Operative approaches to the abdominal organs

When diagnosing dangerous intestinal diseases, the patient is advised to undergo surgery on the colon. Exist different kinds resections that are used for a particular disease. What kind of preparation does a patient need before this serious procedure, how are operations performed and what are the consequences after surgery?

At dangerous diseases The large intestine undergoes surgery, which includes several techniques, depending on the disease.

Indications for testing

When a doctor decides to perform an operation on the large intestine and remove part of it, there are serious reasons for which it is dangerous to delay. There are many diseases that affect the intestines. One of their most dangerous signs is intestinal obstruction, including the rectum, in which the contents of the intestine cannot move normally through this part of the digestive tract due to obstructions formed there. The reasons for this condition are various:

Tumors, inflammations, and ulcers in the large intestine may require surgery.

1. Tumor of benign etiology. These are polyps that grow on the mucous membranes of the walls of the organ, while closing the lumens of the intestine, as a result of which the function of moving food through it is lost. Typically, benign tumors do not pose a danger to humans; if they are detected, you should be regularly monitored by a doctor. However, some types of them develop into malignant neoplasms, and then removal of the colon will be required.
2. A tumor of malignant etiology is colorectal carcinoma, which is life-threatening for the patient. When it is diagnosed, the tumor is removed from the patient. If it has grown to a large size, the patient has problems with stool, constant pain in a stomach. In this case, surgery is the main hope for a favorable outcome; the tumor is removed and the person can live a long time.
3. Diverticulitis, which affects the large intestine, is characterized by the appearance of pouch-shaped protrusions on the organ. The cause of the disease is poor nutrition, bad habits. These protrusions can become inflamed, leading to painful sensations, internal bleeding. Surgical treatment of the disease is carried out in cases where diverticulitis has recurred more than 2 times. Chronic inflammatory processes on diverticula and their rupture lead to the formation of purulent peritonitis, so the tumor is removed immediately.
4. Crohn's disease, in which a person has chronic inflammation intestines. The disease develops in the small intestine area, and if not detected and treated in time, the disease will spread to the large intestine. Surgical surgery for such a disease does not bring results; intervention is carried out only when the mucous membranes of the intestine are severely affected and there is a high risk of rupture.
5. Ulcerative colitis is an inflammatory disease whose cause is unknown. Doctors say that one of the factors is poor nutrition. The disease is cured through surgery and the affected areas are removed.

Types of colon surgery

Radical

Surgical surgery applicable to the colon is indicated only after a complete diagnosis and doctor’s decision.

A radical operation is performed when the patient has cancer or an inflamed part of the intestine removed. Modern medicine also offers laparoscopic operations, in which a small incision is made, and through it, using a video camera, the doctor detects the affected area and removes it. Laparoscopic surgery is less dangerous and the person recovers quickly. In this case, the patient undergoes postoperative therapy aimed at complete cure from illness. For the operation to be successful, special preparation is required. Preparation consists of following special diet and proper nutrition, taking medications that will help the patient recover faster in the postoperative period.

Palliative

When an organ is completely affected by a tumor, neighboring areas and lymph nodes are affected, radical surgical intervention is most often not recommended for a person, since the body is not subject to full restoration and the patient may die. In this case, palliative surgery is indicated, which is divided into two methods:

Palliative measures of the colon are used in case of irreversible destruction in the organ.

• In the first case, the operation does not eliminate the consequences of oncology and the tumor itself. It is aimed at eliminating discomfort during nutrition through gastroenteroanastomosis (connection of the stomach with the small intestine). This makes it easier drug therapy, since the body is weakened due to dysfunction of the organ.
• In the second case, at the last stage of oncology, complete removal tumor focus using palliative surgery, palliative gastrectomies. This type of surgery gives a chance to improve the patient’s health after a course of chemotherapy and radiotherapy. In this way, the tumor is reduced, the patient is less susceptible to intoxication, the problem of obstruction is solved, and with oncology with metastases, the patient can live longer.

Colectomy

During a colectomy, also called a Hartmann operation, a long incision is made in the abdomen. Then the affected area of ​​the colon is removed, and the incision site is stitched. When part of the organ is removed, the surgeon creates a colostomy. He leaves a small hole in the anterior wall of the peritoneum - a stoma, and then removes the open end of the intestine through it. Such a hole may be temporary, but in severe illness it remains forever. Next, the surgeon closes the muscle and peritoneal tissue with sutures. After Hartmann's operation, postoperative manipulations are performed on the patient, and the excised section of the intestine is sent for histological examination. Indications for Hartmann's operations are:

1. suspicion of the development of a cancerous tumor or benign tumor;
2. Stage 2-3 cancer, when intestinal resection will bring results;
3. progression inflammatory processes in the colon, when drug treatment has not brought positive results. Hartmann's operation will help eliminate the disease.

Relevance of the topic:

Lesson duration: 2 academic hours.

General goal:

Logistics of the lesson

2. Tables and models on the topic of the lesson

3. Set of general surgical instruments

Technological map for conducting a practical lesson.

No.	Stages	Time (min.)	Tutorials	Location
1.	Checking workbooks and students’ level of preparation for the practical lesson topic		Workbook	Study room
2.	Correction of students' knowledge and skills by solving a clinical situation		Clinical situation	Study room
3.	Analysis and study of material on dummies, corpses, viewing demonstration videos		Dummies, cadaver material	Study room
4.	Test control, solving situational problems		Tests, situational tasks	Study room
5.	Summing up the lesson		-	Study room

Clinical situation

IN surgery department A patient was admitted with a closed abdominal injury. According to emergency indications, a median laparotomy was performed. During the audit of organs abdominal cavity Bleeding from the vessels of the mesentery, separation of the mesentery from the wall was detected small intestine.

Tasks:

1. What is the surgical tactics of the surgeon?

2. What methods of resection of the small intestine are known?

The solution of the problem:

1. Stop bleeding from the mesenteric vessels, perform marginal resection of the small intestine, restore the integrity of the intestine with end-to-end anastomosis.

2. Regional and wedge-shaped.

Intestinal suture and types of anastomoses

Most operations on the organs of the gastrointestinal tract are one of the following types in nature: opening (tomy) with subsequent suturing of the cavity, for example, gastrotomy - opening of the stomach: fistula (ostomy) - connecting the organ cavity through an incision in the abdominal wall directly with external environment, for example, gastrostomy - gastric fistula, colostomy - colon fistula, cholecystostomy - gall bladder fistula: application of an anastomosis (anastomosis) between parts of the gastrointestinal tract, for example, gastroenteroanastomosis (gastroenterostomy) - gastrointestinal anastomosis, enteroenteroanastomosis - interintestinal anastomosis, cholecystoduodenostomy – anastomosis between the gallbladder and duodenum; excision of a part or an entire organ (resection, ectomy), for example, intestinal resection - excision of a section of the intestine, gastrectomy - removal of the entire stomach.

Intestinal suture used on all organs whose walls consist of three layers: peritoneal, muscular and muco-submucosal. An intestinal suture is used to close wounds of these hollow organs, both of traumatic origin and mainly those made during surgery, for example, when applying anastomoses (ostia) between different parts of the intestine, between the intestines and the stomach.

The main types of intestinal sutures are presented in Fig. 3-14.

Rice. 3. Jobert's seam (Jobert, 1824)

Rice. 4. Pirogov’s seam (1849)

Rice. 5. Schmieden seam

a - general view, b - thread progress, c - contact of cell membranes after tightening the thread.

Rice. 6. Through marginal intestinal suture of Gambi

(From: Kirpatovsky I.D. Intestinal suture and its theoretical foundations. - M., 1964.)

Rice. 7. Connel seam

(From: Littmann I. Abdominal surgery. - Budapest, 1970.)

Rice. 8. Reverden-Multanovsky seam

(From: Schmitt V.V., Hartig V., Kuzin M.I. General surgery. - M., 1985.)

Rice. 9. Continuous furrier's intestinal suture

(From: Littmann I. Abdominal surgery. - Budapest, 1970.)

Rice. 10. Lambert's seam (Lembert, 1825)

Rice. 11. Purse string stitch (Doyen)

Rice. 12. Z-shaped seam

Rice. 13. Double-row Albert stitch

(From: Kirpatovsky I.D. Intestinal suture and its theoretical foundations. - M., 1964.)

Rice. 14. Double-row Cherny stitch

a - general diagram, b - application of the second row of sutures. (From: Kirpatovsky I.D. Intestinal suture and its theoretical foundations. - M., 1964; Simich P. Intestinal surgery. - Bucharest, 1979.)

When applying an intestinal suture, it is necessary to take into account the case structure of the walls of the digestive tract, consisting of an outer seromuscular layer and an inner muco-submucosal layer. We must also keep in mind the various biological and mechanical properties of their constituent tissues: the plastic properties of the serous (peritoneal) layer, the mechanical strength of the submucosal layer, the tenderness and instability of the epithelial layer to injury. With an intestinal suture, layers of the same name should be connected.

Currently, the two-row, or two-tier, Albert seam is generally accepted. , representing a combination of two types of intestinal sutures: through all layers - serous, muscular and mucous membranes - the Jelly suture and the serous-serous suture of Lambert .

With Lambert's serous suture on each of the walls being stitched, an incision and puncture is made through the peritoneal integument of the walls; To prevent the suture from cutting through, the muscular layer of the intestinal wall is also captured, which is why this suture is usually called serous-muscular.

The Jeli (or Cherni) seam is called internal. It is infected, “dirty”, Lambert’s suture is external, uninfected – “clean”.

The internal (through) suture, passing through the submucosal layer, provides mechanical strength. It does not allow the edges of the intestinal incision to diverge under the influence of peristalsis and intraintestinal pressure. This suture is also hemostatic, because captures and compresses large blood vessels in the submucosal layer.

The external seromuscular suture creates a seal: when applying it, the main condition is wide contact of the area of ​​the peritoneum adjacent to the wound; Thanks to its reactivity and plastic properties, in the very first hours after the operation, gluing occurs, and subsequently, a strong fusion of the stitched walls occurs. Under the protection of the external suture, the process of fusion of the internal layers of the intestinal wall occurs.

Inseam, which comes into contact with the infected contents of the intestine, must be made of absorbable material (catgut) so that it does not become a source of a long-term inflammatory process in the future. When suturing the edges of the seromuscular layer, a non-absorbable material is used - silk.

When applying an intestinal suture, it is necessary to ensure thorough hemostasis, minimal trauma and, mainly, asepticity.

The generally accepted two-row seam in most cases satisfies these requirements. However, in some cases complications arise: insufficiency of the suture, development of a narrowing in the anastomosis (stenosis), adhesions in the circumference of the anastomosis. The processes accompanying the healing of an intestinal wound and the fate of sutures have been little studied until recently. Modern research revealed serious disadvantages of a through intestinal suture: such a suture causes severe trauma to the mucous membrane, its necrosis, rejection with the formation of defects - ulcers that penetrate deeply into the intestinal wall. The tortuous suture channel serves as a route for infection to penetrate deep into the intestinal wall; As a result, an inflammatory process develops in the tissue shaft protruding into the lumen of the anastomosis from all three layers of the intestinal wall and wound healing occurs by secondary intention. Epithelization and formation of glands are delayed up to 15-30 days instead of 6-7 days as normal, and the stitched areas turn into a rough, stubborn scar. For normal healing of an intestinal wound, it is necessary to abandon the traumatic end-to-end suture: the layers of the intestinal sheath must be connected separately, independently of each other. An isolated suture of the submucosal suture - a submucosal suture or submucosal suture with mucosa - is provided under the condition of a gentle technique, i.e. without the use of clamps, with only the very edge of the mucous membrane taken into the suture, the absence of necrosis, primary intention, the formation of a gentle linear scar within 6-9 days and the rapid disappearance of the tissue shaft protruding into the lumen of the anastomoses.

Rice. 15. Types of intestinal anastomosis

a - end to end, b - side to side, c - end to side. (From: Littmann I. Abdominal surgery. - Budapest, 1970.)

The imposition of end and lateral anastomosis is used for resection of the small intestines, when connecting the stomach with the intestine, and the application of bypass anastomoses on the large intestines.

The third type of anastomosis is end to side, or “terminolateral”, is used during resection of the stomach, when its stump is sutured into the side wall of the small intestine, when connecting the small intestine to the large intestine, when connecting the large intestines to each other after resection (Fig. 18).

