Protocol of surgery for resection of the slunk Bilroth 2. Stage and technique of resection of the slunk according to Bilrot I (gastroduodenostomy)

The technique of surgery according to Bilroth II allows a large resection of the slunk with overlapping gastrojejunal anastomosis "bik u bik". The technique is givenє the prototype of the onset numerical modifications of the cutter and sprinkler resection in the manner proponated by the Hofmeister and Finsterer.

Ostanniy polyagaє at the offensive. For the upper middle laparotomy, the slunk mobilization is carried out and the stump of the 12th intestine is churned in a general manner. Then the surgical attack is started until the drainage is released and the anastomosis is formed. For whom, from the pilot in the first place, one should know the lull, and the aspirator is worried all the time, then, by the line of the maybutny resection, there are two straight lines on the chuck, and one of the side is not enough. Close to them, you can see a part of the shlunk, take on a crushing slurry pad, using the slurry along the edge, pulling the slunk in front, the organ is pulled with a scalpel and the preparation is applied.

Then, to move to the suturing of the upper third, the kuksi shlunka was established. A large number of fakhivtsiv when applying a double or three-row seam. Tighten the first seam near the pulp and tighten it. With the help of the thread, in a protylezhny straight line, pass through all the balls of the shlunksi without interruption with a seam. Fixing the deserozirovannye dilyanka to the body, for its small curvature to carry out another row of vuzlovy serous-muscular sutures, increasing the boring in front row. The threads of the last seam do not see through, but, having taken them for a grip, they twist in the yoke of the holder.

on happy step The suturing of the upper part of the shlunka can be stitched with a noble ziruvalny seam, a special device - Zshivachi kuksi shlunka and stuck in the anchor of the suture material of the U-shaped staple from the tantalum-niobium dart. Such a pidhіd allows you to eliminate the hermetic Aseptic seam of the bazhanoi dozhina and the very speed of the operation.

Having completed the suturing of the upper third of the kuksi of the shlunks, the surgeons proceed to form the anastomosis. For whom I prepared a short loop in advance small intestine Accurately bring the slurry to the cult so that the part of the part shows little curvature, and the lead is great. At the same time, it means that it is necessary to bring the loops from the upper duodenal fold of the quail until the cob is applied after it is not guilty of repositioning 10 cm.

Bring the loop of the intestine to the cult of the shlunka by means of a nozzle overlaying the decals of the vuzlovy suture seams on the protrusion of 3-4 cm. Pidshivayut intestine to the slunk so that the line is anastomotic, the width of the ligament is not less than 5-6 cm, passed strictly in the middle of the vil edge of the intestinal loop.

After completing the anastomosis application process, from the operative wound, twist all the servettes and vibrate the retinal revision black empty: They see the shelter, which was bought up, reconsider the reliability and tightness of the sutured 12-palate bowel, assess the quality of ligation of blood-bearing vessels.

Then the anastomosis is sewn to the edges of the bridle crosswise colon And, oh, at your heart, fix with 4-5 knotted seams to the side of the shlunka in the open back through such a rosette, but between the stitches there are no great gaps, I will look at those who lack fixation is fraught with penetrating intestinal loops in fine їх obmezhennya. For this purpose, as an anastomosis of the anastomosis, the transverse colon is lowered back into the empty intestine and the wound of the intestinal wall is sewn up tightly and tightly.

Shown before shlunk resection

absolute: evil new affirmations shlunka, pidose on malignant degeneration of the turn, repeated turn of bleeding, stenosis of the collar. indications: pre-city non-destructive twists and turns of the slunk and 12-bowel (especially in young people), perforated twists with a good stance of the ailing, but nad_yshov in the first 6 years I have gone to cut.

If the resection is carried out with the drive of the swelling ailment, then in the case of recurrence, the incisor 2/3 - 3/4 of the length of the shlunk at once with the pyloric release. With a small amount of resection, the main meta - a decrease in the secretory activity of the kuksi shlunka, can not be reached, which can lead to a recurrence of the bend or the establishment of the bend of the jejunum. In case of cancer of the shlunk, 3/4 - 4/5 of the shlunks are seen, one can see the subtotal organ, or they can develop gastrectomy with malim and great omentums. The dissection of the resection does not expand only for the burrow of the shlunk itself, but for the preparation of regional lymphatic collectors, where the metastasis of the chin is more likely.

The operation includes 2 main stages:

1) hanging of the reduced part of the shlunk (vasne resection of the shlunk), moreover, it was possible to see the zone of the shlunk, in which it was secreted ha-Strin, for the reduction of acidity and quantity of shlunk juice;

2) uninterrupted update shlunkovo-intestinal tract by way of imposing-nya anastomosis between the slunk and twelve-fingered or the thin intestine.

See the resection of the shlunka

􀀹According to the amount involved: economical - viewable 1/3 - 1/2 slunk tube size, large - viewable 2/3 of the slurry tube volume, subtotal - viewable 4/5 slunk tube size, total - 90% viewable slunk tube size.

