Pyloroplasty according to Finney: purpose, preparation for surgery, conduct, methods, technique, stages, recovery period and rehabilitation. Pyloroplasty Options Pyloroplasty Complications

Gastroduodenoanastomosis according to Zhabula

The essence of gastroduodenoanastomosis according to Zhabula in mobilization duodenum according to Kocher, followed by the imposition of a gastroduodenal anastomosis with a diameter of more than 2.5 cm, side-to-side, bypassing the place of the obstacle. The fistula should be located as close as possible to the pyloric sphincter (above the major duodenal papilla). Lateral anastomosis between the stomach and duodenum, as a draining operation in combination with vagotomy in case of stenosis, in some cases has an advantage over pyloroplasty.

Technique. In a limited area, the distal part of the stomach is freed from adhesions at the greater curvature so that it can be brought to the anterior surface of the duodenum. After that, the anterior surface of the distal part of the stomach at the greater curvature, and the inner edge of the duodenum can be brought together without any tension.

The upper suture is placed immediately below the pylorus, the lower one at a distance of 7-8 cm. The anterior wall of the stomach and duodenum is dissected in two incisions without crossing the pylorus. To avoid torsion of the duodenum, the line of its fixation with serous-muscular sutures to the stomach and the incision line must be strictly parallel vertical axis intestines. Then the posterior and anterior internal hemostatic sutures are applied with a continuous catgut thread. After that, they begin to apply the anterior outer row of nodal serous-muscular sutures.

Pyloroplasty according to Heineke-Mikulich-Radetsky

The essence of the method lies in the longitudinal dissection of the antrum of the stomach and the initial section of the duodenum on both sides of the pylorus. To create a sufficient pyloric lumen, a longitudinal dissection of the walls of the stomach and duodenum should be performed for 3-4 cm, followed by transverse stitching of the formed wound.

First, the anterior wall of the stomach is opened with scissors in the middle of the distance between the greater and lesser curvature. The contents are removed by suction. Two semi-oval or diamond-shaped incision excised ulcerative infiltrate within healthy tissues. Then the longitudinal incision, the anterior wall of the stomach, and the duodenum is transferred into a transverse one and sutured with a single-row continuous suture through all layers without rough tissue capture, which is quite reliable, excludes rough tissue screwing, gives a gentle scar and guarantees against cicatricial narrowing of the exit from the stomach.

However, it is also possible to use a two-row suture, when serous-muscular interrupted sutures are applied without rough screwing of the tissues.

Pyloroplasty according to Heinecke-Mikulich Radetsky with stitching of a bleeding vessel in an ulcer

Surgery for profuse bleeding duodenal ulcer located along back wall, begin with flashing a bleeding vessel. Vagotomy is performed as the second stage of the intervention.

Technique. After organ revision abdominal cavity and establishing the source of bleeding, sutures are applied to the duodenum along the edges of the anterior semicircle of the pylorus, followed by a wide pyloroduodenotomy. The formed hole is widely stretched in the transverse direction to provide good access to the bleeding ulcer.

To avoid eruption of the callous edges of the ulcer, the suture ligature should capture healthy areas of the mucous membrane at a distance of 0.5-1 cm from ulcer defect and passes under the bottom of the ulcer. Care must be taken to be aware of the possibility of damage to the common bile duct if tissue is sutured too deeply.

After that, proceed to the closure of the pylorotomy incision. Using the sutures of the holders, the incision of the stomach and duodenum is transverse and the wound is sutured according to the method described above. Closure of the pylorotomy incision during this operation can also be performed with a single-row suture.

Pyloroplasty according to Finney

Pyloroplasty according to Finney differs from the described method in that a wider exit from the stomach is formed. This type of pyloroplasty is used for cicatricial-ulcerative stenosis of the outlet section, as well as for combined complications of duodenal ulcers when pyloroplasty according to Heinecke-Mikulich Radetsky may not provide adequate drainage of the stomach.