Rice. 16. End to end anastomosis

a - connecting sections of the intestine with Lambert serous-muscular sutures, b - suturing the posterior wall of the anastomosis with a Reverden-Multanovsky suture, c - suturing the anterior wall of the anastomosis with a screw-in Schmieden suture. d - application of Lambert seromuscular sutures to the anterior wall of the anastomosis.

Rice. 17. Side to side anastomosis

a - connecting sections of the intestine with Lambert's seromuscular sutures, b - suturing the posterior wall of the anastomosis with a Reverden-Multanovsky suture, c - suturing the anterior wall of the anastomosis with a Schmiden screw-in suture, d - applying a second row of Lambert's seromuscular sutures to the anterior wall of the anastomosis. (From: Kotovich L.E., Leonov S.V., Rutsky A.V. et al. Techniques for performing surgical operations. - Minsk, 1985.)

Rice. 18. Stages of end-to-side anastomosis

Small bowel resection

Indications. Tumors of the small intestine or mesentery, necrosis of the intestine due to obstruction, strangulated hernia, thrombosis of feeding vessels (arteries), multiple gunshot wounds.

Anesthesia. Anesthesia, local anesthesia.

Operation technique. The incision is made along the midline of the abdomen, 2-3 cm away from the pubis, continuing above the navel. After opening the abdominal cavity, the area of ​​the small intestine to be resected is removed into the wound and carefully isolated with gauze pads. The boundaries of resection within healthy tissue are outlined. The section of intestine to be resected is separated from its mesentery, having previously ligated all blood vessels located near the edge of the intestine. Vessel ligation is performed using a Deschamps needle or curved clamps. The mesentery is crossed between the clamps and ligatures are applied (Fig. 19-20).

You can do it differently: make a wedge-shaped dissection of the mesentery in the area of ​​the removed loop, ligating all the vessels located along the cut line. Carefully isolate the surgical field with gauze compresses. The contents of the intestine are squeezed into adjacent loops. A crushing clamp is applied to both ends of the removed part, and an elastic sponge is applied to the ends of the remaining part of the intestine to prevent the contents from leaking out. Then, at one end, the intestine is cut off along the crushing pulp and a stump is formed from the remaining part. To do this, its lumen is sutured with a continuous continuous catgut suture, making each stitch a puncture of the wall from the inside (furrier suture, or Schmieden suture); With this suture, the intestinal wall is screwed inward. The seam starts from the corner, makes a knot there, and ends at the opposite corner with a knot, tying the loop to the free end of the thread.

The stump can also be sutured using a continuous suture. The purpose of such methods of suturing the stump is to make it as less massive as possible and leave as much space as possible for subsequent lateral enterojejunostomy. less dead space. The sutured end of the stump is closed over the top with interrupted seromuscular sutures . You can process the stump even faster by tying the intestine at the place crushed by the pulp with a strong catgut thread and immersing the resulting stump after cutting off in a pouch. This method is easier to perform, but the stump is more massive and the blind end is larger.

Rice. 19. Stages of small intestine resection

a - formation of an opening in the mesentery of the small intestine, b - application of an intestinal-mesenteric suture. (From: Littmann I. Abdominal surgery. - Budapest, 1970.)

Rice. 20. Stages of small intestine resection

a - correct intersection of the intestine (slope of the intersection line from the mesenteric edge to the opposite one), b - incorrect (slope of the intersection line from the antimesenteric edge to the mesenteric edge). (From: Simić P. Intestinal surgery. - Bucharest, 1979.)

After removing the resected intestine, a second stump is formed, the lining napkins are changed and the lateral anastomosis is started. The central and peripheral segments of the intestine are freed from the contents, elastic intestinal sponges are applied to them and the side walls are applied to each other isoperistaltically, i.e. one in continuation of the other, while avoiding their twisting along the axis. The walls of the intestinal loops over a length of 8 cm are connected to each other with a series of interrupted silk seromuscular sutures according to Lambert (the first “clean” suture) ; sutures are placed at a distance of 0.5 cm from each other, moving inward from the free (anti-mesenteric) edge of the intestine. A secondary covering of the stitched intestines with napkins is carried out, and on an instrument table covered with a towel, all instruments are prepared for the second, infected (contaminated), stage of the operation. In the middle of the line of applied serous-muscular sutures, at a distance of 0.75 cm from the suture line, grab the fold of the wall of one of the intestinal loops with two anatomical tweezers transverse to the intestinal axis and cut it with straight scissors through all layers parallel to the line of serous-muscular sutures. Having opened the intestinal lumen for some distance, a small tupper is inserted into it and the cavity of the intestinal loop is drained; after this, the incision is extended in both directions, not reaching 1 cm to the end of the line of serous-muscular sutures. In the same way, the lumen of the second intestinal loop is opened. . They begin to stitch the inner edges (lips) of the resulting holes with a continuous wrapping catgut stitch through all layers (Jelly stitch). The seam begins by connecting the corners of both holes ; Having pulled the corners together, tie a knot, leaving the beginning of the thread uncut. When making a blanket seam, make sure to pierce all layers on each side. To avoid corrugation of the suture line and narrowing of the anastomosis, do not over-tighten the thread. Having reached the opposite end of the holes to be connected, secure the seam with a knot and use the same thread to join the outer edges (lips) of the holes using a furrier's Schmieden seam (second “dirty” seam) . To do this, a puncture is made from the mucous side of one intestine, then from the mucous side of the other intestine, after which the suture is tightened; The edges of the hole are screwed inward. Having reached the beginning of the “dirty” seam, the end of the catgut thread is tied with a double knot to its beginning. Thus, the lumen of the intestinal loops closes and the infected stage of the operation ends.

Instruments are changed, contaminated napkins are removed; hands are washed with an antiseptic solution, intestinal sphincter is removed and the last stage is started - applying a series of interrupted seromuscular sutures (the second “clean” suture) on the other side of the anastomosis . These sutures are used to close the newly placed Schmieden suture. Punctures are made at a distance of 0.75 cm from the line of the “dirty” seam.

Thus, the edges of the anastomosis are connected along the entire length by two rows of sutures: internal - through and external - serous-muscular. The blind ends (stumps) are fixed to the intestinal wall with several sutures to avoid intussusception. After anastomosis, the hole in the mesentery is closed with several interrupted sutures; check the width (patency) of the anastomosis with your fingers. At the end of the operation, the covering napkins are removed, intestinal loops are inserted into the abdominal cavity, and the abdominal wall incision is sutured in layers. One of the negative aspects of lateral anastomosis is that erosions may develop in the mucosa of the blind sacs and bleeding may occur.

When resection of the small intestine, end anastomosis is often used. The first moments of the operation before cutting off the part to be removed are performed as described above. During resection of the small intestine, the central and peripheral ends are cut off along an oblique line: due to this, the lumens are wider and the intestinal suture does not cause narrowing. The intestinal loops are applied to each other with their ends facing the same direction, connected at the edges, 1 cm from the cut line, with silk seromuscular stay sutures and a double-row intestinal suture is applied to the anterior and posterior lips of the anastomosis, as described above for lateral enteroenteroanastomosis .

Particular attention should be paid to connecting the lumens in the area of ​​the mesenteric edge, where there is no peritoneum: for peritonization in this area, the suture should also include a section of the adjacent mesentery.

Currently, special stitching devices are used for suturing, for suturing stumps along the gastrointestinal tract, as well as for the formation of anastomoses. To close the lumen of the intestine, for example, the small intestine - during its resection, the duodenum - during resection of the stomach, the UKL-60, UKL-40 apparatus is used (UKL was originally created for suturing the root of the lung). The device is loaded with tantalum brackets shaped like the letter “P”. Tantalum staples are neutral in relation to tissues and do not cause an inflammatory reaction.

The stapler consists of two main parts: stapler and thrust. On the staple part there is a magazine for staples and a pusher connected to the handle. On the hook of the thrust part there is a matrix with grooves, resting against which, the staples, having passed through the fabrics being sewn, bend and take the shape of the letter “B”. The tissue to be stitched—the intestinal wall—is placed between the matrix of the thrust part and the staple magazine; by rotating the nut these parts are brought together, covering the fabrics to be sewn; the handle is squeezed all the way, while the staples are pushed out of the magazine and stitched; Without removing the device, apply a crushing clamp (Kocher) to the part to be removed and cut off the intestine along the line of the applied device. The device is removed and the resulting stump is immersed with interrupted seromuscular sutures. The duodenal stump is sutured with the same apparatus.

The UKZH-7 device (stomach stump suture) applies a double-row suture with immersion of the first row. Devices for mechanical application of intestinal and gastrointestinal anastomoses have also been created.

Suturing wounds of the small intestine

The abdominal cavity is opened with a midline incision and all intestines are examined; damaged ones are temporarily wrapped in a napkin and set aside. After the inspection, treat the detected wounds sequentially.

For a small puncture wound, it is enough to place a purse-string seromuscular suture around it. When tightening the pouch, the edges of the wound are immersed into the intestinal lumen with tweezers.

Incised wounds several centimeters long are sutured with a double-row suture:

1) internal, through all layers of the intestinal wall - with catgut with the introduction of the edges according to Schmiden;

2) external, seromuscular - interrupted silk sutures are applied. A single-row seromuscular suture can also be used. To avoid narrowing of the intestine, longitudinal wounds should be sutured in the transverse direction.

In case of multiple closely spaced wounds of one loop, it is resected (Fig. 21).

Rice. 21. Scheme of suturing an intestinal wound

A – application of stay sutures;

B – application of a Schmieden suture to the edges of the wound (first row of sutures);

C – application of Lambert sutures (beginning of application);

D – tying Lambert sutures (second row of sutures).

Theoretical questions for the lesson:

1. Definition of the concept of “intestinal suture”.

2. Indications for intestinal sutures.

3. Classification of intestinal sutures.

4. General requirements presented to intestinal sutures.

5. Biological basis of the Lambert seam.

6. Stages of surgical resection of the small intestine.

7. Types of mobilization.

8. Errors and complications during small intestine resection surgery.

Practical part of the lesson:

1. Master the technique of ligating vessels in the mesentery.

2. Master the technique of applying various types of intestinal sutures.

3. Master the technique of applying end-to-end, end-to-side and side-to-side anastomoses.

Questions for self-control of knowledge

1. Classification of intestinal sutures.

2. Which seams belong to the seams of the first row?

3. Name the types of aseptic sutures.

4. Which type of anastomosis is the most physiological?

5. How is the inner lip of the anastomosis sutured?

6. Name the order of sutures on the outer lip of the anastomosis.

7. Indications for resection of the small intestine.

8. When is wedge mobilization of the intestine used?

9. Errors and complications during small intestine resection surgery.

Self-control tasks

Problem 1

A patient was admitted to the surgical department with complaints of sharp pains in a stomach. Objectively: the abdomen is swollen, painful on palpation, tension in the abdominal wall muscles, Shchetkin’s symptom is positive. During emergency laparotomy, thrombosis of the superior mesenteric artery was discovered. List the parts of the intestine in which blood circulation may be impaired.

Problem 2

After surgical treatment and suturing of a wound in the descending colon, a 68-year-old patient developed severe intestinal paresis. On the third day after the operation, symptoms of peritoneal irritation, increasing leukocytosis, and an increase in temperature to 39°C appeared. Specify possible ways spread of exudate in the case of peritonitis resulting from divergence of the sutures of the colon.

Problem 3

During surgery for a strangulated oblique inguinal hernia A loop of the small intestine with signs of necrosis (lack of peristalsis, thrombosis of the mesenteric veins, disruption of the integrity of the intestinal wall) was found in the hernial sac. Due to the discrepancy between the diameters of the lumen of the afferent and efferent loops, the surgeon, after resection of a section of the intestine, performed an interintestinal anastomosis of the “side to side” type, the size of the anastomosis was 2.5 times greater than the width of the lumen of the efferent loop. IN postoperative period intestinal obstruction occurred in the area of ​​the anastomosis. What are the probable causes of this complication, and how can they be prevented?

Standards of correct answers

Problem 1

Blood circulation is impaired in the jejunum, ileum, caecum, ascending colon, % transverse colon and appendix.

Problem 2

The inflammatory process develops in the left mesenteric sinus and can move into the pelvic cavity, into the right mesenteric sinus.

Problem 3

As a result of crossing the circular muscle layer over a long distance, intestinal paresis occurs in the area of ​​the anastomosis with the development of dynamic intestinal obstruction.