􀀹By a bit of evidence: distal resection (visualization of the distal cavity of the slunk), proximal resection (visualization of the proximal visualization of the slurry at once from the card), pilorectomy, anthrumectomy, cardiac

With a large slunk resection, the level of the small curvature is 2.5-3 cm distal to the travoduct; on the great curvature of the line, go to the lower pole of the spleen, at the stage of the 1st short slunk artery, and go to the slurry in the storehouse of the slurry-spleen connection. When resecting 1/2 of the slunker, the small holes are raised at the level of the entrance to the slunker of the 2nd ventricular artery; the great curvature is raised at the mice, de anastomoses between themselves of the offense of the shlunkov-cap artery. Antrumectomy, along the lines of the line, allows the change in size to be seen in the body in case of shlunkovy viraztsi, rostashovaya visoko. According to the method of restoring the absence of interruptions to the shlunkovo-intestinal tract, all the developmental options for resection of the shlunks can be represented by 2 types:

Operational resection of the slunk based on the principle of renewal of the processes of direct gastroduodenal anastomosis for the Bilrot-1 type;

Operations resection of the slunk, based on the principle of gastroenteroanastomosis stemming with unilateral 12-palate bowel movements of the Bilrot-2 type.

slunk mobilization

Razkrivayut top middle rozryzom. Mobile-connection of the shlunka on the great curvature of the connection. I repair from the middle third of the great curvature in a courtless space between the shlunkov-omentum arteries. At the openings of the holes, introduce the vignutius zatiskach and overwhelm to lay the hand on the bell. Distal to the 1st lock, apply the 2nd and the overwhelmed part of the shlunkovy-rim links scatter. So, in small portions, they can mobilize a great curvature up to and including the upper third of the shlunka, sounding a courtless bow-stick of great curvature in the proximal right. It is especially necessary to pay special attention to them when mobilizing the gatekeeper part of the slunker, t. K. In this hallway, without the middle to the slurry-rim ring, the breeze is attached to the transverse rim intestine to live with the vessels. At the gatekeeper okremo bandage the right shlunkov-omental ar-terii and vein. Having finished the mobilization of the great curvature, proceed to the mobilization of the small curvature of the slunk. Let us zignutym zatiskachom, hold behind the slag, loosen the openings in the unarmed seat of the small omentum, and then, using the small omentum with the help of the small glands, we open it up to the left. With the mobilization of a small curvature of the slurry, it is necessary to avoid the use of additional furnace arteries, as it is not often seen to go to the other slunk arteries (A. Gastrica sinistra) and straight to the left side of the oven. The main point of this stage is to get involved in the ligation of the slunk artery in the slunk-and-slunk artery. For the slug arteries of the shlunkovoi artery of the shlunks, the swelling is significant; right side of the small omentum with passing through the right slunk artery. We help to promote the mobilization of a small curvature in the area of ​​the collar, de-tie and overturn the right artery and vein. Yakshko rezhek-tsiyu shlunka is transferred to the viconati for the type Bilrot-1, in the number of vypadki it is necessary to mobilize the 12th intestine according to Kocher.

Mobilization of the 12 intestine

For the whole opening of the anterior and posterior leaves of the shlunkovo-rim ligament i, pulling the pyloric view of the slurry up the hill, expose the jugs of the right shlunkovo-omental artery of the 12th vein until the very first Їx re-tie with clamps and bandage. Re-mash the shlunkovy-rim link vyroblyayut lower the shlunkov-omentum arteries with a bandage of the omentum gland arteries. At the same time with the great omentum, lower the popi-river colon into the empty gland and, pulling the slurry up the hill, re-tie a sprinkle of other throats for the back wall of the 12-palate intestine, until the end of the period.

Shlunk resection behind the Bilrot-1 type

For mobilization of the slunk, start the distal cordon of the slunk. In all cases, it is guilty of passing below the collar, which is due to the characteristic draining of the wall at the viglyadi of the roller and of the Mayo's frontal vein, so that it passes through the pepper straight through the axis of the slurry. Apply intestinal pulp on the 12-palate of the intestine below the collar. Spreading pulp is placed on the collar and with a scalpel to rewind 12 pallets along the upper edge of the seal. On the middle one-third of the shlunyuyut pulp Pair і parallel to yom 2 zip. When the shlunks are fed to the 12-palate intestine, having entered the pulp by 0.7-0.8 cm, sew with serous-oily sutures the back wall of the cannula from the back wall of the 12-palate intestine. The threads of the overlapping seams are drawn, behind a vignette of the extreme, which, in the case of an anastomosis applied, serve as holders. We use the slurry to re-flow between the pulp and the preparation. On a small curvature of the visce, if you have lost the pulp, apply a seam-holder and open the edge of the shlunkovaya stinka at the same time with the upper pulp. A spatula without interruption of a catgut suture is placed on the kuksa of the shlunk, which passes through all the balls of the shlunks, and then the knotted serous-myazovy suture. After skimming the suturing of the upper part of the kuksi, look at the edge of the wall of the slunk and 12-palate intestine under the zhomami. On the back of the lip and the anastomosis, impose a wrong-cut catgut suture, repair the sewing from bottom to top. At the upper edge of the anastomosis, the thread is flooded and continue to put a suture on the front of the lip. On top of the 1st row of seams on the anterior wall of the anastomosis, the 2nd row of serous-myasic seams is placed. At the same time, a special fight comes to respect the suturing of the anastomosis in the upper cuff on the stick of 3 stitches, and the dots of the additional stitches are added to the top. By applying the anastomosis of the thread-holder to see and sew up the defects in the slurry-rim and the slurry-slurry connection.

