Surgical treatment acute pancreatitis is required in situations where foci of necrosis appear in the pancreatic tissue. Often tissue necrosis is accompanied by infection.
Regardless of need surgical intervention The answer to the question of which doctor treats pancreatitis is the word surgeon. It is he who will be able to promptly recognize complications and choose the correct tactics for managing the patient.
Surgical intervention for acute pancreatitiscarried out in two versions:
Laparotomy is performed if purulent complications pancreaticonecrosis: abscesses, infected cysts and pseudocysts, widespread infected pancreaticonecrosis, retroperitoneal cellulitis, peritonitis.
They resort to extensive interventions even if there are clear negative dynamics during treatment with minimally invasive and conservative methods, bleeding.
Laparoscopy and puncture followed by drainage are used to remove effusion in aseptic forms of the disease and the contents of infected liquid formations. Minimally invasive methods can also be used as preparatory stage to laparotomy.
The main activity in preparing a patient for surgery is fasting. It is also first aid for pancreatitis.
The absence of food in the patient's stomach and intestines significantly reduces the risk of complications associated with infection abdominal cavity intestinal contents, as well as with aspiration of vomit during anesthesia.
On the day of surgery:
Premedication consists of administering medicines, facilitating the patient’s entry into anesthesia, suppressing fear of surgery, reducing the secretion of glands, preventing allergic reactions.
For this purpose, sleeping pills, tranquilizers, antihistamines, anticholinergics, neuroleptics, analgesics.
Surgical treatment of acute pancreatitis is usually performed under general endatracheal anesthesia in combination with muscle relaxation. The patient is on mechanical ventilation during the operation.
Most dangerous complications postoperative period are:
In more late period in patients who have undergone pancreatic surgery the consequences could be:
In the first 2 days after surgery, the patient fasts. Then tea, pureed vegetarian soups, boiled porridges, steamed protein omelettes, crackers, cottage cheese are gradually introduced into the diet - this is all that can be eaten after pancreatic surgery during the first week.
In the future, patients adhere to the usual diet for diseases of the digestive system. Physical activity The patient is determined by the extent of the operation.
The purpose of the operation is to open the purulent-necrotic lesion, drain the wound until the necrotic tissue is completely rejected.
1. dissection of the skin, subcutaneous tissue and gland capsule parallel to the course of the branches facial nerve(if the purulent-necrotic focus is located in the retromandibular part parotid gland make a vertical incision parallel to the posterior edge of the branch lower jaw);
2. dissection of the soft tissues of the gland using a blunt method (to avoid damage to the facial nerve);
3. drainage of a purulent-necrotic focus.
Surgical treatment of retropharyngeal abscess
Access is through the mouth.
The patient's position is sitting.
1. The scalpel blade is wrapped in gauze, adhesive tape or limited with a clamp, leaving a free end 1 cm long;
2. an abscess is opened with a vertical incision 1 cm deep and 2 cm long above the site of the bulge;
3. After the incision, the patient’s head is sharply tilted anteriorly to prevent aspiration of pus into the respiratory tract.
Surgeries for facial clefts
The operation is performed at the age of 10–12 months.
1. an incision along the edges of the cleft at the border of the skin and the red border;
2. dissection of subcutaneous tissue, muscles and oral mucosa;
3. excision of excess mucous membrane;
4. layer-by-layer suturing of the mucous membrane, muscles, subcutaneous tissue, skin.
Lecture No. 3. Topographic anatomy neck and neck operations. Topographic anatomy of the neck
1. top – line passing along bottom edge mandible, apex mastoid process, superior nuchal line, external occipital protuberance;
2. lower (between the neck, upper limb, back and chest) - the jugular notch of the sternum, the clavicle, and a line drawn from the acromial process of the scapula to the spinous process of the VII cervical vertebra.
By the frontal plane passing through the transverse processes of the cervical vertebrae, the neck is conventionally divided into two sections: the anterior (neck itself) and posterior (nuchal region).