Test tasks for self-control

Literature

Main:

1. Kulchitsky K.I., Bobrik I.I. Operative surgery and topographic anatomy. Kyiv, Vishcha school. – 1989. – p. 225-231, p. 254-258.

2. Kovanov V.V. (ed.). Operative surgery and topographic anatomy. - M.: Medicine. – 1978. – p. 342-346, p. 349, p. 356, p. 367-368.

3. Ostroverkhov G.E., Bomash Yu.M., Lubotsky D.N. Operative surgery and topographic anatomy. – Moscow: MIA. – 2005, p. 568-584.

4. Sergienko V.I., Petrosyan E.A., Frauchi I.V. Topographic anatomy and operative surgery. / Ed. Lopukhina Yu.M. – Moscow: Geotar-med. – 2001. – 1, 2 volume. – 831, p. 99-111, p. 186-193.

Additional:

1. Shalimov A.A., Redkin S.N. Atlas of surgical operations on the abdominal organs. // Health – Kyiv. 1965, p. 15-17, p. 321-328.

2. Welker F.I., Vishnevsky A.S. and etc. (Edited by Shevkunenko V.N.) – “Medgiz” - 1951. – p. 340-344, p. 368-376.

Online library

For notes

For notes

TOPIC: “Operations on the abdominal organs. Intestinal sutures. Resection of the small intestine"

Relevance of the topic: The most common complication of surgical interventions on hollow organs digestive system is a failure of the intestinal suture. In this regard, mastering the technique of intestinal suture is important.

Lesson duration: 2 academic hours.

General goal: Study the theoretical basis and master the technique of applying intestinal sutures, intestinal-intestinal anastomoses, and stages of small intestinal resection surgery.

Specific goals (to know, to be able to):

1. Know their anatomical and physiological features of the structure of the walls of hollow organs.

2. Know the basic requirements for intestinal sutures.

3. Be able to apply various types of intestinal sutures and anastomoses.

4. Know the indications for small bowel resection.

5. Be able to conduct an inspection of the jejunum and ileum using Gubarev’s technique.

6. Know the stages of small intestine resection surgery and the technique for performing them.

7. Be able to form three types of anastomosis.

It is a special section of general and visceral surgery, dealing with the treatment of benign, malignant and inflammatory diseases of the small and large intestines, as well as the rectum.

Bowel surgery - overview

The need for surgical treatment of diseases of the small intestine occurs quite rarely. To diseases of the small intestine, the treatment of which is possible through bowel surgery, include adhesion, polyps, Meckel's diverticulum, short bowel syndrome and mesenteric thrombosis (infarction of the intestine). Treatment of the large intestine and rectum is often carried out surgically. A particularly challenging disease in the field of intestinal surgery is intestinal cancer.

Along with the classic open bowel surgery(laparotomy) minimally invasive bowel surgery (laparoscopy) is increasingly being performed.

The branch of medicine, intestinal surgery, treats a large number of diseases and uses a variety of methods for these purposes, and therefore this article presents to your attention only a brief overview of intestinal diseases and possible ways intestinal surgery.

Small Bowel Surgery: Disease Review

The length of the small intestine ranges from 3 to 7 meters, and the intestine itself is divided into:

• duodenum (duodenum)
• jejunum (jejunum)
• ileum (ileum)

IN duodenum chyme (food gruel) coming from the stomach is neutralized. Next, in the small intestine, the largest in area, the digestion products are absorbed (absorption) into the blood. The small intestine, which is attached to the posterior wall of the abdomen through the mesentery (Latin mesenterium), is mobile and receives oxygenated blood through the mesenteric artery. The peritoneum (peritoneum) lines the abdominal cavity with serosa and covers most of the small and large intestine.

Diseases of the small intestine only in in rare cases require surgical intervention. Treatment benign tumors, for example, polyps, or other diseases of the small intestine, for example, Meckel's diverticulitis, is most often performed using a minimally invasive method (laparoscopy). In most cases, part of the small intestine is removed. To treat intestinal obstruction (ileus), it is still necessary intestinal surgery, during which the cause of the obstruction is eliminated, and, if necessary, an artificial anus (colostomy) is applied. In the treatment of very rare malignant diseases of the small intestine or disorders of the blood supply to the intestine, the affected part of the intestine is removed through open surgery (laparotomy).

Short bowel syndrome

When, due to intestinal surgery, a large section of the small intestine is removed and only a small intestine remains active part, we are talking about short bowel syndrome. However, this syndrome can also be congenital. Experts tend to avoid such extensive removal of the small intestine, but sometimes it is unavoidable. Such cases include mesenteric infarction (acute occlusion of mesenteric vessels), cancer of the small intestine, Crohn's disease (chronic inflammatory bowel disease), radiation enteritis (after radiation therapy abdominal area) or intestinal damage.

Adhesion (fusion or sticking together)

Adhesion is the fusion of, as a rule, unrelated organs and tissues, such as the small intestine and peritoneum. In particular, after surgical interventions on the abdominal organs, adhesions occur (the so-called adhesions or scar cord of the abdominal cavity), causing in rare cases stenosis (narrowing) of the intestine and thereby preventing the transport of chyme through the intestines. Most often, fused organs are separated through intestinal surgery, but especially difficult cases partial bowel resection and colostomy are required.

Ileus (intestinal obstruction)

Intestinal obstruction, i.e. cessation of intestinal transit may result from mechanical constipation (eg, due to a tumor or foreign body), adhesions, insufficient blood supply to the intestinal wall (eg strangulated hernia) or as a result of intestinal paralysis). Therapy is prescribed depending on the cause of the obstruction, but in most cases it is not possible to do without intestinal surgery.

Peritoneal carcinomatosis

Peritoneal carcinomatosis, also called peritoneal carcinomatosis or Peritonitis carcinomatosa) is a lesion of a large area of ​​the peritoneum (peritoneum) by malignant tumor cells. As a result, fusion of the small intestine with the abdominal cavity can occur and thus provoke intestinal obstruction. Through intestinal surgery, namely intestinal bypass, an attempt can be made to restore intestinal transit.

Mesenteric infarction (intestinal infarction)

Blockage of intestinal vessels entails an insufficient supply of oxygen to the affected area of ​​the intestine, thereby causing infarction and necrosis (death) of this section of the intestine. If it is not possible to restore blood flow using a conservative method through medications, it becomes necessary bowel surgery, i.e. removal of dead intestine.

Small intestine surgery: surgical treatment methods

Small bowel surgery includes various techniques surgical treatment. Below we present some of them to your attention.

Adhesiolysis in intestinal surgery

Adhesiolysis - dissection of adhesion (unions, scarring, adhesion due to operations, tumors, injuries or inflammatory processes). Adhesion can occur between sections of the intestine, between sections of the intestine and organs, or between the intestine and the peritoneum (peritoneum). There are two types of adhesion:

• Laparoscopic adhesion: in the process of minimally invasive intestinal surgery, the adhesions are dissected using a laparoscope inserted through the abdominal wall.
• Open adhesion: Surgical treatment of the intestine in which dissection of the adhesion is performed after opening the abdominal cavity through an incision in the abdominal wall (laparotomy).

Small bowel resection in intestinal surgery

Resection is an operation on the intestine during which a tumor or some part of the tissue of a certain organ is removed. Thus, in intestinal surgery, the doctor talks about resection of the small intestine when it is necessary to remove part of the small intestine. This type of surgical treatment of the intestine, which is performed both minimally invasive (laparoscopy) and open (laparotomy), is used for:

• Tumors of the small intestine (lipoma, lymphoma)
• Mesenteric infarction
• Necrosis of the small intestine (after ileus or as a result of fusion)
• Crohn's disease (chronic inflammatory bowel disease)
• Atresia of the small intestine (a disorder of the development of the intestine that causes obstruction of the small intestine)
• Damage

Intestinal obstruction (ileus) in intestinal surgery

Surgical treatment of intestinal obstruction means the removal of ileus (intestinal obstruction) by surgery.

Ileostomy in bowel surgery

An ileostomy is the end of the small intestine brought out through a separate opening. During the operation, an ileostomy creates a connection between the small intestine and the abdominal wall, thereby creating an opening for the contents of the intestine to exit. Creation of an artificial outlet of the small intestine may be necessary if the colon has been removed, the patient has diverticulitis, or there is an injury to the abdominal cavity. Depending on what surgeons do with the two ends of the dissected intestine, in intestinal surgery there are two types of ileostomy:

• Single-barrel ileostomy: the end of the healthy intestine is brought out and sutured to the skin.
• Double-barreled ileostomy: the intestine (loop of the small intestine) is brought out through the abdominal wall, an incision is made on top of it and the intestine is tucked in such a way that the two ends of the intestine are visible. This ileostomy is designed to relieve the load on the lower intestine and is usually transferred back into the abdominal cavity after a few weeks.

Closure of ileostomy in bowel surgery

When an ileostomy is no longer necessary, in the field of bowel surgery there is a method for closing the ileostomy, i.e. connection of the two ends of the intestine. After this, the entire intestine again participates in the digestion process.

Meckel's diverticulum in intestinal surgery

Meckel's diverticulum is a protrusion of the wall of the jejunum (jejunum) or ileum (ileum), which occurs in 1.5-4.5% of people. If inflammation of Meckel's diverticulum is suspected, it can be removed surgically.

Whipple operation in intestinal surgery

The Whipple procedure in intestinal surgery, also called pancreaticoduodenectomy or Kausch-Whipple procedure, is the removal of the head of the pancreas, duodenum, gallbladder, common bile duct, two-thirds of the stomach and nearby lymph nodes. Most often, the need for this intestinal surgery occurs when:

• Malignant tumors of the head of the pancreas
• Malignant tumors of the bile duct
• Papillary cancer
• Chronic inflammation of the pancreas (pancreatitis)

Colon Surgery: Disease Review

The colon is the part of the intestine that begins at the ileocecal valve (small intestine) and ends anus. About 6 cm wide and about 1.5 m long, it is divided into:

• ileocecal valve (Bauginian valve)
• cecum (cecum) with celiac appendix (appendix)
• colon (colon) with its ascending (Colon ascendens), transverse (Colon transversum), descending (Colon descendens) and sigmoid parts.
• rectum.

Along with the reabsorption of water and electrolytes, the intestines perform the function of storing feces until bowel movement and protecting against infections. Unlike the small intestine, the large intestine is more often susceptible to diseases that can be treated with intestinal surgery. These include appendicitis (inflammation of the celiac appendix), colon polyps and colon cancer.

Appendicitis (inflammation of the celiac appendix)

Appendicitis is actually an inflammation of the celiac appendix, which is where the large intestine begins. However, it is colloquially called inflammation of the cecum. Typical symptoms of appendicitis are pressing pain in the lower right abdomen, high fever, vomiting and lack of appetite. In most cases, acute appendicitis is included in the scope of medical services of intestinal surgery. Depending on the degree of complexity, the operation is performed open or minimally invasive (“keyhole surgery”). A dangerous complication is perforated appendicitis, i.e. rupture of inflammation into the abdominal cavity (perforation).

Diverticulitis

Diverticulitis is an inflamed hernia-like protrusion of the wall of the colon (diverticulum), most often found in the sigmoid region. Multiple occurrences of diverticula are called diverticulosis. Diverticulitis is usually accompanied by pain in the lower left side of the abdomen, high temperature, nausea and vomiting (especially if perforation has occurred, i.e. a break in the intestinal wall) and leads to peritonitis (inflammation of the peritoneum). Perforation, in most cases, requires immediate surgical intervention. In other cases, surgery to remove the affected area of ​​the intestine is performed after acute phase passed. In particularly difficult cases of sigmoid diverticulitis, when there is perforation and infection of the abdominal organs, sometimes it becomes necessary to apply a temporary colostomy (artificial anus).

Colon polyps and colon cancer

Colon polyps are benign tumors in the form of a mushroom-shaped formation on the intestinal mucosa, ranging in size from a few millimeters to several centimeters. Initially, benign polyps do not cause any complaints, but over several months or years they can turn into malignant tumors (colon cancer). Due to this early diagnosis changes in the colon acquires everything higher value. The most common method of examining the colon is coloscopy, during which polyps of concern can be detected and, if necessary, painlessly removed. In this way it is possible to avoid complex intestinal operations.