Technique. The duodenum is mobilized according to Kocher, the antrum of the stomach and the initial section of the duodenum are dissected with a continuous incision 4-6 cm long. Interrupted serous-muscular sutures connect the greater curvature of the pyloric part of the stomach with the inner edge of the duodenum. The incision is sutured according to the principle of the upper gastroduodenal anastomosis, side-to-side. The upper seam is located immediately at the pylorus, the lower at a distance of 7-8 cm from the pylorus.

The anterior wall of the stomach and duodenum is dissected with a continuous arcuate incision. After that, a continuous suture with an overlapping catgut thread is applied to the posterior lip of the anastomosis to ensure reliable hemostasis.

The anterior lip of the anastomosis is sutured using a screwing Schmiden suture from the lower angle of the incision up towards the pylorus. After that, they begin to apply the anterior outer row of nodal serous-muscular sutures.

Vagotomy in the treatment of duodenal and gastric ulcers is in most cases combined with draining operations on the stomach. More than two dozen drainage operations have been proposed, which can be divided into two fundamentally different groups - with and without intersection of the pyloric muscle.

The first group of draining operations includes pyloroplasty according to Heineke-Mikulich and its modifications, pyloroplasty according to Finney and its modifications, as well as some plastic interventions on the pyloroduodenal region.

The group without crossing the pyloric sphincter should include different kinds gastrointestinal anastomoses (gastro-duodenoanastomosis according to Jabulei, gastrojejunoanastomosis) and duo-denoplasty. With some reservations, pyloro- and duodeno-dilation can be attributed to the same category of draining interventions.

Finally, special attention should be paid to antrumectomy and more extensive resections of the stomach, which, although they are not draining operations, are often combined with vagotomy.

We will not describe in detail the technique of all existing drainage operations, but will focus on the most common in wide surgical practice.

Heineke-Mikulich pyloroplasty and its modifications

The Heineke-Mikulich pyloroplasty technique has undergone some changes during the existence of this operation and is now performed in compliance with the rules developed by the authors who have the most experience in its application. These rules are that the incision of the pyloroduodenal canal is made over 5-6 cm, spreading 2.5-3 cm in both directions from the pyloric sphincter with the intersection of the latter, the edges of the wound of the stomach and duodenum are sutured in the transverse direction using single-row nodal sutures made of synthetic threads through all layers of the organ (Fig. 8). To prevent adhesions between the area of ​​pyloroplasty and the lower surface of the liver, which can lead to gross deformation of the gastroduodenal canal and disruption of the evacuation of gastric contents, some authors recommend covering the suture line with a strand of the omentum on the stem, hemming it

Rice. 8. Scheme of pyloroplasty according to Heineke - Mikulich.

a - section of the wall of the stomach and duodenum; b - formation of the gastroduodenal canal using a single-row suture; c - view after the end of pyloroplasty.

on both sides of the suture line to the wall of the stomach and duodenum [Kurygin A. A., 1976; SmallW „JahadiM., 1970]. A two-row suture is disadvantageous in that when the second row of sutures is applied, invagination of the wall of the stomach and duodenum often occurs and their lumen narrows. However, if the mucous membrane of the duodenum is very mobile, it is permissible to first sew the mucous and submucosal layers of the stomach and duodenum with thin absorbable threads and then the second row of sutures - the serous and muscular layers of these organs. In this case, the double-row suture is similar in its configuration to a single-row one, and the absorbable threads of the first row subsequently cannot cause the formation of so-called ligature ulcers in the area of ​​pyloroplasty.

A sufficiently long incision and a single-row suture prevent a sharp narrowing of the gastroduodenal canal, which inevitably occurs to one degree or another as the ulcer heals and scarring in the area of ​​the suture line. Practice shows that pyloroplasty is adequate when the width of the lumen of the gastroduodenal canal in the remote period after surgery remains within at least 2 cm [Dozortsev VF, Kurygin AA, 1972; Bloch C., Wolf B., 1965]. After the formation of a single gastroduodenal canal in this way, pseudodiverticula are formed along the poles of the suture line, which are clearly visible on radiographs of this area and sometimes taken by radiologists inexperienced in this matter for an ulcerative niche (Fig. 9).