Straight gastroduodenal anastomosis. According to the methodology, the formulation of a slurry and 12-palate intestine of the type Bilrot-1 through a slurry through the slurry can be divided into 4 groups:

1.gastroduodenal anastomosis for the type of bone in the bone:

At the great curvature of the slunk;

At a small curvature of the slunk;

Zvuzhennyam prosvіtu kuksi slunk.

2. gastroduodenal anastomosis for the type of bone in the bik with the pro-light of the shlunk.

3. gastroduodenal anastomosis for the type of bik in kinets.

4. gastroduodenal anastomosis for the type of bik to bik without cutting off the solution through technical folding.

Resection of the slunk according to Bilrot-1 as modified by Gaberer

When the cutter is cut, it enlightens the yogi kuksi to sound the order of the corrugated seam up to the 12th bowel stake, with the muff, which is put on the type of kinets in kynets.

Neighborhoods and shortcomings . The functional communication operation is the most powerful. A great triumphant operation of the Bilrot-1 type є those who are all involved in flying over the breech of the transverse rim intestine. However, resection according to the Bilrot-1 type in the classical viglyadi vyroblyayut ridko, head rank, through difficult mobilization of the 12-palate intestine and inappropriateness by assigning the slunk and the 12-palate intestine.

Shlunk resection behind the Bilrot-2 type

Investigations of the resection for the type Bilrot-1 and Bilrot-2 polarity:

􀀹 in the zakritta kuksi shlunka method;

􀀹 in the lining of the loops of the small intestine to the shlunk (anterior or posterior gastroenterostomy);

􀀹In the way of rosetting її on the way up to the transverse rim intestine (anterior rim or posterior rim gastroenteroanastomosis).

Classical method of shlunk resection behind the Bilrot-2 type is less historical significance... At the current surgery, you will become vicious in its development.

Shown. Localization of the cicatricial movement in the pyloric or antral appearance of the slunk, the appearance of cicatricial changes in the 12-palate intestine.

Classical method of slunk resection according to Bilrot-2 polyagaє in the offensive insertion of the resection of the gastroenteroanastomosis shlunks after the type of bik in bik.

Hofmeister-Finsterer method- one of the most advanced methods of operation. The essence of the operation of the polyagus in the resection of 2/3 - 3/4 of the shlunka, the suturing of the shlunks to the shlunks through the slightest curvatures from the holes in the viglyadas of the chunks in the illumination of the chicks and the overlapping of the back-to-back ga-construction of the short anastomosis of the petrolysis see view of the Treitz connection by the type of end in the bik with the sieve of the shlunk. At the same time, bring the loop to fix the anastomosis with a stretch of 2.5-3 cm until the new small curvature. Formed by such a rank "spur" is pereshkodzhaє by throwing a corkscrew instead of leading a loop. In addition, when the slunker can be removed and the stump of the 12th intestine is chipped, proceed to the opening of the slunker and the anastomosis is applied. For tsogo on the shlunny along the line of the maybutny overflow impose 2 straight shlunkovyh pulp. One press on the side of the great curvature, and the second - on the side of the small curvature, so that the ends of the beetles were stuck; instructing them to apply a razdavlyuyuy shlunkovy pulp on the removed part of the g-ludka. Then, pulling on the slurry, the surgeon guided the scalpel along the edge to open the pulp and saw the preparation.

If the anastomosis is modified only by a part (approximately 1/3) of the slunk hole, then it is necessary to suture this part, in other words, it is necessary to formulate a new small curvature of the slunk joint. Most of the surgeries sew the kuksa with 2 or 3-row seams. Apply the first seam near the gastric pulp as it is on the 12-palate bowel. Tighten the seam and use a thread to apply a continuous seam through all the balls of the shlunksi into the protylezhny straight. Fixing from the deserted dilyanka, at the slightest curvature put on the 2nd row of high-knot seros-but-myazovy seams, so that the front seam becomes rusted, especially in the area of ​​the upper cut. The threads of the last seam do not see through, but they take it for a grip, a vikoristovuchi yak holder. Having finished the suturing of the upper part of the kuksi shlunka, proceed to the application of the gastroenteroanastomosis. For the whole kuksu, turn the back wall in front of the Kocher clamp, and earlier prepared and passed through the window of the transverse colon a loop of the small intestine, pull the small intestine up to the stump of the slurry, and move the curves in such a low order , and the ledge - up to the great curvature of the rail. Dovzhina to bring the loops from 12-skinny vigina to the cob is not to blame for the anastomosis, 8-10 cm. ... Sew the back wall of the shlunka over the entire width of the anastomosis to the greatest curvature from the wall edge of the small intestine with a bundle of high-knot serous-myazovy sutures. Come out with 7-10 mm seams. See all the shvi, the last one (in the great kriviz-no). It is necessary to move the intestine to the shlunk so that the line of the anastomo passed through the middle of the vital edge of the intestinal loop. At the dermal suture, no less than 5-6 mm of serous and ovarian membranes of the intestine and gall were sealed. All the threads of the thread, behind the vignette of the holders, are visible. For the whole, having entered the line of seams at 6-8 mm and parallel to it, open the intestines for additional gaps, similar to the lining of the slurry. In the gut, I see elektrov_dsmoktuvannyam.