When colon cancer (colorectal carcinoma) develops from polyps, open surgery is usually performed and the affected area of ​​the colon, along with nearby lymph nodes and blood vessels, is removed. In most cases, a colostomy is not necessary. Colon surgery is currently undergoing a test phase to remove colon tumors using a minimally invasive method.

Diseases of the rectum

In the area of ​​the rectum (anal canal) there are various diseases, which often manifest themselves through itching, rectal bleeding, foreign body sensation or pain. Due to the easy accessibility of the rectum for examination, its diseases can be detected by inserting the index finger. In addition, other research methods are known in intestinal surgery, for example, measuring the pressure of the anal sphincter (anal manometry), proctorectoscopy, as well as imaging methods ( CT scan pelvic organs and magnetic resonance imaging). Diseases of the rectum include:

• Hemorrhoids (increased volume and blood flow of the veins of the hemorrhoidal plexus located in the anal canal); advanced hemorrhoids, as a rule, are subject to surgical treatment. For this purpose, in intestinal surgery there are several types of surgical interventions that preserve intestinal function (for example, Logo surgery).
• Anal fistula (formation of deep pathological canals (fistulas) between the rectum and skin) and anal abscess (abscess in the anus); in most cases, abscesses require surgical treatment.

Colon surgery: surgical treatment methods

There are various methods of surgical treatment in colon surgery; in the following we will talk about some of them.

Enterostomy (artificial anus, colostomy, unnatural anus, anus praternaturalis) in intestinal surgery

When creating an artificial anus in bowel surgery, doctors create a connection (an opening) between the small or large intestine and the anterior abdominal wall, allowing stool to be expelled. A colostomy is an opening between the colon and the abdominal wall. Just like an ileostomy (see above), a colostomy can be single-barrel or double-barrel. An artificial anus is most often formed as a result. cases:

• for colon and rectal cancer after removal of the rectum
• for severe chronic inflammatory bowel diseases (Morbus Crohn, ulcerative colitis)
• after surgical interventions, in order to unload the part of the intestine that has undergone surgery

Appendectomy

In intestinal surgery, appendectomy is the removal of the celiac appendix (appendix). The need for this operation may arise when acute appendicitis or for tumors of the appendix. Depending on the type of surgical intervention, there are:

• Open (conventional) appendectomy: open bowel surgery in which the appendix is ​​removed through a cut in the skin (laparotomy)
• Laparoscopic appendectomy: A minimally invasive bowel surgery in which the appendix is ​​removed through an endoscope (laparoscopy).

Diverticulum resection (diverticulum cutting, diverticulopexy)

In intestinal surgery, diverticulum resection means surgical removal pouch-like protrusion (diverticulum) of the wall of the colon. Depending on the type of access to the affected area of ​​the intestine, intestinal surgery is distinguished:

• Open resection of diverticulum: classic intestinal surgery, with opening of the abdominal wall
• Laparoscopic diverticulum resection: removal of the diverticulum using an endoscope through a small incision in the abdominal wall
• Endoscopic diverticulum resection: removal of the diverticulum using an endoscope through the anus, during a bowel examination

Interposition of the colon

Interposition of the colon in intestinal surgery means wedging a segment of the colon into another part of the digestive tract (anastomosis). The need for this may arise when the esophagus is removed (esophagectomy) or when the stomach is removed (gastrectomy).

Colectomy in bowel surgery

Colectomy is classic method, used in colon surgery in which the entire colon is removed. Proctocolectomy refers to the removal of the rectum and colon. In bowel surgery, colectomy is the only treatment option ulcerative colitis. This method of surgical treatment is also used in the treatment of hereditary (familial) polyposis.
Operation using the Longo method (Longo operation, stapled hemorrhoidopexy) in intestinal surgery
Longo's operation in intestinal surgery refers to the removal of hemorrhoids or other pathologically changed areas of the mucous membrane using a special set based on a circulating stapler (the so-called stapler). This intestinal surgery is performed through the anus without external wounds.

Operation STARR in intestinal surgery

Operation STARR (stapled trans anal rectum resection) is the removal of part of the rectum using a special device that works on the principle of a stapler. This operation is performed for defecation disorders, anal prolapse, rectocellus or hemorrhoids. Unlike Longo's operation, not only the mucous membrane is removed, but also the intestinal wall.

Photo: www. Chirurgie-im-Bild.de We thank Professor Dr. Thomas W. Kraus for kindly providing us with these materials.

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LECTURE No. 9

Operative access to the abdominal organs. Surgeries on the abdominal organs
Considering that surgical interventions on the abdominal organs dominate in surgical practice, it is necessary to consider the clinical anatomy of the abdomen and the technique of surgical interventions in this area.
1. Clinical anatomy of the abdomen
The boundaries of the abdomen are considered to be at the top - the costal arches and the xiphoid process, at the bottom - the inguinal folds, pubic tubercles and the upper edge of the pubic symphysis. But these formations limit only the anterior wall of the abdomen. The boundary between the cavities of the abdomen and pelvis is conditional and corresponds to the plane drawn through the boundary line. Since there is no anatomical barrier between the abdominal cavity and the pelvic cavity, fluids formed during pathological processes in the abdominal cavity (pus, effusion, intestinal contents), as well as blood from damaged parenchymal organs and blood vessels, often flow into the pelvis, which leads to secondary inflammation of the lining its peritoneum and organs.

According to Shevkunenko, there are two extreme forms of the abdomen in the form of a pear with different orientations of the base: with the base facing upward; with the base facing downwards.

The first form of the abdomen corresponds to a wide lower aperture chest, and the distance between the lower points of the X ribs at the level of the mid-axillary line exceeds the distance between the anterior superior iliac spines.

The second form is combined with a wide entrance to the pelvis. In this case, the distance between the lower points of the X ribs is less than the distance between the upper anterior iliac spines.

The shape of the abdomen with a wide lower thoracic outlet and narrow pelvis is more often observed in people with a brachymorphic physique, the second (narrow thoracic aperture, wide pelvis) - in people with a dolichomorphic constitution. People of brachymorphic physique are also characterized by a high position of the diaphragm and, in accordance with this, the high position of the liver, transverse colon, cecum, attachment of the root of the mesentery of the small intestine is oriented almost horizontally, and the loops of the small intestine take a position close to transverse.

People with a dolichomorphic physique, on the contrary, have a relatively low diaphragm. At the same time, the abdominal organs are located relatively low: there is a relatively low position of the greater curvature of the stomach and a high position of the cardia. The transverse colon sags downward. The liver often protrudes from under the costal arch, the cecum descends into the pelvic cavity. The line of attachment of the mesenteric root approaches the vertical direction, the loops of the small intestine take a position close to longitudinal.

In the position of internal organs, there is not only individual, but also age-related variability. In children of the first years of life, the abdomen is relatively larger in the upper sections, the abdominal wall protrudes into the epigastrium due to the fact that the relative volume of the organs of the upper floor of the abdominal cavity, especially the liver, is much larger in them, and the lower floor is smaller compared to adults . In elderly people and multiparous women, the stomach is in vertical position usually protrudes into lower sections, and in a lying position - in the lateral position, which is associated with a decrease in the tone of the abdominal press and the phenomenon of general visceroptosis.

The shape of the abdomen can change significantly due to pathological processes: fluid accumulation, swelling of intestinal loops due to intestinal obstruction, tumors, hernias, etc.

When studying the abdomen, you need to know the following concepts.

The walls of the abdomen are muscular-fascial layers that surround the internal organs on all sides.

The abdominal cavity is a space lined with intra-abdominal fascia.

The abdominal cavity is a space lined by the parietal layer of the peritoneum, which in the form of a bag surrounds the organs lying inside it.

The peritoneal cavity is a slit-like space between the parietal and visceral layers of the peritoneum, containing a small amount of serous fluid.

The preperitoneal space is a layer of fatty tissue between the parietal peritoneum and the intra-abdominal fascia lining the anterior abdominal wall.

Retroperitoneal space - between the parietal peritoneum and the intra-abdominal fascia lining the posterior wall of the abdomen; it contains organs and large vessels (kidneys, pancreas, aorta, inferior vena cava, etc.). Considering the walls of the abdomen, we conventionally distinguish between the anterolateral wall, bounded above by the costal arches, below by the inguinal folds, on the sides by the continuation of the middle axillary lines, and the posterolateral wall, limited above by the XII rib, below by the iliac crest, and on the sides by the continuation of the middle axillary line. The anterolateral wall is the area through which most approaches to the abdominal organs are made; the condition of this wall (pain, muscle tension, temperature) skin etc.) affect functional and pathological changes in internal organs. The back wall of the abdomen is formed mainly by the muscles that are located along the spine. Anatomically, it belongs to the lumbar region, through which access to the organs of the retroperitoneal space is made.

For convenience, when examining a patient, it is customary to divide the anterolateral abdominal wall into areas using conditional lines.

Two of them are carried out horizontally - through the lower edges of the costal arches and the anterior superior iliac spines. As a result, three sections are distinguished - epigastric, celiac, hypogastric. Then vertical lines are drawn along the outer edges of the rectus abdominis muscles. As a result, each department is divided into three areas:

1) epigastrium – to the epigastric and subcostal areas (right and left);

2) womb - on the umbilical and lateral areas (right and left);

3) hypogastrium - on the pubic and inguinal areas (right and left).

In each of the selected areas of the anterolateral abdominal wall, the corresponding abdominal organs or their parts are projected, but it is necessary to make adjustments taking into account the characteristics of the constitution (body shape), age and gender differences, functional state organs (filling or emptying, spasm or paresis, etc.), body position during the examination.
2. Access to the abdominal organs
To date, many options for accessing the abdominal organs have been developed.

General requirements for access for operations on the abdominal organs.

The first requirement is a good overview of the abdominal organ that is the object of the operation, which is ensured by opening the abdominal wall according to the projection of the organ. The location of the incision determines the shortest path to the exposed organ. The distance from the surface of the skin to the object of the operation, i.e. the depth of the surgical wound, determines more or less freedom of movement and performing the necessary manipulations.

In addition, a good overview of the desired organ is ensured by a sufficient size of the incision (latitude of access). The length of the abdominal wall incision should be as long as necessary and as short as possible. The incision should ensure accessibility of any part of the organ and the feasibility of surgery.

The second requirement for access is low trauma.

This means minimal damage to the muscular aponeurotic layers of the abdominal wall during access to the abdominal organs, preservation, if possible, of neurovascular bundles, careful handling of tissues, etc.

The third requirement for the incision of the anterolateral abdominal wall is the simplicity and speed of the incision.

The fewer layers of the abdominal wall that have to be cut, the easier and faster the incision can be made. This requirement is facilitated by the absence of large vessels in the incision area, damage to which leads to bleeding.

The fourth requirement is the ability (if necessary) to extend the incision in the desired direction (expanding access).

This may be caused by an atypical position of the organ, detection of tumor growth outside the “accessibility zone” during surgery, or detection of pathological changes neighboring organs. The fifth requirement for access is the possibility of reliable closure and good fusion of the edges of the surgical wound.

As a rule, the abdominal wall is sutured in layers after surgery. The smaller the number of stitched layers, the faster this stage of the operation can be performed, but the strength of the scar may be insufficient, especially in the low-vascular area.

When choosing an access, it is necessary to determine in which part of the abdominal wall it is advisable to make an incision.

To expose the abdominal organs, approaches through the anterolateral abdominal wall are most often used. Through this area you can approach almost all abdominal organs in the shortest possible way. In addition, the large area of ​​the anterolateral abdominal wall allows for wide access and provides the ability to extend the incisions in the required direction.

Lateral approaches to the abdominal organs from the sides are used less frequently. They are unsuitable because they violate the integrity of the broad abdominal muscles. In addition, these approaches allow you to operate on organs only on the corresponding side - right or left. They are used in operations on individual organs (spleen, liver, right and left flanks of the colon).

Very rarely, the abdominal organs are exposed from behind - through the lumbar region. This area is small in size, limited by bone formations - the iliac crest, the 12th ribs and the spine, which does not allow large incisions to be made. The soft tissues of this section are of considerable thickness; when accessing the abdominal organs, it is necessary to open the retroperitoneal cellular spaces, etc. Accesses through the lumbar region are used primarily for operations on the pancreas and duodenum, kidneys, i.e., on organs, partially or completely located in the retroperitoneal space.

All approaches to the abdominal organs through the anterior abdominal wall can be divided into two groups:

1) general (universal) accesses, allowing exposure of almost all abdominal organs;

2) special accesses for surgery on one organ or on a group of organs located close to each other.