Neck triangles and their practical significance
1. Internal triangle (bounded by the edge of the lower jaw, the sternocleidomastoid muscle and the midline of the neck):
* Submandibular triangle (limited by the edge of the lower jaw and both bellies of the digastric muscle).
Contents: submandibular salivary gland and the same name lymph nodes, facial artery, lingual and hypoglossal nerves.
* Sleepy triangle(limited by the posterior belly of the digastric muscle, the anterior edge of the sternocleidomastoid and the superior belly of the omohyoid muscles).
Contents: main neurovascular bundle of the neck, including the common carotid artery, internal jugular vein, vagus nerve.
* Scapulotracheal triangle (bounded by the superior belly of the scapulohyoid and sternocleidomastoid muscles and the midline of the neck).
Contents: common carotid, vertebral arteries and veins, inferior thyroid artery and vein, vagus nerve and sympathetic cardiac nerves, inferior laryngeal nerve, cervical loop.
2. External triangle (bounded by the clavicle, sternocleidomastoid and trapezius muscles);
* Scapulo-trapezoid triangle (limited by the sternocleidomastoid, lateral edge of the trapezius, lower belly of the omohyoid muscles).
Contents: cervical plexus and its cutaneous branches.
* Scapuloclavicular triangle (limited by the sternocleidomastoid, inferior belly of the omohyoid muscles and the clavicle).
Content: subclavian artery and vein, trunks of the brachial plexus, thoracic lymphatic duct.
Fascia of the neck and its practical significance
Functions of the fascia of the neck:
1. protective;
2. fixation;
3. promote muscle biomechanics;
4. limit cellular spaces;
5. regulation of blood inflow and outflow from the brain due to their fusion with outer shell veins (for the same reason, the development of air embolism is possible due to the non-collapse of veins during injuries, the proximity of the right atrium and the suction action of the chest).
As already mentioned above (see section 10.9.), indications for surgical treatment
Complications of pancreatic necrosis include:
- enzymatic or purulent peritonitis,
· - omentobursitis,
- acute postnecrotic cysts,
· - accumulation of fluid in the retroperitoneal tissue,
· - septic phlegmon of parapancreatic tissue,
- abscess of the pancreas or omental bursa,
· - biliary hypertension (papillostenosis, etc.), obstructive jaundice (wedged
· calculus in the ampoule of the BDS), cholangitis,
- high small intestinal obstruction,
· - profuse arrosive bleeding in the area of pancreatic necrosis, etc.
Of the many proposed operations currently for acute pancreatitis,
those/pancreatic necrosis are used diagnostic laparoscopy, incl. in combination with
laparoscopic drainage of the abdominal cavity, laparocentesis, puncture
ultrasound-guided surgical interventions, laparotomy, incl. in co
combination with necrosequestrectomy, lumbotomy.
Types of surgical interventions
Resection of the pancreas in case of pancreatic necrosis, they are performed according to strict
indications. In case of complete (full thickness of the organ) necrosis in the tail area
and/or body of the pancreas and the patient’s stable condition is absolutely
shows corpocaudal resection of the pancreas en bloc with
spleen (or with its preservation).
The most important stage of surgical interventions performed in early dates
diseases in patients with sterile pancreatic necrosis - elimination of bile duct pathology.
For destructive cholecystitis, cholecystectomy is indicated, and for
biliary hypertension (obstructive jaundice syndrome, ultrasound
signs of extrahepatic biliary hypertension) and inability to perform
endoscopic papillotomy and lithoextraction before laparotomy - decompression
gallbladder by cholecystostomy. With cholelithiasis, as the cause of developing
pancreatic necrosis, absence of pronounced infiltrative changes in the hepato-
duodenal zone, stable general condition of the patient during the main
stage of surgical intervention, it is justified to perform simultaneous
cystectomy.