On the posterior lip and anastomosis, impose a continuous catgut suture through all balls of the intestine and the slunk. Dovgoyu catgut nі-ma, repaired from the great curvature, sew the back walls of the slurry and the intestine with a twisted without interruption suture right up to the upper cut of the anastomosis. Make an anastomosis up to the cut, the remaining stitch of the suture is swollen and the anastomosis is sewn together with a thread. At the same time, fix the Shmid seam. When the skin stiffness of the suture is tightened, the stitching of the lacrimal membrane of the slunker and the intestine was zanyuryuvali in the middle of the anastomosis, I suppose with a tweezers. Zastosovuyuchi tsiyom, to reach the lower edge of the anastomosis and move to the anterior wall, de-cob and end-woo threads of the uninterrupted suture knit and add. Minify tools, servetki, wrinkle hands and apply the 2nd row of vuzlovy serous-myasial sutures on the anterior wall of the anastomosis. In order to increase the adductor appearance of the small intestine to the line of seams of small curvature, to prevent the insertion of an anastomosis into the loop and to improve the weakness of the anastomosis. For the whole, 2-3 sutures should be put on, flushing the serous-myaz shell of both sides of the slunk without the middle at the seams of small curvature and leading to the intestine. In case of need, Anastasia-moz should be made with additional high-knot seams in the area of ​​great curvature. Reconsider the passage of the anastomosis and adjust it to the edges of the bridging of the transverse colon. For the whole transverse rim of the intestine, twist from the black empty, slightly pull on the burns, and perform anastomosis in the first place. From the edge of the brigade, make the anastomosis with 4-5 knot sutures with such a rosette until the wall of the shlunk, so that there are no great slits between the stitches. Insufficient fixation of the anastomosis can be the reason for the penetration of the loops of the small intestine in the window of the breech with a further utterance.

Sposib Raichel-Polia zasosovyut schob uniknuti stenosing vi-go from kuksi shlunka. The essence of the operation is in the overlapping of the posterior-buttocks gastroenteroanastomosis with the help of the lining of the shlunka and the short loop of the small intestine (by the type of end-to-end) on the 15 cm of the Treitz ligament.

Resection of the slunk according to Bilrot-2 in the modification of Spasokukotsky

After resection of the slunk 1/3 of the hole in the side of the small curvature is sewn and on the sieve of 2/3 of the chuck, anastomosis is applied in the loop of the small intestine.

Processing of kuksi 12-gut

An important stage of the cuticle resection is the suturing of the 12-palate bowel. When the operative sutures are loose on the part of the 12-palate bowel, the seizure is 90%, and only in 10% of the cases, the sutures of the gastroenteroanastomosis develop inoperability.

1. Sposib doyen - impose a razdavlyuyuy jam, the intestine is ligated with a catgut, pererizayut. Kuksa zanyutsya in a purse string seam.

2. Sposib Shmid - put the Schmid seam screwed in, on top - the Lambert seam.

3. Moinigen-Mushkatin seam - a nasal twisted suture over the clamps, which can be tied into a serous-muffin suture.

A surgical operation, for an hour I see 2/3 or 3/4 of the damaged shlunk, called resection. The procedure is traumatic, so it is recognized only in extreme cases, if you cannot help it. If a slunk resection is performed, then a part of the organ is slightly damaged, and at the same time it is renewed without interruptions between the twelve-fingered intestine and the mucus. Let's take a look at how effective the operation is.

What is the resection of the shlunka?

Resection (visualization) of the shlunk (code for the international classification of ailment K91.1) is required if there is no force conservative methods lykuvannya. It is recognized for patients who have diagnosed cancer, fever ailment, polyp and іnshі ailment of the intestinal tract. The operation on the shlunk is carried out in decilkoh options:

1. A part of the resection of the lower part of the shlunka, if the part is saved, it will be located with a twelve-fingered intestine.
2. Part of the resection of the upper part of the shlunk, if there is a bit of the upper area, the yak is involved in a pathological process, and then it is carried out farther away from the lower part body.
3. Sleeves (later) gastroplasty, This is a type of surgery for stagnation in case of obesity, if you see a larger part of the slunk due to the natural sparing of the two-fingered intestine and the intestinal tract.
4. On the resection of the shlunk, if you see the whole organ, and then there is a detachment between the twelve-fingered intestine and the end portion of the stravohode.

Shown before surgical engagement

Absolute indicators before the resection є malignant swelling of the shlunk, if the operation gives a chance to the sick person for a prolonged life. Lіkarі signify surgical intervention, if you don’t go to hell, the acidity of the slurry juice is lowered or the important scarring changes, which give a brightly twisted picture.

Crawfish cancer

All the organizations of the human body are stored in cells, which grow and move, if new cells are required. If the process breaks down and starts, it doesn’t work in the same way: the clients fix it, if the organism doesn’t need it, and the old cells don’t die. The accumulation of additional clines is added to the fabrics, as they call them chubby or new solutions. The smell can be good or bad (cancer).

Slunk cancer to be repaired internal cells, Ale in an hour to invade the big gliboki shari. In general, puffin can germinate in the middle organisms: stravohid, intestines, fodder zalose, liver. The reasons for the malignant new slunk are added to the number of types:

• nasty food, especially tied to the sinister grease, canned food, fatty and greasy food;
• chicken and alcohol;
• chronic illness of the shlunkovo-intestinal tract: virazka, gastritis;
• spadkova slenderness;
• hormonal activity.