According to the direction of the incision, approaches of both one and the other group are divided into four types: longitudinal, transverse, oblique, angular (combined).

A typical representative of general longitudinal approaches is median laparotomy. Depending on the length and location of the incision, the following types of median laparotomy can be distinguished: upper median (above the navel); lower middle (below the navel); total median (from the xiphoid process to the pubic symphysis).

Most full review organs is achieved with a median total laparotomy. With upper and lower laparotomy, more limited access is provided, respectively, to the organs of the upper and lower floors of the abdominal cavity.

Median laparotomy has the following advantages: it allows a good overview of most abdominal organs; does not damage muscles when cutting tissue; when performing a median laparotomy, it preserves large vessels and nerves intact; access is technically simple - almost three layers are dissected:

1) skin with subcutaneous tissue;

2) linea alba with adjacent superficial fascia;

3) parietal peritoneum. If necessary, the upper median laparotomy can be extended downward, and the lower median laparotomy can be extended upward.

That is, special access can be transformed into general access. A total midline laparotomy can be supplemented by a transverse incision or a lateral incision at an angle (this approach is called an angular approach).

The disadvantages of median laparotomy include the relatively slow healing of the wound edges due to poor blood supply to the aponeuroses of the broad abdominal muscles along the linea alba. In the postoperative period, the suture line experiences severe stress due to the traction of the wound edges in the transverse direction. In some cases, this can lead to the formation of an incomplete scar and postoperative hernias.

Wide access to the abdominal organs can be provided by performing transverse incisions. A transverse incision of the abdominal wall, made 3-4 cm above the umbilicus from one mid-axillary line to the other, allows examination of most abdominal organs. In this case, the organs lying at the lateral walls of the abdomen (ascending and descending parts of the colon) are especially accessible. It is somewhat more difficult to operate in the upper and lower sections (subphrenic space, pelvic organs). However, if necessary, the transverse incision can be supplemented by dissection of the linea alba. If there is no need for a complete revision of the organs, transverse laparotomy can be more limited both in the length of the incision and in the level of its execution (upper transverse or lower transverse laparotomy).

In transverse incisions, dissection (dissection) of the broad oblique abdominal muscles is performed, and one or both rectus abdominis muscles are also crossed (Czerny approach). With some methods of transverse laparotomy, the rectus muscles can be moved apart (Pfannenstiel suprapubic approach).

Advantages of transverse approaches: preservation of the intercostal neurovascular bundles intact, since the incisions are made parallel to their course; accesses can easily be extended to the lateral side almost to the midaxillary line; the edges of the wound heal well, since the muscle traction perpendicular to the length of the wound is relatively small.

Disadvantages of transverse approaches:

1) relative limited visibility - access allows you to clearly examine the organs of only one floor (upper or lower);

2) labor intensity during dissection and subsequent restoration of the rectus abdominis muscles.

Special access

1. Longitudinal incisions through the rectus sheath.

Paramedian incision. This incision is made over the medial edge of the rectus abdominis muscle, while cutting the anterior layer of its vagina in the same direction. The advantage of this incision is the formation of a durable postoperative scar due to the “rocker” displacement of the rectus abdominis muscle and the discrepancy between the projections of the incisions of the anterior and posterior layers of its vagina.

Transrectal incision (access through the thickness of the rectus abdominis muscle). The incision is made parallel to the outer edge of the rectus abdominis muscle. The muscles of the anterior wall of the vagina are dissected, its edge is retracted medially, and then the posterior wall of the vagina and the parietal peritoneum are dissected. The incision can only be made over a limited extent. When trying to expand access, the intercostal nerves approaching the muscle from the lateral side are damaged.

2. Oblique cuts.

The subcostal oblique incision is widely used to perform operations on the biliary tract and spleen. The incision is made from the xiphoid process downwards and outwards with a bend parallel to the costal arch, departing from it by 2–3 cm. Oblique incisions can also be made in other parts of the abdominal wall, the Volkovich-Dyakonov-McBurney oblique approach.

Angled (combined) incisions of the abdominal wall are used when it is necessary to expand access; sometimes, “combining” a longitudinal incision with an oblique one, a massive flap is formed, allowing a wide view of the corresponding area. Minimally invasive methods of operations performed using endovideosurgical equipment are widely used in modern surgery, which ensures minimal invasiveness and good cosmetic results.

Surgical interventions performed in abdominal surgery can be divided into emergency and planned according to the urgency of their implementation. Emergency interventions can be performed for diseases, postoperative complications or trauma to the abdominal organs.
3. Closed injuries and abdominal wounds
Closed injuries and injuries of the abdomen have always represented a complex surgical problem. In case of damage to the abdominal organs, accurate and rapid diagnosis, thoughtful surgical tactics, adequate therapy. In the structure of peacetime injuries, closed abdominal injuries account for 2–4% of all types of injuries, while the mortality rate ranges from 10–57.5%. The modern period is characterized by a tendency both to a general increase in the number of abdominal injuries and to an increase in the relative number of gunshot wounds. All abdominal wounds are divided into open and closed, penetrating and non-penetrating. Non-penetrating abdominal wounds should be considered damage to the walls (usually anterolateral and posterior) without damage to the peritoneum. Penetrating abdominal wounds are injuries accompanied by damage to the peritoneum.

Closed injuries present significant difficulties for diagnosis. The basis of the clinical picture is the manifestations of shock, internal bleeding(with ruptures of the liver, spleen, pancreas, intestinal mesentery, liver) and peritonitis (with opening of the lumen of a hollow organ). In recognizing internal organ damage during closed injury abdominal puncture, laparocentesis using a “fumbling catheter” and emergency laparoscopy are effective methods.

Abdominal puncture can detect effusion and blood. First performed by Mikulic in 1880 in a patient with suspected perforated ulcer. Exudate during puncture is detected if its amount exceeds 300–500 ml. A typical place to perform a puncture of the abdomen is the middle of the distance between the navel and the upper edge of the pubic symphysis. If blood accumulation in the pelvis is suspected, a diagnostic puncture of the posterior vaginal vault in women or the anterior wall of the rectum in men is possible. The topographic-anatomical prerequisite for performing these manipulations is the position of the peritoneal layer, which from the anterior abdominal wall passes to the upper and posterolateral walls of the bladder, and then (in men) covers the anterior wall of the rectum, forming a depression called excavatio rectovesicalis. In women, the peritoneum, passing from the bladder to the anterior surface of the uterus, forms excavatio vesicouterina, and behind the uterus - excavatio rectouterina (Douglas space). In the lower, deepest part of this space, the peritoneum that forms it is in contact with the posterior fornix of the vagina, which makes it possible to diagnostic puncture to detect pathological fluids in the pouch of Douglas. Technique: after processing surgical field the skin and deep layers of the abdominal wall are anesthetized with a 0.5% solution of novocaine. The skin at the puncture site is incised with the tip of a scalpel. The puncture is made with a trocar, perpendicular to the surface of the abdomen. The capabilities of a diagnostic puncture are limited to detecting pathological contents in the abdominal cavity and determining its nature (blood, gas, intestinal contents, exudate), and only if there is a large amount of it. Laparocentesis has wider diagnostic capabilities. It is performed in places of the most pronounced pain and muscle protection, as well as dullness of percussion sound. The classic site for laparocentesis is 2–3 cm below the umbilicus in the midline. Under local anesthesia, a 1–2 cm long skin incision is made and the aponeurosis is exposed, onto which two silk holders are placed. The abdominal wall is pulled forward last. The abdominal wall is pierced between the holders with a trocar and the stylet is removed. Through the trocar, a catheter is inserted into one or another part of the abdominal cavity - the right subphrenic space, the right lateral canal, the left subphrenic space, the left lateral canal, the right and left mesenteric sinuses, the small pelvis (“fumbling catheter”). As the catheter moves, the contents are aspirated. To increase the diagnostic value, an aseptic solution (200–400 ml) can be injected into the abdominal cavity, followed by aspiration. The use of diagnostic laparocentesis makes it possible to confidently diagnose damage to internal organs in a closed abdominal injury and resolve the issue of the need for urgent surgery.

In the mid-1960s, in addition to laparocentesis, laparoscopy became firmly established in emergency surgery. It is indicated not only for closed abdominal trauma, but also for an unclear clinical picture of an “acute abdomen”, as well as for penetrating wounds in order to determine the location and nature of organ damage. The insertion of the laparoscope is preceded by the application of pneumoperitoneum. Puncture with a Veress needle is usually performed 2–3 cm below the navel in the midline. Control of needle penetration into the abdominal cavity - free flow of novocaine from the syringe through the needle without piston pressure. After gas insufflation is completed, the laparoscope is inserted. The insertion site of the trocar intended for the laparoscope is selected taking into account clinical manifestations so as to ensure an optimal angle for bringing the laparoscope to the intended site of injury and ease of viewing.

Under appropriate conditions, laparoscopy is performed using video endosurgical equipment. When a diagnosis of damage to internal organs and ongoing profuse bleeding is established with a closed abdominal injury, urgent surgery is indicated.