There are several modifications of Heineke-Mikulich pyloroplasty. In doing so, the authors pursue different goals. Some, eliminating the obturator function of the pyloric sphincter, seek to maintain the normal lumen and configuration of the pilorhoduodenal canal. So, according to the method of Frede-Weber (1969), the serous and muscular layers of the pilorhoduodenal canal are longitudinally cut to the mucous membrane with a complete intersection of the pyloric muscle. In the future, no sutures are applied, i.e., the operation is performed as it is done with pyloric stenosis of newborns. The same is performed with pyloroplasty according to Weber-Braytsev (1968), but, unlike the previous operation, the serous-muscular layer is sutured in the transverse direction.

The technique of Devere-Bourden-Shalimov (1965) pursues the same goal as the previous two modifications: by dissecting the serous-muscular layer along the pyloric sphincter, excising the latter for 2 cm and suturing the resulting tissue defect in the same circular direction (Fig. ten). Payr (1925) does the same, but after excision of the anterior semicircle of the pyloric muscle, the defect in the serous-muscular layer of the stomach is sutured in the longitudinal direction.

In pyloroplasty according to Zolanka (1966), a loop wall is sewn into the incision of all layers of the pyloroduodenal zone with the intersection of the pyloric sphincter small intestine, the serous cover of which becomes a continuation of the mucous membrane of the pyloric canal and is in contact with the gastroduodenal contents. Kvist (1969) does the same, but sews a strand of omentum on the stem into the defect in the wall of the pnloro-duodenal canal. These authors believe that after this kind of pyloroplasty, duodenal gastric reflux occurs less frequently.

Violation of the obturator function of the pyloric muscle and the preservation of the configuration of the pyloroduodenal canal

Rice. 10. Scheme of pyloroplasty according to Dever-Bourdin-Shalimov (according to I. S. Bely and R. Sh. Vakhgangishvili, 1984).

a - section of the stomach wall to the muscle layer; b - partial excision of the pyloric muscle; c - completion of the operation

they are also cut in a V-shaped incision according to Vohell (1958) or in the form of a triangle according to Izbenko (1974) with excision of the ulcer, if it is located on the anterior wall of the duodenal bulb, and the intersection of the pyloric sphincter. In this case, the acute angle of the pyramid faces the duodenum, and the resulting defect is sutured so that the wall of the stomach moves to this acute angle (Fig. 11).

A number of modifications of pyloroplasty according to Heineke-Mikulich provides for the intersection or excision of a part of the pyloric sphincter together with the ulcer in rhomboid (according to Judd, 1915) or in the form of a square (according to Starr-Judd, 1927; according to Aust, 1963; according to Borisov, 1973) incisions, followed by suturing wounds in the transverse direction (Fig. 12).

Some authors, using various technical tricks, achieve a significant expansion of the pyloroduodenal canal to ensure the fastest emptying of the stomach. So, with pyloroplasty according to Burri Hill (1969), a longitudinal incision in the wall of the stomach and duodenum is made in the same way as in pyloroplasty according to Heineke-Mikulich, but the anterior part of the pyloric muscle is excised from an additional incision along it, after which the wound is sutured in the transverse direction.

Rice. 11. Stages (a-c) of pyloroplasty according to Vohell (according to I. S. Bely and R. Sh. Vakhtangishvili, 1984).

It should be noted that neither with a simple intersection of the pyloric muscle, nor with partial excision of its anterior semicircle, its obturator function is completely eliminated. The pyloric sphincter is not an isolated muscle ring; it is closely connected with the wall of the stomach and duodenum [Saks F. F. et al., 1987], and therefore the remaining part of it is able to contract and perform

Rice. 12. Scheme of pyloroplasty according to Judd-Horsley (according to I. S. Bely and R. Sh. Vakhtangishvili, 1984). a - diamond-shaped excision of the ulcer; b - pnloroplasty.

more or less obstructive function. This phenomenon can be seen with fibrogastroscopy, fluoroscopy of the stomach; it is especially clearly visible in X-ray examination.