Shlunka vyrazka vyrazka

Virazkoy is the defect of the mucous membrane of the shlunk. Virazkov's ailment is characterized by periodic sharpening, especially in the spring-autumn period. head cause development of getting sick є part of stress, start the robot nervous system, Yaka wiklikє myazovi spasms in the intestinal tract. As a result of such a process, there is a waste in the grating slunk, and shlunkovy sіk supra-lip infusion onto the mucus membrane. Інші factories, scho to produce before development swirling ailments:

• violation of the mode of eating;
• chronic gastritis;
• genetic strength;
• trivial reception of medicines.

In case of chronic damage, the slunk is brought to the mucous membrane of the organ to inspect the reddened defects. Resection of cich pathologies shows up in the development of an accelerated disease, if the effect of conservative therapy is visible, bleeding, development of stenosis. The most traumatic type of surgical involvement in the presence of a shlunk virus, ale and most effective.

Laparoscopic resection for obesity

Laparoscopic surgery is an endoscopic method of surgery on a slunk, which can be seen through punctures in a black empty with a special tool without a wide rosette. Such a resection is carried out with the least traumatic effect for the patient, and the cosmetic surgical result is more beautiful. Indicated before the laparoscopic resection of the slunk is the extreme stage of obesity, since no one is sick, no suvor is not a patient anymore.

In case of obesity, there is a broken exchange of words, and if the process of thinning cannot be controlled, the lickers have to clean up a part of the slunker, because of which ailments are allowed to go away from the problem, it is worse and stepwise to turn to haunted life... Alle the most advanced laparoscopy - the process of renewing the normal exchange of speech, reducing the risk of manifesting atherosclerosis, and ischemic ailments of the heart. Wonder at the video, how the laparoscopic resection of the slunk is carried out:

operation technology

Carrying out the resection of the shlunk is a technically folding process, and the schob does not get stuck with the operation fired, the appearance of cicatrices and the appearance of cicatrices, which should be placed seriously before the vibration medical mortgage and before the quality of surgery. The vibration of the operation technique is to lay down at the level of the organ, I will become sick, yogo vikovyh, anatomical and other features. All types of resections are performed before gallant anesthesia, A triviality prompt engagement I don’t pass three years to the slunk.

The main methods of carrying out the operation

There are no new options for resection and replacement of the shlunks. For the first time, Theodore Bilrot went through an operation in 1881, and in 1885, he proponated another method of updating the slunk-intestinal tract. The entire operation on the slurry will freeze up to the number of feasts, albeit on the current day, the stench of modernization and forgiveness, so that they can be great stake practical surgeons. The type of surgery for the treatment is individual in the skin lesions, and more often it is stasis:

1. Subtotal distal resection, if there is an increase in retouching in the pyloroantral part of the lower third of the shlunks (all small curvature).
2. Subtotal proximal resection, carried out in case of cancer of the 1st and 2nd stages of the shlunk, if there is a malium omentum, lymph nodes, a lesser curvature and a dilation of the great omentum.
3. Gastrectomy, which is carried out for the presence of primordial plump, or for infiltrative cancer, roztasovanim in the middle of the slunk. The whole organ is visible, and an anastomosis is applied between the stravohode and the small intestine.

For Bilrot 1

The resection of the slunk along the Bilrot 1 is the cost of hanging 2/3 of the organ, if the physiological path is taken care of for the participation of the excreta of the slurry and the beetle. After an hour of surgical engagement, it will be necessary to obtain a twelve-fingered intestine and a shlunk to the end. It stagnates in a way in case of polyps, small twists, small crayfish puffs of shlunk antral viddilu.

For Bilrot 2

During resection according to Bilrot 2, a large part of the deaf kuksi of the two-fingered intestine and the slunk, the anterior and posterior anastomosis (two organs) are seen. During the whole operation, the physiological path to ruin is ruined - you can go straight to the worst of the intestine, you can throw it back and break the anastomosis. Resection according to Bilrot is 2 years more significant, so as you can see on the slopes of the slunk, whether it is localization or in case of cancer, some of them give the opportunity to see the organ up to 70%.

For Hofmeister-Finsterer

The Hofmeister-Finsterer technique is a series of modifications of the variant Bilrot 2, which is transferred by resection not less than 2/3 to the organ in case of swollen ailments. Before the hour of the operation, they see the entire secretory zone, for which the function of the slunk is known for significant changes: weak peristalsis, the function of the gate, which will prevent the actions of evacuation, vzagal vipad.

for Ru

Method Ru - the most visible part of the organ with U-podibnym gastroenteroanastomosis. A thin bowel is squeezed into the whole vipad, and the distal end is sewn in and out from the lower third of the shlunkovaya kuksi. The chain of modification Bilrot 2, yaka is indicated for duodenogastric reflux esophagitis, which is characterized by the loss of two bowels in the slunker.

for Balfour

Balfour's way - the tse of imposing a shlunkovo-intestinal connection on the back loops of the small intestine. Tsey method zapobіgaє pathological changes in the organs of the intestinal tract, as well as stagnate with a very high resection from the drive of the sickle ailment, or the unhappiness of the sludge, in the same way through the anatomical peculiarities of the shlunk. Resection according to Balfour lіkvіduє intermediate between the colonies of the small intestine, scho vyklyuchaє in the general diagnosis of intestinal imperfections.

The process of revision of the operation

As a result of any surgical intervention, as well as during the resection of the slunk, there is an increase in the development of negative symptoms: peritonitis, bleeding, anemia, reflux esophagitis, damping syndrome. The average triviality of the patient's transfer to the stationary during the operation becomes 2 to 3 times, and the sickness can sit on the 5-6 day after the resection. For the recommendation of a doctor physical activity she was guilty of being surrounded for a day, and wearing a bandage for 4-6 months later. Outside of the renewal of the functions of the intestinal tract, it takes 3-5 years.