Surgical intervention begins with an incision in the anterior abdominal wall and opening of the abdominal cavity (laparotomy). The precise definition of laparotomy is the opening of the abdominal cavity with diagnostic or therapeutic purpose. The incision should allow inspection of all parts of the abdominal cavity and good access to damaged organs. As a rule, a midline incision is used above or below the navel (upper or lower midline laparotomy). This incision provides the best access to the abdominal organs. It is simple to perform and ensures rapid penetration into the abdominal cavity. After the operation is completed, suturing the wound is quite simple. Thus, one of the basic rules of emergency abdominal surgery is observed: rapid entry into the abdominal cavity and rapid exit from it. In addition, it is very important to be able to easily expand the incision up or down, and also, if necessary, to the right or left by transversely cutting the rectus muscles. The purpose of further actions of the operating surgeon is to establish the localization and nature of pathological changes, as well as determine their severity. An examination of organs is called an audit. The primary goal is to quickly detect the source of bleeding and ensure reliable hemostasis. When examining the abdominal cavity, natural landmarks can be the location of the mesenteries, ligaments and relatively fixed organs, the topography of which is relatively constant and changes little under pathological conditions. Such a landmark should be considered, first of all, the mesentery of the transverse colon, which divides the abdominal cavity into the upper and lower floors. In the first of them on the right is the liver, in the epigastric region is the stomach, and in the left hypochondrium is the spleen. Above the right lobe of the liver, between it and the dome of the diaphragm, there is the right subdiaphragmatic space (bursa hepatica), which opens into the right lateral canal of the lower floor of the abdominal cavity downwards and to the right. The left subphrenic space is located above the upper edge of the spleen and the fundus of the stomach. Below the spleen there is a relatively wide ligament stretched - ligamentum phrenicocolicum, closing the blind sac of the spleen (saccus coecus lienis) and delimiting left half the upper floor of the abdominal cavity from the left lateral canal located in the lower floor. In front of the stomach, between its anterior surface and the parietal peritoneum of the anterior abdominal wall, there is a pregastric bursa (bursa praegastrica). In case of injury or perforation of the anterior wall of the stomach, the contents of the latter can flow along the anterior surface of the greater omentum (preomental fissure) and accumulate in the peritoneal pockets of the small pelvis (spatium rectovesicale in men, pouch of Douglas in women), and pathological contents may not be detected in the lower floor of the abdominal cavity . This circumstance makes it especially necessary special examination pelvic pockets (insertion of electric suction tips, control gauze swabs). To understand the features of the topography of the organs and the techniques used by the surgeon during the revision, it is necessary to mention the existence behind the stomach, limited by the leaves of the peritoneum, of the so-called omental bursa (bursa omentalis). The latter is limited in front by the ligaments that form the lesser omentum (lig. hepatoga-stricum, hepatoduodenale, phrenicogastricum), the posterior wall of the stomach and the gastrocolic ligament (lig. gastro-colicum). The lower wall of the omental bursa is the mesocolon transversum. The bursa is bounded above by the peritoneum lining the lower surface of the diaphragm, and behind by the parietal peritoneum covering the pancreas. The bag is thus closed on all sides and communicates with other parts of the abdominal cavity only through a relatively small omental opening (foramen epipioicum Winslowi). The latter is located behind the lig. hepatoduodenal. Its upper boundary is the caudate lobe of the liver, the posterior boundary is the peritoneum, passing from the lower surface of the liver to right kidney(lig. hepatorenale), lower lig. duodenorenale. The lower floor of the abdominal cavity contains loops of the small intestine, surrounded from the sides and above by various parts of the large intestine (on the right - caecum, colon ascendens; on the top - colon transvesum with its mesentery; on the left - colon descendens, turning into colon sygmoideum). Lateral to the ascending and descending colon are the right and left lateral canals of the abdominal cavity. The space located medial to the colon ascendens and colon descendens is divided by the root of the mesentery of the small intestine into two mesenteric sinuses, the right of which is relatively closed due to the horizontal position of the mesentery ileum terminate, and the left one opens into the small pelvis along the mesentery. sigmoid colon. Blood found in the abdominal cavity is removed using an electric suction device or large gauze pads. At the same time, performing aspiration liquid blood and removal of clots, it should be taken into account that the main places of fluid accumulation are the right lateral canal, where blood flows primarily in case of liver injuries; the left lateral canal and the blind sac of the spleen, filled with blood when the spleen ruptures. The presence of blood in the mesenteric sinuses or the detection of retroperitoneal hematomas indicates kidney damage or injury to the branches of the superior or inferior mesenteric arteries. To examine the liver, it is necessary to raise the costal arch. Continued bleeding from the liver can be stopped by packing the wound with a pad soaked in hot saline. In case of significant bleeding, you can use the technique of pinching the hepatic artery and portal vein, which run as part of the hepatoduodenal ligament along with the common bile duct. To do this, the index finger of the left hand should be inserted into the omental foramen, the anterior wall of which is the hepatoduodenal ligament. The ligament, together with the hepatic artery and portal vein located in it, is compressed between the first and second fingers (no more than 5–7 minutes), which provides a temporary cessation of parenchymal bleeding from the liver wound and allows for a good examination of it. For better inspection of the convex (diaphragmatic) surface of the liver, the round and partially falciform ligaments are crossed. The posterior semicircle of the diaphragmatic surface, which is poorly accessible for inspection, is examined with a hand inserted into the subphrenic space up to the coronary ligament located in the frontal plane. The surgeon’s task is to treat the liver wound and finally stop the bleeding. Treatment of the wound consists of economical removal of non-viable tissue, blood clots, and foreign bodies. Common methods of stopping bleeding from the liver when it was injured during the Great Patriotic War 1941–1945 there was wound tamponade with gauze, muscle or omentum. The omentum was most often used, either as an isolated area or as a flap on the feeding pedicle. To stop bleeding, a prepared section of the omentum was inserted into the wound and fixed to the edges of the latter with several sutures. It is believed that superficial non-bleeding wounds 2–3 cm deep should not require stitches. If the wound is located on a convex surface, Clary hepatopexy can be performed: the free anterior edge of the liver is fixed with sutures to the parietal peritoneum and muscles along the edge of the first costal arch, pressing the liver to the diaphragm. Damaged gallbladder , as a rule, are removed. In case of damage to the spleen, it is currently proposed to use various types of organ-preserving operations. Indications for removal of the spleen: separation of the spleen from the vascular pedicle; complete crushing or multiple fragmentation of the spleen; damage to the spleen in combination with multiple trauma to other internal organs; finally, bleeding from a rupture of the spleen, which does not stop after tamponade with the omentum and suturing the parenchyma. The technique for examining, stopping bleeding and, if necessary, removing the spleen is as follows. The anterior end and the part of the surface of the spleen visible in the wound are examined. The diaphragmatic surface and the posterior end of the spleen are examined with a hand inserted into the left subphrenic space. If damage is detected, especially in the area of ​​the upper edge and posterior end of the spleen, the surgical approach should be expanded by transversely cutting the left rectus abdominis muscle and, if necessary, dissecting the transverse and oblique abdominal muscles in the lateral direction. In case of significant bleeding from the splenic parenchyma, you should clamp its vascular pedicle with your fingers or apply an elastic vascular clamp to it. For a complete revision of the organ, it is necessary to mobilize the spleen and remove it into the surgical wound. For this purpose, the splenic-diaphragmatic ligament, as well as part of the gastrosplenic ligament with the short arteries of the stomach, are crossed between the hemostatic clamps. Crossing the ligaments allows you to bring the spleen along with the tail of the pancreas into the surgical wound and examine it from all sides. If there are single cracks in the parenchyma, tamponade is performed with an omentum on the feeding pedicle and the spleen is sutured, making sure to pass the threads under the bottom of the wound. If the pole of the spleen is torn off, resection of the organ can be performed by wrapping the wound surface with an omentum and applying hemostatic sutures. U-shaped sutures or Kuznetsov-Pensky type sutures can be used as hemostatic sutures. If indicated, splenectomy is performed. In the area of ​​the hilum of the spleen, an artery and vein are isolated and strong ligatures are placed on these vessels. It is recommended to apply a ligature to the splenic vessels as close as possible to the hilum of the spleen in order to avoid exclusion of the arterial branches to the tail of the pancreas from the bloodstream with necrosis of the latter. The artery and vein must be ligated separately. After splenectomy, the splenic bed is usually drained. When performing an inspection of the liver and spleen, it is necessary to carefully examine the right and left subphrenic spaces, respectively, in order to identify possible damage (ruptures) to the diaphragm. Due to the negative pressure in the pleural cavities, the moving organs of the abdomen may be drawn into the chest cavity. After removing the organs, the diaphragm wound must be sutured with two rows of sutures. Pleural cavity drained at the end of the operation. Stopping bleeding from parenchymal organs can be significantly facilitated by modern means of hemostasis: hemostatic sponges, electro-, laser coagulation, etc.

The source of bleeding in the lower abdominal cavity may be the branches of the superior and inferior mesenteric arteries. Damaged vessels should be carefully bandaged, and preferably stitched ligatures should be applied to prevent them from slipping off a bleeding vessel, even a relatively small one. At the bottom of the sinuses, the kidneys are probed and examined. The extent of the operation was determined by the nature of the damage. The method of choice is organ-preserving surgery; if it is necessary to remove a kidney, it is necessary not only to ensure the presence of another, but also of its functional viability (excretory urography). The parietal peritoneum should be sutured after the end of kidney surgery. The retroperitoneal space is drained through an incision in the lumbar region.

Having completed the stop of bleeding and surgical interventions on parenchymal organs, they begin to audit the hollow organs of the abdomen. Examination of the hollow organs of the abdomen (digestive tract) is performed in a strict sequence, starting from the abdominal esophagus and the cardiac part of the stomach to the rectum. Before the examination, additional anesthesia is recommended by injecting a warm 0.25% solution of novocaine into the root of the mesentery of the small intestine, the mesentery of the colon and into the lesser omentum. Inspection of hollow organs begins with examination of the anterior wall of the stomach, starting with the cardiac region. Pay attention to the gastric vessels running along the greater and lesser curvature, evaluate their pulsation, identify subserous hematomas, etc. It is necessary to examine the wall of the stomach, which faces posteriorly, into the omental bursa, and is not accessible to direct inspection. To revise the posterior wall of the stomach, it is necessary to dissect the gastrocolic ligament (lig. gastrocolicum) between hemostatic clamps along the greater curvature. This technique allows you to move the greater curvature of the stomach anteriorly and upward, which provides a fairly good view of not only the posterior wall, but also the entire omental bursa. Particular attention should be paid to the condition of the pancreas, located under the parietal peritoneum, lining the posterior wall of the omental bursa. When opening the omental bursa, it must be remembered that the gastrocolic ligament, especially in its left part, often comes into contact with the upper surface of the mesentery of the transverse colon. Therefore, dissection of the ligament and application of ligatures to its vessels is recommended to begin in the middle part of the ligament and further manipulations are carried out under the control of a finger placed under the ligament in order to avoid accidental entrapment of the vessels feeding the transverse colon into the ligature and necrosis of the wall of the latter. After examining the stomach and performing the necessary surgical procedures, the surgeon begins to inspect other parts of the gastrointestinal tract. The examination begins from the duodenal-jejunal fold, corresponding to the beginning of the small intestine. To detect it, the transverse colon should be brought out into the wound along with the greater omentum and, thus, provide the possibility of free access to the organs of the lower floor of the abdominal cavity. The topography of flexura duodenojejunalis is such that it is located at the root of the mesentery of the transverse colon immediately to the left of the spine. Visually, a fold of the peritoneum (plica duodenojejunalis) is detected. Starting from the duodenal-jejunal flexure, all loops of the small intestine are examined, sequentially removing them from the abdominal cavity. Particular attention is paid to the mesenteric edge of the intestine. Large subserous hematomas must be opened and emptied. Special difficulties For examination, the fixed sections of the intestine are presented - the duodenum, the ascending and descending sections of the colon. The duodenum has an intraperitoneal upper horizontal part, which is examined simultaneously with the stomach, as well as retroperitoneal descending and lower horizontal parts. Inspection of the retroperitoneal parts of the duodenum is carried out from the side of the omental bursa, simultaneously with the revision of the pancreas, as well as from the side of the lower floor of the abdominal cavity, when examining flexura duodenojejunalis. When examining the duodenum, pay attention to the presence of hematomas in the retroperitoneal space, swelling with greenish-yellow permeation of the retroperitoneal tissue in this area, and gas bubbles. If these signs are detected, it is necessary to mobilize the duodenum according to Kocher. To do this, by lifting the right lobe of the liver with a wide blunt hook and moving the pyloric part of the stomach down and to the left, the hepatoduodenal ligament is stretched. Along the right contour of the duodenum, a layer of the parietal peritoneum is dissected along the transitional fold, starting from the lower edge of the foramen 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.

Examination of the colon presents some technical difficulties due to the topographic and anatomical features of this section of the gastrointestinal tract. In particular, this applies to the ascending and descending colon, since they are inactive, located at a considerable distance from the midline incision used for revision, and have wide extraperitoneal areas inaccessible for direct inspection. To inspect the posterior wall of the ascending or descending colon, it is necessary to make an incision in the parietal peritoneum along the transitional fold along the lateral wall of the intestine. Peeling off the intestine from the tissue, shift it in the medial direction and examine the posterior wall. It must be remembered that the branches of the mesenteric artery supplying the intestine approach it from the medial side and are located directly under the parietal peritoneum lining the mesenteric sinuses. In addition, behind the intestine, separated from it by retroperitoneal fascia and fiber, are the right and left kidney with their vessels.

The examination of the abdominal cavity ends with an inspection of the pelvic organs, where, in addition to the rectum, the bladder is located, and in women, the uterus. Indirect signs of extraperitoneal ruptures of the bladder or rectum are swelling of the pelvic tissue and subperitoneal hematomas.

In case of damage to hollow organs, their integrity is restored, the damaged areas are isolated from the abdominal cavity and, if indicated, drained. Although the nature of operations performed for abdominal wounds, their volume and degree of complexity are very different, they all require the use of special sutures to restore the tightness and integrity of the gastrointestinal tract. All types of sutures used in abdominal surgery are collectively known as intestinal suture. Currently, a two-row, or two-tier, Albert suture is generally accepted, representing a combination of two types of intestinal sutures: through all layers - the serous, muscular and mucous membranes - the Jelly suture and the serous-serous suture of Lambert.

More physiological and promising is a single-row intestinal suture (serous-muscular-submucosal suture - Pirogov, muscular-submucosal), widely used in operations on the stomach and small intestine. When modified with tying knots inside the lumen of a hollow organ, they speak of a Mateshuk suture. The use of a three-row or wraparound suture to connect hollow organs is unacceptable from a modern surgical perspective. Along with the methods described above for applying an intestinal suture, special devices are used during conventional and endoscopic approaches to speed up and automate the suturing of the edges of the intestinal wound. The microsurgical technique of intestinal suture is increasingly used.

