The sutured part of the stomach stump is sutured to the anteroposterior vertical part of the duodenum below the anastomosis, forming a spur. This is the classic Tomoda way.

Figure 3.24. Roux-en-route gastric resection

Modified method. After resection of the butt, its stump is sutured from the side of the lesser curvature, leaving an opening for the anastomosis at the greater curvature. The opening of the duodenum is enlarged by an oblique incision of the anterior wall and anastomosed with the unsecured part of the stomach stump at the greater curvature (Fig. 3.25).

After careful abdominal revisions in order to search for metastatic lesions, attention is directed to the hepatobiliary and duodenal zones. To do this, mobilize according to Vautrin-Kocher. It is performed in two stages. At the first stage, the transverse colon and its mesentery are retracted downward, as shown in the figure. In this case, the descending part of the duodenum and the lateral side of the lower horizontal part become available for review. Bringing down is performed in a sharp way using scissors.

Transverse colon with its mesentery wrapped with a napkin and pushed down. Then the second stage of Vautrin-Kocher mobilization is performed. The peritoneum is dissected along the entire length of the lateral edge of the descending part of the duodenum to the lateral segment of the lower horizontal part of the duodenum, including it and the anterior leaflet of the hepatoduodenal ligament.

Lateral edge of the descending parts of the duodenum lead up and to the left. This can be done by the first assistant with a hand or atraumatic forceps such as Foerster or Babcock. This technique enables the surgeon to easily mobilize the duodenum and pancreatic head in the virtually bloodless area of \u200b\u200bthe Treitz fascia. Correctly performed mobilization according to Vautrin-Kocher will allow you to see the lower segment of the common bile duct, the upper-posterior part of the head of the pancreas, the inferior vena cava, a section of the right renal vein (R), the inner part of the renal fat capsule together with the kidney and the right ureter (U), the right gonadal vein (G), aorta (A) and the beginning of the superior mesenteric artery. Mobilization according to Vautrin-Kocher will facilitate subsequent surgical procedures and will reveal the invasion of the tumor into the underlying tissues and the inferior vena cava. When invading the inferior vena cava, the tumor should be considered inoperable.
After completing mobilization by Vautrin-Kocher, dissect the gastro-colic ligament under the vascular gastroepiploic arch.

Surgical revision of the pancreas.

After dissection of the gastro-omental the ligaments of the stomach are pulled up, and the transverse colon with its mesentery is pulled down, exposing the entire anterior surface of the pancreas, as seen in the figure.

This technique allows adequately examine the head of the pancreas from the front and back, as well as the anterior surface of its body and tail. For palpation of the head of the pancreas, the left thumb is placed in front, and the index and middle fingers of the left hand are placed behind, as shown in the figure. This technique allows you to establish the presence of a tumor in the head of the pancreas, as well as its size, shape, consistency, softness and borders. If the pancreatic duct is significantly enlarged, it can also be felt by sliding the thumb to the left of the tumor, revealing the difference between a dense, uneven mass and an elastic-elastic pancreatic duct in consistency. The inset shows this technique in a semi-schematic section.

Palpation of the Vater papilla.

On palpation of the Vater papilla the technique shown in this figure may be helpful. The surgeon's right thumb presses the antimesenteric, or outer, edge of the duodenum against the mesenteric, or inner, edge. Thus, the exophytic growing tumor of the Vater papilla is easily palpated. A small soft tumor or small intrapapillary tumor is much more difficult to palpate. Some of the other techniques required to identify these tumors will be described in other articles.

By performing these pre-resection techniques, it is necessary to try to grope the hook-shaped process. In this case, the following technique turns out to be useful. To perform it, the peritoneum is dissected over the inner edge of the pancreas at the level of the isthmus. Then the surgeon should place the palm of his left hand behind the head and isthmus of the pancreas and push his right index finger under the isthmus, trying to feel the hook-shaped process located behind the mesenteric vessels.

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DUAL MOBILIZATION BY KOHHER

see Kocher mobilization of the duodenum.

Medical terms. 2012

The value of mobilization of the duodenum by coher in medical terms. Kocher mobilization of the duodenum Mobilization of the duodenum 12 according to the Kocher scheme

Causes

Signs

Classification

Kinds

Power

Diagnostics

Therapy for I, II degree

Therapy for grade III

Surgical revision of the pancreas.

Palpation of the Vater papilla.

See also the interpretations, synonyms, meanings of the word and what is MOBILIZATION OF THE DOUBLE IN KOHER in Russian in dictionaries, encyclopedias and reference books:

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