Diet and Harchuvannya Pislya resection

When a part of the shlunk was seen, it was guilty that it was taken into small intestine Then, for an hour, do not expect to see more of the words of the Corinthians. Uniqueness the acceleration of the operation on the slunker to help the offensive rules of grafting:

• take up to 6 times a day;
• I do not keep up, I am reliably overwhelmed;
• obmezhiti gravy, scho to revenge easily in carbohydrates: honey, tsukor, boiled;
• tea, milk, kefir and іnshі napoї slіd live not earlier, not after 30 hviliin pislya yzhі, do not overwhelm the slurry;
• Especially meaningful should be given to the creatures of the big ones, as they take refuge in chicken, eggs, ribs, siri, siri and vitamins, for revenge in vegetables, fruits, berries, herbs.

In the first 3 months of the year for resection, it is necessary to put a special emphasis on harvesting, and at the same time, add the herbal system to new minds. At the end of the hour, you need to live in the house, wipe it or fine-tune steamed products. Recommended herbs: soup with vegetable broth, grated milk porridge, vegetable soufflé, fruit puddings, steamed omelets, unbroken milk, sour cream sauces, German cava with tops and tea with milk.

Zrazkov menu

• 1st day: outside of hunger;
• 2nd day: fruit sour, non-trivial tea, mineral water without skin gas 3 years, 30 ml each;
• 3 and 4 days: egg is not cool, 100 ml of unsalted tea, rice porridge, meat cream soup, vidvar shipshini, sirne souffle;
• 5 and 6 days: steamed omelet, tea with milk, mashed Greek porridge, grated rice soup, steamed meat dumplings, carrots puree, fruit sour;
• 7th day: rice porridge, 2 eggs not cool, sirne souffle without zukru, grated sheep soup, meat steamed cutlets, steamed ribne fillet, potato puree, sour, rusks with white bread.

There is a visible part of the slunk. The principle of clearing in the visible part of the organ and the renewal of the herbal canal by way of the formation of the anastomosis between the shlunkovaya mucus and the twelve-fingered or the small intestine.

See slunk resection

for a large part of the distant part - economy of resection: visible from the third to half of the cutter; large (type): visible two thirds of the slunk; subtotal: visible 4/5 shlunks; total-subtotal: 90% visible to the organ and gastrectomy. Obsyag resection to lay down all the indications;

according to the distribution of the outer part - the pyloroantral: the view of the gatekeeper and cavernous parts; anthrumectomy; distal slunk resection; proximal: visible cardial part; chastkov: visible only urazhenoi part; circular, wedge-shaped resection of the shlunk;

for the method of renewing the passage of the grass rope: operations according to Billroth 1 and Billroth II. When resecting on Bilrot 1, when the distal part of the mucus organ is visible, the slunk and the twelve-fingered intestine should be followed by an additional "end to end". When rezektsії on Bіlrot 2 pіslya vidalennya distalnoї Chastain body Cooksey shlunka i dvanadtsyatipaloї intestine zashivayut and mіzh shlunkom i hudoyu intestine utvoryuyut gastroenteroanastomoz the type of "bіk in bіk." We suchasnіy abdomіnalnіy hіrurgії klasichnі varіanti rezektsії on Bіlrot 1 i Bіlrot 2 tsієї stattі not zastosovuyutsya ...

At the same time, the development of different types of slunk resection is broken down.

Typical modifications of slunk resection options according to Bilrot 2 є methods according to Bilrot, Raichel-Polia, Hofmeister-Finsterer, Balfour, Ru, Moynichen.

showing

Absolute indications: (malignant new conditions, collar stenosis developmental ethology, goodness new, Malignant twists, bleeding, which is uncomfortable for zupiniti with conservative therapy).

Daily indications: (chronic slurry swings, but conservative therapy doesn’t need to be done; twisting in the early term; polyp).

go operations

The position of the sick person: on the back with a roller under the lower edge of the shoulder blades. Quick access: upper middle out sword-like sprout down from the extensions below the navel.

Slunk resection technique... For viznachennya razmіrіv part of the shlunk, yaku planuyut vidalyti, zasosovuyt specially shattered for the whole organization. So, at the cut of the half of the shlunk, 2/3, 3/4 of the opening is a point on the small curvature, like the cord between the upper third and middle third of the shlunk, that is, E. Misciya underneath the side of the hopper in front of the artery. Three lines lead from the point to the right of the great curvature of the shlunk: one - to the cordon between the third and middle third of the shlunkovo-rim link, as half of the shlunka flows out; іншу - up to the middle of the left third of the shlunkovy-rim link, yak viddilya two thirds to the organ; the third line - before the transition of the shlunkov-splenic ligament into the shlunkov-rim, which is seen by the body three times.

Resection of the slurry - the line of rozrizu is carried out from the right pivkol to the stravohode from the transition from the cardio to the great curvature of the slurry-spleen ring and the slurry-rim ring.

For distal resection of the slunk, the following main stages of the operation should be performed:

1 stage of slunk resection - mobilization:

Carry out revision of organs in the black waste, visually start operability. To create a great omentum on all the way from the transverse rim gut, to see the shlunk artery, to tie it with sewing threads, to rewind it with clamps, and to tie it again.