Often in emergency surgery there is a need for resection of a hollow organ. Resection of the stomach and small intestine is most often performed. When deciding on resection, it should be remembered that the outcome of the operation is influenced by the size of the resected area. It is known that resection of a section of intestine up to 50 cm in length is tolerated relatively easily by the wounded; with resection of more than 1 m of intestine, the mortality rate is high. Techniques for bowel resection can be divided into several main stages. The first of these is the mobilization of the loop subject to resection, i.e. ligation of all vessels that are part of the mesentery to the damaged intestinal loop that is subject to removal. The second stage of the operation is the removal of the damaged and mobilized section of the intestine. As a rule, to perform this stage of the operation it is necessary to delimit the part of the intestine to be removed with special intestinal sponges. The splints are applied at an angle of 30° to the long axis of the intestine so that the free edge of the intestine is cut off to a greater extent than the mesenteric one. Excision of the removed part of the intestine is carried out between the sphincter, after which the anastomosis begins. There are 3 types of interintestinal anastomoses: end to end, side to side and end to side. The most physiological is end-to-end anastomosis, however, due to its simplicity and reliability, side-to-side anastomosis is more often used in emergency surgery. After anastomosis, regardless of its type, it is necessary to suture the mesenteric defect. This final stage of bowel resection must be performed in such a way that the sutures do not compress the vessels passing through the mesentery. If it is impossible to suture the intestinal wound and there are contraindications for resection (for example, extreme serious condition wounded) you can use a method of removing the damaged loop from the abdominal cavity. This operation involves removing a loop of intestine into the wound of the abdominal wall and suturing it around the entire circumference to the parietal peritoneum. In case of damage to the ascending colon, the operation of choice is suturing the wound with the simultaneous application of a cecostomy to unload the damaged area. For injuries of the transverse colon, small defects are sutured with a three-row suture. In connection with the mention of such terms as fecal fistula (colostomy, cecostoma, sigmostoma) and unnatural anus (anus praeternaturalis), it is necessary to dwell on the differences in the technique of performing these operations and the indications for them. A fecal fistula is formed by a surgeon either for the purpose of isolating (removing from the abdominal cavity) the damaged area of ​​the colon, or for the purpose of “unloading” (discharge of gases and, partially, intestinal contents) the underlying area. The technical implementation consists of suturing the serous cover of the colon around the existing wound to the parietal peritoneum. In this case, in order to avoid infection of the tissues of the abdominal wall, it is recommended to first suture the edge of the parietal peritoneum to the skin around the circumference of the surgical wound. With a fecal fistula, part of the intestinal contents is released out (through the fistula), part passes through the intestine into the underlying sections (partial unloading). When applying an unnatural anus, the purpose of the operation is to completely drain the intestinal contents through the wound of the abdominal wall, isolating the underlying sections of the intestine from the entry of intestinal contents into them. This is achieved either by bringing the adducting and efferent ends of the intestine onto the abdominal wall after its resection, or by forming a so-called “spur”. The latter is a fold of the intestinal wall at the site of its inflection and is formed by the surgeon using special sutures that are applied to the walls of the adductor and efferent loops in contact with each other on both sides of the mesentery. As in the case of colostomy, the serous membrane of the intestine around the area with the formed spur is sutured to the parietal peritoneum. By opening the wall of the withdrawn loop above the spur 24–48 hours after the operation, the openings of the adducting and efferent ends of the intestine (“double-barreled gun”), separated by the first spur, are formed. The spur prevents the contents from entering the efferent end of the intestine.

Another resection operation, quite often performed both in an emergency and in a delayed and planned manner, is gastric resection (removal of part or all of the stomach).

Based on the volume of the removed part, they are distinguished:

1) total resection (gastrectomy), when the entire stomach is removed;

2) resection of 3/4 of the stomach;

3) resection of 1/2 of the stomach.

Based on the method of execution, there are two main types of operations:

1) Billroth-I resection;

2) Billroth-II resection.

During Billroth-I resection, the stumps of the stomach and duodenum are connected end to end. During Billroth II resection, the remaining part of the stomach is connected to the small intestine attached to it. The first type of operation is more physiological, as it preserves the normal movement of food from the stomach to the duodenum. During Billroth II resection in the Hofmeister-Finsterer modification, after mobilization of the stomach by crossing its ligaments (lig. gastrocolicum, lig. hepatogastricum) with simultaneous ligation of the vessels, the stomach is cut off along the right border of the resection and the duodenal stump is treated. Before this, the initial loop of the jejunum is found and through a hole made in the mesocolon, it is brought to the upper floor, into the bursa omentalis. The gastric stump is covered with a large gauze napkin and tilted to the left. They begin to close the duodenal stump, for which it is immersed in two half-purse bags and sutured with a second row of interrupted sutures. Then they begin to remove the stomach and apply a gastrointestinal anastomosis. Along the line of the left border of the resection, two Kocher clamps are applied in a direction transverse to the axis of the stomach, the resected area is cut off with a scalpel along the crushing sphincter, and the upper part of the gastric stump is sutured using the clamp applied from the lesser curvature. The removed loop of the jejunum is sewn to the unsutured part with a series of serous-muscular sutures, an anastomosis is applied and fixed in such a way that the adducting end of the loop faces upward, to the lesser curvature of the stump, and the abducent end to the greater curvature. During the Billroth I operation, before cutting off the resected area, the duodenum is mobilized according to Kocher, then an end-to-end or end-to-side anastomosis is performed between the stomach and duodenum.

Another common operation on the stomach is gastrostomy (a gastric fistula). It is produced when it is impossible to eat food by mouth. It was first performed on animals in 1842 by V. A. Basov. The first operation on a person was performed by Sedillo (1849). When applying a gastrostomy according to Witzel, a transrectal incision is made on the left. The anterior wall of the stomach is removed into the wound. At the middle of the distance between the lesser and greater curvature of the body of the stomach along its long axis, closer to the cardiac section, a rubber tube with a diameter of 0.8 cm is applied and immersed in the groove formed by two folds of the stomach wall and fixed with 5-7 serous-muscular interrupted silk sutures, to the left of the last suture, another one is applied in the form of a pouch, leaving it untightened. Inside it, the wall of the stomach is dissected, the end of a rubber tube is inserted into the resulting hole to a depth of 5 cm and the purse-string suture is tightened. Thus, the rubber tube is located in a channel that opens into the stomach cavity. If it needs to be removed, the canal usually closes on its own.

The most common operation in abdominal surgery is appendectomy. The first successful appendectomy was performed by William T. Morton in 1887, and in Russia in 1890 by A. A. Troyanov. Many options for surgery have been proposed. In our country, the most common method is the Mac Burney-Volkovich method. An incision 8-10 cm long is made at the border of the middle and outer third of the line connecting the anterior superior iliac spine to the navel, perpendicular to it, and the upper third should be above it, and the lower two thirds below. The skin, subcutaneous tissue, and aponeurosis of the external oblique muscle are dissected. Under the aponeurosis, the internal oblique muscle, first the internal oblique, and deeper, the transverse abdominal muscle, are bluntly pulled apart parallel to the fibers and stretched with Farabeuf hooks. The transverse fascia of the abdomen is dissected, the wound is covered with gauze napkins, the fold of the parietal peritoneum raised by two anatomical tweezers is cut and its edges are fixed to the napkins. After opening the abdominal cavity, the wound is stretched with plate hooks and the search for the vermiform appendix begins. The cecum is recognized by its position, grayish color, and the presence of muscle bands (taenia). The vermiform appendix is ​​pulled upward so that its entire mesentery is clearly visible. The mesentery of the process is dissected between sequentially applied clamps down to its base. After crossing the mesentery, the captured areas are bandaged. A silk seromuscular purse-string suture is placed on the wall of the cecum, 1.5 cm away from the base of the process, leaving its ends loose. The vermiform appendix is ​​compressed at its base with a clamp, a ligature is applied to the compressed area, and its ends are cut off; a clamp is applied to the process distal to the ligation site. Holding the base of the process with anatomical tweezers, it is cut off above the ligature immediately below the applied clamp. The stump of the appendage is cauterized with iodine and immersed into the intestinal lumen with anatomical tweezers; The pouch is tightened and when the tweezers are removed, it is tied in a knot. A seromuscular suture in the shape of the Latin letter z is placed over the purse-string suture, which is tightened after cutting off the ends of the purse-string suture. The cecum is inserted into the abdominal cavity. The abdominal cavity is drained, drained if necessary, and the wound is sutured in layers.

Operative surgery of the stomach

Stomach surgeries:
1). Gastrotomy.
2). Gastrostomy.
3). Gastroenterostomy.
4). Gastric resection.
5). Vagotomy.
6). Surgeries that drain the stomach.

Gastrotomy.

Indications:
- to remove a foreign body
- to stop stomach bleeding from an ulcer
- for removal of benign tumors

Surgical technique.
1). The incision is an upper midline laparotomy. For wider access, the midline incision can be supplemented by dividing the left rectus abdominis muscle.
2). The stomach is removed into the wound along with the transverse colon and omentum and covered with napkins.
3). An incision is made in the stomach - perpendicular to the axis of the stomach if the operation is performed to remove a foreign body.
If the operation is performed to stop bleeding (ulcerative or traumatic), then a small incision is made, the contents of the stomach are sucked out through it (if there is no gastric tube) and a wide incision is made parallel to both curvatures.
4). The wound in the wall of the stomach is sutured with a two-layer suture.

The following technique can be used to detect the source of bleeding. The surgeon stupidly divides the lig. gastrocolicum or lig. hepatogastricum, inserts the left hand through this hole, presses on the back wall of the stomach and looks for a bleeding vessel.

Gastrostomy.

The purpose of the operation is to create an artificial entrance to the stomach for introducing food when it is impossible to take food through the mouth.

Types of gastrostomies:
1). According to Witzel.
2). According to Topver.
3). According to Kader.

Gastrostomy according to Witzel.

1). The incision is longitudinal through the left rectus abdominis muscle, immediately below the costal arch.
2). The anterior wall of the stomach is removed into the wound.
3). A tube is placed on the front wall, two folds are made along its two edges, which are then connected with Lambert serous-muscular sutures.
4). A small hole is made at the top, a five cm tube is inserted there. The tube is secured in the mucous membrane with a thin knotted catgut suture.
5). Immerse the stomach. The tube is fixed to the anterior abdominal wall. Stitch up the wound.

Gastroenterostomy.

The purpose of the operation is to create a bypass for food in case of obstruction of the gastric outlet.

There are 4 types of gastroenterostomy:
1). Anterior anterior colic anastomosis (antecolica anterior).
2). Posterior anterior colic anastomosis (antecolica posterior).
3). Anterior retrocolic anastomosis (retrocolica anterior).
4). Posterior retrocolic anastomosis (retrocolica posterior).

Anterior gastroenterostomy (according to Wölver).

1). Median laparotomy.
2). Finding the beginning of the jejunum. There are several ways to do this.
A. With the right hand, slide up the left side of the spine. Pancreatic tissue is found in the corner between the spine and the stretched mesentery of the colon. Just below the pancreas is where the loop of jejunum emerges. They pull on the intestine, and if it turns out to be fixed, then this is the intestine being sought.
B. Take the transverse colon and pull it upward. The loops of the small intestine are pulled down and to the right. In this case, the plica doudenojejunalis (ligament of Treitz) is stretched. To the left of the spine is the transition between the duodenum and the jejunum.
3). From the beginning of the jejunum, 50-60 cm are counted, a section of the intestine is thrown over the omentum and the transverse colon and applied to the anterior wall of the stomach so that the abducent leg faces the pylorus, and the adductor leg faces the fundus of the stomach (this position is called isoperistaltic and prevents the emergence of a vicious circle).
4). The stomach and part of the intestine are taken into soft clamps. An interrupted suture is placed on the edges of the future anastomosis. This helps to match the walls of the stomach and intestines.
Seromuscular sutures are applied (at a distance of 0.5 cm from each other).
5). The lumen of the stomach and intestines is opened. 1 cm is removed from the seromuscular suture, the seromuscular membrane is dissected to the submucosal layer, large vessels are ligated in the submucosal layer, the mucous membrane is grabbed with tweezers, pulled in the form of a cone and cut along the entire length of the seromuscular suture. The anastomosis opening should be at least 6-8 cm (allow the tips of three fingers to pass through).
6). Stitching the stomach wall to the intestine. Circular sutures are applied to the posterior semicircle, and figure-of-eight sutures are applied to the anterior semicircle. Another row of seromuscular sutures is applied.
7). An anastomosis is performed according to Brown.

Posterior gastroenterostomy (according to Gakker-Peterson).

In this case, the intestine is sutured to the back wall of the stomach. You can use a short or long loop (the shorter the loop, the better the functional results). The stomach incision can be made horizontally (longitudinal) or vertically (transverse).