As can be seen from the above data, many modifications of Heineke-Mikulich pyloroplasty do not contain any fundamental features, and, in our deep conviction, many technical tricks are often unnecessary and complicate the operation.

The term "pyloroplasty" refers to surgical intervention, during which the expansion of the hole located between the stomach and the duodenum is carried out. This is necessary in order to ensure the normal passage of processed food into small intestine. Currently, there are several techniques for performing the operation. Finney pyloroplasty is considered the best method.

Indications

During the surgical intervention, the integrity digestive tract is not violated. The task of doctors is only to expand the pathologically narrowed area, which occurs due to the influence of various kinds of provoking factors. Pyloroplasty according to Finney is not difficult. In addition, the risk of developing negative consequences minimal. In this regard, doctors may include surgery in the treatment regimen. a large number patients.

The main indications for pyloroplasty according to Finney:

• in particular, the pyloric department. Usually, this pathology occurs in elderly patients.
• Stenosis of cicatricial and ulcerative nature in young children.
• Ulcer. Pyloroplasty according to Finney is performed even in the presence of complications in the form of profuse bleeding and perforations.
• pyloric stenosis innate character in infants.

In addition, the operation is indicated for people who suffer from concomitant diseases that require vagotomy. This term refers to the surgical dissection of the branches vagus nerve or its entire trunk, after which the secretion decreases of hydrochloric acid.

Training

Pyloroplasty according to Finney is an operation that requires preliminary preparation. First of all, the patient must take a blood and urine test, and also undergo x-ray examination. Based on the results of the diagnosis, the doctor decides on the appropriateness of the surgical intervention.

Immediately before the operation, the patient is strictly forbidden to eat and drink water. The duration of the fasting period should be at least 10 hours. Mandatory stage in preparation - setting a cleansing enema. If the patient suffers from nausea and/or vomiting, gastric emptying is carried out using a special tube.

Technique

The operation is carried out exclusively general anesthesia. The patient is put into a sleep state in which pain are completely blocked. After that, the operation begins. The Finney pyloroplasty technique is not particularly difficult for surgeons.

The operation is carried out according to the following algorithm:

1. In order to provide access to the pylorus, the doctor makes an incision in the upper abdomen. AT last years Increasingly, the operation is performed using laparoscopic instruments, which eliminates the need to cut the anterior wall of the peritoneum.
2. The doctor puts stitches, 4-6 cm long, which connect the stomach and duodenum along the greater curvature. In this case, the gatekeeper should be in the upper part.
3. The surgeon opens the lumen of the duodenum and stomach. The cut should be curved.
4. In order to stitch the walls of the anastomosis, the doctor applies a continuous suture. It covers all layers of the stomach and duodenum.
5. The next task of the surgeon is to prevent tension in the sutures. To do this, he mobilizes the duodenum according to the Kocher method. The essence of the method lies in the release of the descending part of the body and the subsequent stitching of its inner edge with a large curvature of the pyloric part of the stomach.
6. The surgeon creates an anastomosis. In other words, it is a connection of tissues.
7. After pyloroplasty according to Finney, the doctor restores the integrity muscle tissue. On the skin covering staples or sutures are placed at the incision site.

The duration of the operation is on average 1-2 hours.

Recovery period

The first few hours after surgery, the patient is constantly monitored. Nurses regularly monitor arterial pressure, body temperature, respiratory rate and heart rate.

In the first 1-2 days, nutrient solutions are injected intravenously into the patient's body. After the operation, it is allowed to drink only a little water (up to 0.5 liters). From the second day, this restriction is removed. The patient is transferred to medical nutrition. The diet involves frequent meals, but portions should be very small. The expansion of the diet is gradual.

From the second day, it is also allowed to take short walks and exercise breathing exercises. Each time the intensity physical activity should get bigger. An exception is situations in which the patient feels unsatisfactory or experiences severe pain.

The sutures are removed 8-10 days after the Finney gastric pyloroplasty. The patient is discharged if his condition is assessed as satisfactory, and the results laboratory research cause no concern.