Vidokremlyuyut the great omentum from the proximal views of the great curvature. At the same time it is necessary to rewire and re-tie up the slabs of the slurry of the nozzle, so that it goes through the main stubs of the slurry-stuffing boxes. If you have saved 25% of the proximal opening of the shlunk from the great curvature of the great curvature with the bandage and reclining, do not carry out the shlunk distal to the shlunk.

To know the right of the shlunk artery in the world, de von to go out of the power pechinkovo ​​artery, to rewire it with clamps and to bandage it.

The narrowing of the proximal views of the small curvature raises the slurry-pechink connection, the line of growth propels up the hill, along the trawler, 2 cm proximal to the stravochid-slurry connection. Maliy omentum is pulled out from the stove and pulled down to the bottom, along the pechinko-duodenal ligament.

The release of the small omentum will start at the level of the resection of the organ.

2 stage of slunk resection - opening:

Apply Payr's pulp transversely to the slurry so that the end is located at the point, roztashovan_y 4 cm distal to the stravohidno-shlunkovy z'udnannya along the smallest curvature. Parallel to this and to the trochus proximal, on the side of the great curvature, at the top of 4 cm from the side, apply a paddle, and, with the help of an electric cauter, open a wall of the skimmer.

In order to ensure that the line of the slurry wall will be brought up to the point of the first slurry, apply another clamp, so that the slurry will be 2 cm distal from the stravohidno-slurry drainage, then we will tighten the slurry.

The anastomosis scars should be molded with single-row vuzlovy serous-myazovy sutures, it is necessary to reach hemostasis for additional retinal cauterization of the lineage, so that a clear scab appeared, which widened the bisque behind the anastomosis.

We will put the thick part of the shlunk on it with a tamped Payr, and with a great omentum, drive it up the mountain, baking it into the proximal end of the two-fingered intestine. Distal to the collar on the intestine, impose two lugs, and then re-use the electrocauter for help. Writing the preparation is seen from the operative field.

When a gastroduodenoanastomosis is formulated after a modified method, Bilrot 1 is used to determine the onset of the stage of the operation.

Stage 3 of the slunk resection - the form of gastroduodenoanastomosis:

To fix the small curvature of the kuksi behind the additional row of vuzlov serous-myazovy seam seams No. 000, superimposed on top of the seal. Lastly, knit tsi shvi, step by step, take the jam, the line of the seam is screwed into the middle. When the seams are laid on, they see a lull with a slide, and the coagulative mucus shell gets screwed in by the cym sutures. Nizhniy zatiskach not seen: nadal vin bude vicoristany for the formation of gastroenteroanastomosis.

Apply two seams on the side of the small and large curvature. On the side of a small curvature - a spatula on the shlok in a transverse straight line to the edge of the molded small curvature. and then on the gut of two hundred and twenty, the bridle of the axis. On the side of the great curvature is the bridle of the yak kuksi, and the twelve-fingered intestines.

In order to see the mobilization of the two-fingered intestine, weaken the tightness of the formed anastomosis. To shape the gastroduodenoanastomosis with vuzlovy serous-myazovy suture sutures, applied to the back wall of the kuksi and twelve-fingered intestines.

The zatiskachi turn so that you can lay the front row of seams on top. Pidtyaguyuchi threads of the front row of seams, viymaut zatiskachі, tie seams; at the end of the anastomosis, screw it into the glib.

At the point, de kutoviy seam of low curvature (Hofmeister's seam), overlap with the line seam anastomosis, apply another seam, from one side transversely to the line seam of small curvature (on the bowel), in the lower part of the anastomosis Tsei priyom pidsiluє screwing up the miscibility of two welders and changes in the incapability of anastomosis at the same point.

Sew up the empty ends and drain if necessary.

In case of post-colic gastrojejunostomy anastomosis after a modified method, Bilrot 2 should be noted onset of the stage of surgical intervention:

3 stage of the slunk resection - the close of the kuksi of the two-fingered intestine:

The cult of the twelve-fingered intestine in typical vypadki is sewn up using the Moynikhen-Mushkatin method. For a whole lot of drowning її rozchavlyuyut with intestinal tamping, apply a twisting seam, slightly tightening the thread. The jam is carefully opened and seen, the thread on the cult is tightened. Pull the thread and squeeze the bowels of the intestines and the phalanges great fingers, Tie її on a thread in the folds and tie the knots. Apply an extraordinary seam chain suture from the bores of the two-fingered bowel.

In case of short and cicatricial changes in the cult of the twelve-fingered intestine, there is a folding to the plastic method of clotting (according to KS Sapozhkova, S.S. Yudina, A.A. Shalimov).

Stage 4 of the slunk resection - the form of gastrojejunostomy:

Cult dance with a narrow loop of the proximal small intestine. By sending the rosette to pull out the links (Treitz; shown by the dashed line), the mobile part of the small intestine expands the brisket of the transverse rim intestine, which is unique to the lining of the court arcades.

Crosswise the line of seams of small curvature, put another seam on the slink, and also on the small intestine, then screw the two seams together and prevent them from being able to be found in the same point.

Gastrojejunoanatomiasis fixes in the opening of the breech of the transverse rim of the intestine.