1). Median laparotomy.
2). The beginning of the jejunum is found.
3). In the mesentery of the transverse colon, in its avascular zone, a hole of 5 by 6 cm is made. Then, pressing on the anterior wall of the stomach, the posterior wall of the stomach is pushed through the hole in the mesentery. The stomach is pulled out in the form of a cone and a soft clamp is applied to it in a direction transverse to the axis of the stomach.
When making a hole in the mesentery of the transverse colon and subsequently, one should be careful not to damage the middle colateral artery.
4). The stomach twists along its axis in such a way that its greater curvature turns upward, and its lesser curvature turns downwards.
5). A soft clamp is also applied to the intestinal loop and turned so that the branches of the two clamps come together.
6). An anastomosis 6-8 cm long is made.
7). The mesentery of the transverse intestine is fixed to the stomach with several sutures to prevent a hernia from forming.

Posterior gastrostomy has several advantages:
- with it, the intestinal loops are located normally and are not excluded from the act of digestion
- the possibility of a vicious circle is almost excluded
- no need to perform a Brownian anastomosis
However, the operation is more difficult technically - since you have to work in depth, on fixed organs.

Complications after gastrostomy:
1). Compression of the intestine by the transverse colon and greater omentum.
2). Circulus vitiosus. In this case, the contents of the stomach do not enter the abductor knee, but into the adductor one, stretching it to a significant size. Then this content enters the stomach again. Thus the contents make a circle. Food has to exit through the esophagus.
Persistent vomiting mixed with bile for 2-3 times after surgery is the first symptom of this complication.
Causes of the vicious circle:
- antiperistaltic arrangement of the stomach and intestines
- formation of a “spur” - closing the opening of the abductor knee when the anastomosis is incorrectly applied. Therefore, the anastomosis must be applied closer to the lowest point of the greater curvature, attaching it to the stomach with several more serous sutures above the anastomosis. Then the reverse flow of food becomes impossible.
The formation of a vicious circle is eliminated when a Brownian anastomosis is applied and during the Roux operation.

Gastric resection.

There are two methods of gastric resection:
1). The stump of the stomach is connected to the stump of the duodenum (Billroth I).
2). The gastric stump is connected to a new anastomosis of the small intestine, and the duodenal stump is sutured tightly (Billroth II).

Resection of the stomach according to the Billroth II method.

2). Mobilization of the stomach.

First, the stomach is mobilized along the greater curvature - individual sections of the ligament are grabbed with two clamps, the ligament between them is crossed and ligated. Here you need to be careful not to ligate the middle colon artery, which runs in the mesentery of the transverse colon. Therefore, you must try to stay as close to the stomach as possible.
However, the line of transection of the gastrocolic ligament depends on the reason for the operation. If resection is performed for an ulcer, then the intersection line goes as close as possible to the stomach and passes above a. gastroepiploica dexter. If stomach cancer is resected, the transplantation line passes below a. gastroepiploica dexter and lymph nodes are removed along the greater curvature.

Release of the duodenum from ligaments. Particular care must be taken when freeing pancreatic tissue from the intestine. Since there are numerous vessels from the pancreas to the intestine that need to be ligated. You also need to avoid damaging the pancreatic tissue.

Mobilization along the lesser curvature - begins with the fact that, under the control of a finger passed through the lesser omentum, the right gastric artery is grabbed with clamps, crossed and ligated. When dissecting the hepatoduodenal ligament, you must always remember about the common bile duct, hepatic artery and portal vein passing through this ligament. Therefore, only the anterior layer of the ligament is cut, and the tissues are bluntly separated in the dorsal direction. It is necessary to separate the stomach from the ligament 2-3 cm above the intended resection.
It should be taken into account that a branch may extend from the left gastric artery to the liver - ligating it threatens necrosis of the left lobe of the liver (test clamping of it changes the color of the liver). In this case, the arteries originating from the left gastric should be crossed, preserving the main trunk.

3). Excision of the stomach. There are two options for gastric excision.

A. The duodenum is first transected and the stomach is tilted to the left.
Two clamps are placed on the pylorus of the stomach and crossed between them. The incision sites are covered with napkins. The stomach leans to the left.
Then three clamps are applied (one is a safety clamp, since the second will be removed when a gastroenterostomy is applied) to the upper border of the resection and the stomach is crossed.

B. First, the stomach is crossed in the proximal direction, then tilted to the right and cut off in the area of ​​the pylorus. This option is used in the presence of adhesions in the area of ​​the duodenum or in the pancreas that is difficult to separate.

4). The lumen of the stomach is shortened to 5-8 cm.

5). Suturing the duodenal stump.

6). Connection of the stomach with the duodenum. There are two options for connecting the stomach to the duodenum, depending on the distance at which the anastomosis is made.

A. According to Peterson - with the initial section of the jejunum, immediately close to the ligament of Treitz.
The initial section of the jejunum is found. A window is made in the mesentery of the transverse colon. Through this window, a loop of intestine is brought into the upper floor of the abdominal cavity and brought to the stump of the stomach. This manipulation is carried out before the stomach is cut off. The intestine is fixed to the stomach at the lesser and greater curvature. An anastomosis is performed. The adductor knee is fixed to the stomach above the anastomosis site to avoid the flow of food into the adductor colon. The mesentery of the transverse intestine is also sutured to the wall of the stomach so that there is no hernia through this opening.

B. According to Reichel-Polya - with a loop removed 40-50 cm from the ligament of Treitz. There are also two options here - the intestine is carried out in front or behind the transverse colon.

Gastric resection according to Billroth II modified by Balfoy.

An anastomosis between the intestine and the stump of the stomach is placed in front of the colon on a long loop with an additional interintestinal anastomosis according to Brown.

Gastric resection using the Billroth I method.

Opening the abdominal cavity, mobilization and excision of the stomach are performed in the same way as with the Billroth II method.

4). Part of the gastric stump is sutured from the lesser curvature side.

5). An anastomosis is performed between the stomach and duodenum.
The anastomosis can also be formed from the lesser curvature.

6). Several sutures are used to close the hole in the gastrocolic ligament.

Complications after gastric resection.

1). Bleeding from the anastomosis, which manifests itself as bloody vomiting or black stool.

2). Obstruction of the anastomosis. It can be caused by both edema and improper anastomosis.

3). Adductor loop syndrome - overflow and expansion of the afferent loop.

4). Failure of the sutures of the duodenal stump.

Suturing the duodenal stump.

The choice of method for suturing the duodenal stump depends on the length of the stump and the presence of an ulcer.

Moynigen-Topver method - two clamps are applied to the stump. The duodenum is sutured with a continuous suture, capturing both clamps in the stitch. The seam stitches are placed at a distance of 0.3 cm from each other, without pulling the thread tightly. The clamps are removed, the seam is tightened and tied. A purse string suture is placed on top. The third row of sutures is placed on the anterior wall of the duodenum and the peritoneum on the pancreas.

Toupet's method - the first row of sutures is placed on the duodenal stump with knots inward (Mateshuk), the second row is seromuscular sutures.

Yakobovichi method - a continuous entwining suture is applied to the stump. Then a purse string suture is applied. The ends of the threads of the first suture are stitched through the wall of the duodenum above the purse-string sutures and tied, invaginating the first row of sutures.

Doyen-Bier method - used for long stumps. The duodenal stump is stitched in the middle through both walls and tied. Then a purse-string suture is placed below, tightened, and the stump is immersed inside. The duodenum is sutured to the pancreatic capsule.

Yudin's method ("snail") - used for penetrating ulcers of the duodenum. The intestine is excised at the level of the ulcer in an oblique direction, leaving more of the anterior wall. Next, starting from the bottom, a continuous screw-in furrier's suture is applied and tied at the upper corner of the stump. Then, through the top of the stump, from the side of the seam, through the entire thickness of the stump, a second suture is applied, thus creating the last turn of the cochlea. The suture forming the cochlea is tightened, the cochlea is immersed in the penetrating ulcer, after which the suture is passed through the proximal edge of the ulcer, where it is tied. The edges of the cochlea are fixed to the edge of the ulcer with interrupted seromuscular sutures.
Rozanov simplified the application of the cochlea by reducing the turns, which reduces the risk of circulatory disorders in the stump.

Sapozhkov method (cuff) - usually used for low duodenal ulcers. The duodenum is not mobilized, but transected transversely through the ulcer. Then the intestinal wall is divided into two cylinders - muco-submucosal and seromuscular. The outer cylinder is shifted distally by 3-4 cm, and a cuff of mucous-submucosal membrane is formed. Two purse-string sutures are placed on it and invaginated into the intestinal lumen. The muscle layer is sutured with interrupted sutures and the stump is peritoneized by the peritoneum.

Nissen method - used for ulcers penetrating into the pancreas. The duodenum is transected transversely through the ulcer. Interrupted sutures are placed on the distal edge of the ulcer and the anterior mesh of the duodenum. Then interrupted seromuscular sutures are placed on the anterior wall of the intestine and the upper edge of the penetrating ulcer, capturing the pancreatic capsule. Thus, the ulcer is packed with the wall of the duodenal stump.

Vagotomy.

There are three types of vagotomies:
1). Truncal vagotomy.
2). Selective vagotomy.
3). Selective proximal vagotomy.

Truncal vagotomy.

1). Access - upper midline laparotomy. Transpleural access is rarely used.

2). The anterior (left) trunk of the vagus nerve is identified. On the abdominal part of the esophagus, the peritoneum is dissected in the transverse direction by 2-3 cm. The anterior vagus is located by palpation. The nerve is taken with clamps and isolated from the connective tissue sheath. A section of the nerve at a distance of 2-3 cm is excised, both ends are tied with thin ligatures.

3). The posterior vagus is located between the esophagus and the aorta; it is easier to detect by pulling the stomach to the left and downward. It is excised in the same way as the anterior one.

4). The peritoneal incision is sutured with interrupted sutures.

Truncal vagotomy is usually complemented by a stomach drainage operation.

Double truncal vagomy leads to gastric paresis.

Selective vagotomy.

Jackson showed that isolated denervation of the stomach with preservation of the visceral branches of the vagus prevents the development of dysfunction biliary tract, pancreas and intestines.

1). Upper midline laparotomy.

2). The anterior layer of the lesser omentum is incised along the entire lesser curvature of the stomach. The anterior vagus is located by palpation. There is a hepatic branch extending from it. The nerve is divided below the origin of this branch.
The descending branch of the left gastric artery and the gastric branches of the anterior left trunk of the vagus nerve are intersected.
The strands of the lesser omentum are dissected and ligated from the cardia of the stomach to the pylorus.
The serous layer of the stomach is also intersected and bandaged in separate portions.

3). A hold is placed on the lesser curvature and the stomach is retracted to the left. All gastric branches of the posterior vagus are intersected in stages.

4). The lesser curvature of the stomach is sutured with gray-serous sutures.

This type of vagotomy can be performed with or without stomach drainage operations.

Proximal selective vagotomy.

Proximal selective vagotomy involves leaving the part of the nerve that innervates the pylorus.

The peritoneum is incised on the anterior and posterior surfaces of the stomach, 2-3 cm from the lesser curvature, extending from the left edge of the esophagus to the antrum of the stomach.
The hepatic branch of the anterior and celiac branch of the posterior vagus nerve are preserved.

The Latarget nerve, which in the form of a “crow’s foot” approaches the pylorus, is also preserved.

The operation ends with peritonization of the lesser curvature of the stomach.

Surgeries that drain the stomach.

Pyloroplasty according to Geinike-Mikulich.

The wall of the pylorus is dissected longitudinally 3 cm above and below the pyloric sphincter and transversely sutured with a double-row suture.
If there is an ulcer on the anterior wall, it is excised.

Pyloroplasty according to Finney.

The descending part of the duodenum is mobilized according to Kocher. The pyloric section of the stomach along the greater curvature and the inner edge of the upper horizontal part of the duodenum are sutured with seromuscular sutures. An arcuate incision is made within the sutured areas. A continuous catgut suture is placed on the posterior lip of the anastomosis and Schmieden sutures on the anterior lip of the anastomosis. Seromuscular sutures are also placed on the anterior part of the anastomosis.

Gastroduodenostomy according to Jaboulei.

A stay suture is applied to the area of ​​the pylorus from the lesser curvature, which is pulled upward. A side-to-side gastroduodenostomy is performed on the contacting stomach and duodenum.

Hemisphincterectomy according to Star-Tanak-Judd.

Above the pyloric sphincter, a semi-oval incision in the transverse direction is used to excise the wall along with half of the pyloric sphincter. The wound is sutured with a double-row suture in the transverse direction.

Drainage operations also include anterior and posterior gastroenteroanastomosis.