Possible Complications

The possibility of undesirable consequences is not excluded. But it is important to know that they appear only in isolated cases. Among the complications:

• peritonitis;
• pancreatitis;
• internal bleeding;
• violation of the process of evacuation of partially digested food from the stomach;
• diarrhea of ​​a chronic nature;
• violation of the integrity of the intestine;
• formation of a hernia in the incision zone.

The risk of complications increases with dehydration, smoking, unbalanced diet, obesity. Provoking factors are also respiratory diseases, elderly age, bleeding disorders and heart disease.

Finally

During the Finney pyloroplasty, the surgeon expands the pathologically narrowed area between the stomach and duodenum. Currently, this method is considered optimal for solving this problem. Moreover, it is not associated with a high risk of developing postoperative complications. The criteria for a successful intervention are the satisfactory condition of the patient, nice results analyzes, restoration of normal evacuation of partially digested food.

a) Indications for pyloroplasty according to Heineke-Mikulich, Finney, Jabulei:
- Planned: cicatricial obstruction of the output department; after pylorotomy performed during other operations.
- Alternative operations: gastroenterostomy, dilatation.

b) Preoperative preparation:
- Preoperative studies: contrast radiography, endoscopy.
- Patient preparation: nasogastric tube.

in) specific risks, informed consent patient:
- Delay/acceleration of gastric emptying
- Divergence of the seam line
- Bleeding
- Injury to the pancreas
- Damage to the bile ducts

G) Anesthesia. General anesthesia (intubation).

e) Patient position. Lying on your back.

e) Access for pyloroplasty. Upper midline laparotomy, but a transverse laparotomy or an incision in the right hypochondrium is also possible.

and) Stages of pyloroplasty:

- Lengthwise cut
- Dissection of the anterior wall

- Completed seam line
- Pyloroplasty according to Finney
- Jabulei principle

h) Anatomical features, serious risks, operational methods:
- The Heineke-Mikulich operation is impossible in the presence of a fibrous, inflammatory, deeply cicatricial wall of the small intestine.
- The Heineke-Mikulich incision is made in the middle of the anterior wall of the stomach, while in Finney and Jabulei operations, the incision is shifted to the greater curvature and pancreas.
- Wide mobilization of the duodenum (Kocher maneuver).
- When using a stapler, select 4.8mm staples.
- Warning: Avoid "dog ears" due to too wide anastomosis.

and) Measures for specific complications. Warning: beware of papillary narrowing and damage to the bile duct. If in doubt, perform an immediate exploration of the bile duct (X-ray, endoscopy).

to) Postoperative care after pyloroplasty:
- medical care: remove the nasogastric tube after 2-3 days, depending on the reflux. Perform follow-up endoscopy in 3-6 weeks.
- Refeeding: liquid diet from day 4 (depending on the overall situation). Eating solid food after the first postoperative stool/flatus.
- Activation: immediately.
- Physiotherapy: breathing exercises.
- Disability period: 1-3 weeks.

l) Operative technique of pyloroplasty:
- The principle of pyloroplasty according to Heineke-Mikulich
- Lengthwise cut
- Dissection of the anterior wall
- Transverse suturing with separate seams
- Completed seam line
- Pyloroplasty according to Finney
- Jabulei principle

1. The principle of pyloroplasty according to Heineke-Mikulich. After a longitudinal incision of the pylorus and Kocher mobilization of the duodenum, the pylorus can be expanded without tension using a transverse suture.

2. Lengthwise cut. Between the sutures-holders, a longitudinal incision of the anterior wall is made, extending symmetrically in both directions: to the pylorus and duodenum.

3. Dissection of the anterior wall. The front wall is dissected to the full thickness between the sutures-holders. The ulcer or scar tissue is excised. The lumen must be completely free. The duodenum is fully mobilized according to Kocher, which allows you to compare the edges of the wound without tension.

4. Transverse suturing with separate sutures. After complete mobilization of the duodenum, the longitudinal incision is sutured with transverse single sutures. Excessive tension on the retainer sutures should be avoided to prevent the formation of dog ears.

5. Completed seam line. The right combination incision and tension of the sutures-holders allows to perform pyloroplasty with a smooth elastic expansion and without "dog ears".