Proximal resection of the shlunk is performed when the shlunks are newly approved, as they switch to stravochid, cardiological and subcardial changes and new solutions. Before the hour of the operation, a slight curvature is seen more often, and the stravochid is resected at the site of 3 cm from the top of the neoplasm in case of advanced forms of cancer and 5-6 cm - in case of infiltrative. In addition, I see an omentum injury, shlunkov-splenic, shlunkov-pidshlunkovu ligaments and klitkovin, which will drain the cardio and resected part of the stravohode.

a) Shown for resection of the slunk according to Bilrot II (gastrojejunostomy):
- Vidnosnі is shown: how the stem of the gastroduodenostomy is ill-advised for anatomical reasons.
- Alternative surgery: Bilrot I, so called combined resection, gastrectomy.

b) preoperative training:
- Preoperative pre-surgery: transabdominal and endoscopic ultrasound dosage, Endoscopy from biopsy, X-ray of the upper views of the intestinal tract, computer tomography.
- Preparing a patient: nasogastric tube.

v) Specific risks, according to the year of the patient:
- Poshkojennya, splenectomy (0.5% vypadkіv)
- Bleeding (2% of blood pressure)
- homologous blood transfusion
- Inability to anastomosis (gastroenterostomy - in 1%, duodenal intestine - in 2% of cases)
- Loop collapse (5-15% of vapors; dumping syndrome, lead loop syndrome)
- Possibility of the zagalny zhovnoy channel
- Secondary rim artery
- Virazka anastomosis
- Cancer kuksi shlunka
- Pancreatitis (less than 2% of vipads)

G) sun love... The place of zebooluvannya (іntubatsіya).

e) the position of the patient... Lying on the back.

e) access... Upper middle laparotomy.

g) The stage of slunk resection according to Bilroth II:
- gastrojejunostomy according to Billroth II: back seam
- gastrojejunostomy according to Billroth II: seams of the anterior wall
- Billroth II: Brown enteroenteroanastomosis
- Bilrot II with Brown's enteroenteroanastomosis

h) Anatomical peculiarities, serious studies, operative priyomy:
- The bottom of the slunker and the spleen (short slunkers), the curvature and the transverse rim of the gut / її breeze are great, distal view small curvature and hepatic-duodenal ligament, as well as the posterior wall of the slunker and the lactiferous zalosa roztasvani close one to one.
- Isnu kіlka of important vindicators: between the slunk arteries and the right slunk arteries from the chink arteries - the curvatures of little curvature; mіzh lіvoy shlunkovo-omental artery from the spleen artery and lіvoi shlunkovo-omental artery from the shlunkovo-omentum artery - bridle of great curvature; mіzh short cinder arteries from the spleen artery - in the area of ​​the bottom of the slunk. An important venous stovbur of a small curvature (vintseva vein of the shlunk) flows into the vortic vein.
- Remedy: Vіdriv Sudin.
- Approximately in 15% of vypadkiv in the small omentum there is an additional liva pechinkova artery, which is also seen in the lesser omentum.

і) Come in with specific expeditions:
- Shrinkage of the gum duct: apply the first suture, soak it dry with material (4-0 PDS) when the T-shaped tube is inserted.
- Shielding the spleen: try to save the spleen by way of hemostasis by electro- / sapphire / argon plasma coagulation and application of hemostatic material.
- Rose of the duodenal fistula: if it is not a matter of reapplication of the overlapping seams, then if you don't want to slip into the Y-like skinny loop along the Roux, or open the duodenal fistula with a gate of the introduction of the katstoy (pastoral) omentum and insertion of the catheter through the cranial wall.

To) Pislyoperatsіyniy look for the resection of the slunk according to Bilrot 2:
- Medicinal look: I saw the nasogastric tube for 3-4 days, I saw the drainage for 5-7 days.
- Renovation of food: small sips of pure birth in 4-5 days, firm їzha - for the first self-styled style.
- Intestinal function: cleansing from the 2nd day, oral delivery - from the 7th day.
- Activation: immediately
- Physiotherapy: dikhal right.
- Period of inconsistency: 2-4 times.

1. Gastrojejunostomy according to Billroth II: tailoring of the back... The renewal of the discontinuity of the gastrointestinal tract for the resection of the slunk can be done by the route of gastrojejunostomy according to Billroth II. For the whole shlunnye Anastomoses with the loop of the small intestine, the yak is carried out in front or backward. The anastomosis is repaired from the back wall, with three sutures (3-0 PGA). The width of the anastomosis is to blame but is approximately two times greater than the width of the lumen of the duodenal intestine.

2. Gastrojejunostomy according to Billroth II: front seams... After completing the back line of seams, the front flap is folded along with the seams. I especially respect the approach to the process of closing the shlunkovo-intestinal anastomosis and resected small curvature. Insulation of the gum flap of the shlunka and the edge of the anastomosis is closed with U-sutures. In this case, it is possible that the anastomosis in the so-called "code of sorrow" is not possible.

3. Bilroth II: brown enteroenteroanastomosis... In case of more skinny loops, it is necessary to impose an enteroenteroanastomosis according to Brown in order to bring and introduce the loops. Anastomosis can be made by hand or hardware suture.

4. Bilrot II with Brown's enteroenteroanastomosis... Renovation of the smoothness of the gastrointestinal tract by resection of the slunk after an additional anastomosis according to Bilrot II, including the closure of the duodenal bowel and the imposition of Brown's enteroenteroanastomosis in the anterior obstruction.

5. Video of slunk resection technique according to Bilroth 2 .