6. Pyloroplasty according to Finney. Pyloroplasty according to Finney consists of a longitudinal dissection of the pylorus with the inclusion of the distal part of the stomach and the proximal part of the duodenum in the form of an inverted "and" into the incision. A wide fistula between the stomach and duodenum is created by appropriate suturing of the flaps.

7. Jabulei principle. Jabulei's principle is to exclude the gatekeeper. This is a side-to-side gastroduodenostomy. It can be performed with a double-row or single-row suture, if the condition of the walls of the organs allows. The gatekeeper remains untouched.

8. Video lesson of pyloroplasty according to Heineke-Mikulich .

- Return to the section heading "

As independent surgical interventions drainage techniques are not used, but as an addition to vagotomy, elimination proximal stomach, they are useful. When to install a drain, the doctor decides. It is often carried out if a duodenal ulcer or pylorus is diagnosed, a violation of the innervation of the stomach, which occurred after cicatricial and ulcerative stricture of the duodenum 12.

Which option is better?

There are more than two dozen types of drainage operations, which are divided into such methods: with and without intersection of the pyloric muscle. The first type includes pyloroplasty on the stomach according to Heineke-Mikulich and according to Finney. The goal is the reconstruction of the gatekeeper in order to expand its canal. From a surgical point of view, these interventions are quite simple and do not lead to serious complications and a high risk of morbidity and subsequently lethal outcome. Surgeons also use both the traditional approach to the operation and the laparoscopic one. The latter significantly reduces trauma and shortens the rehabilitation period for the patient.

The second type includes gastroduodenoanastamosis, which, compared with pyloroplasty, has some disadvantages:

• Does not always provide effective drainage of the stomach.
• It is made much more difficult.
• Does not ensure the integrity of the stomach.
• Violates the physiological mixing of pancreatic and bile secretions with the food mass.
• It does not allow to accurately determine the place of bleeding and quickly implement a local stop of blood in patients with a bleeding ulcer.
• The specialist cannot analyze the condition of the mucous membrane of the anterior digestive tract and ulcers.

When carrying out the intervention, it is important not to touch the ulcer formation itself.

To start, carry out initial inspection organs of the abdominal cavity and establish the place of bleeding. It is indicated for cicatricial stenosis against the background of a pyloric ulcer. The pyloric sphincter is crossed in the longitudinal direction. The wall of the duodenum and stomach is affected. After that, the duodenum is sutured with a holder with further extensive pyloroduodenotomy. The suture ligature should be used, capturing the mucosa at a distance of half a centimeter to 2 from the ulcer, in order to avoid cutting through its edges. Next, the pylorotomy incision is closed, in a longitudinal position, and the incision is sutured with a single-row suture.

It must be remembered that there is a risk of damaging the joint duct for bile, so you should not flash very deep.

Pyloroplasty according to Finney

More often this method is used when the previous type of piloplasty cannot guarantee the drainage of the stomach. The incision is made wider than in the previous method, serous-muscular sutures are applied, an arcuate incision is made and an anastomosis is formed. The duodenum is fixed according to Kocher, then the pylorus section of the stomach and the initial section of the duodenum are dissected with a continuous incision up to 6 cm long. The larger bend of the pyloric section of the epigastrium is connected with interrupted sutures to the inner border of the initial section of the small intestine. Further, the upper shell of the stomach and intestines is divided by a section without interruption. On the distal lip of the anastomosis, an incessant suture is applied with overlapping material to prevent bleeding.

The intervention is inherently combined.

This procedure includes fixing the duodenum according to Kocher and performing a gastroduodenal anastomosis with a diameter of at least 2.5 cm, side-to-side. In order to bring the far section of the stomach at a large bend to the duodenal membrane, it is relieved of accretion. Carefully, without incision of the sphincter, the anterior membrane of the epigastrium and intestine is dissected with a pair of incisions. Next, two internal antihemorrhagic sutures are established with a continuous thread. After an incision in the duodenum and stomach, a lateral gastroduodenal fistula is formed by means of longitudinal sections (without crossing the pylorus).