Necrectomy(removal of necrotic tissue within the blood supply -
zones associated with the parenchyma of the organ) or sequestrectomy(delete
free-lying necrotic tissues within dead tissues) are performed
through careful and dosed digitoclasia to prevent arrosive
significant bleeding from the arteries and veins of the mesenteric basin, which are associated
with large blood loss and high mortality. In this regard, it is advisable
use of vacuum aspirators.
Drainage operations.
“Closed” methods of drainage operations are indicated for limited
(small and large focal) forms of sterile and infected pancreatic
necrosis, accompanied by the formation in the retroperitoneal space or
abdominal cavity volumetric fluid formations that do not suggest
large-scale sequestration.
“Semi-open” method of drainage of retroperitoneal tissue during pan-
Creonecrosis involves installation in areas of necrosis and infection of tubular
multi-channel (active) drainage structures in combination with rubber-
gauze “cigar” drainages of Penrose-Mikulich (rubber-gauze
tampon). Under these conditions, the surgical wound is sutured tightly, and
combined design of “hard” (tubular) and “soft” (Penroz-Mikulich)
drainage is removed through a wide counter-aperture in the lumbar-lateral areas
or lumbotomy wounds.
2. Pararectal fistulas, clinical picture, diagnosis, classification, methods surgical treatment.
Paraproctitis (pararectal abscess) - acute or chronic inflammation
burning of pararectal tissue. It accounts for about 30%
of all diseases, the process affects approximately 0.5% of the population. Men
suffer 2 times more often than women; they become ill at the age of 30-50 years.
Etiology and pathogenesis. Paraproctitis occurs as a result of contact with
pararectal microflora fiber (staphylococcus, gram-negative
and gram-positive rods). With ordinary paraproctitis, most often you
exhibit a polymicrobial flora. Inflammation involving anaerobes accompanied
expected especially severe manifestations of the disease - gas phlegmon
pelvic tissue, putrefactive paraproctitis, anaerobic sepsis. Spezi
physical pathogens of tuberculosis, syphilis, actinomycosis very rarely
are the cause of paraproctitis.
The routes of infection are very diverse. Microbes get into the steam
rectal tissue from the anal glands that open into the anal groove
hee. During an inflammatory process in the anal gland, its duct is blocked
occurs, an abscess forms in the intersphincteric space, which ruptures
is inserted into the perianal or pararectal space. Process transition
from the inflamed gland to the perirectal tissue, lymphoma is also possible
in a phogenic way.
In the development of paraproctitis, injuries may play a certain role.
zestous membrane of the rectum by foreign bodies contained in the lining of the rectum
le, hemorrhoids, anal fissures, nonspecific ulcerative colitis, bo
Crohn's disease, immunodeficiency states.
Classification of paraproctitis
I. Acute paraproctitis.
1. According to the etiological principle: normal, anaerobic, specific
skiy, traumatic.
2. According to the localization of abscesses (infiltrates, leaks): subcutaneous,
ischiorectal, submucosal, pelviorectal, retrorectal.
II. Chronic paraproctitis(rectal fistulas).
1. According to anatomical characteristics: complete, incomplete, external, internal
2. According to the location of the internal opening of the fistula: anterior, posterior,
3. In relation to the fistula tract to the sphincter fibers: intrasphinc-
thorny, transsphincteric, extrasphincteric.
By degree of difficulty: simple, complex.
Acute paraproctitis characterized rapid development process.
Clinical picture and diagnosis. Clinically, paraproctitis manifests itself
There is quite intense pain in the rectal area or between
anxiety, increased body temperature, accompanied by chills, feeling
malaise, weakness, headaches, insomnia, disappearance
lack of appetite. Extensive phlegmon of pararectal tissue leads to you
severe intoxication, development of vital dysfunction syndrome
organs, threatening the transition to multiple organ failure and
sepsis. Patients experience malaise, weakness, headaches, demons
sleepiness, loss of appetite. Frequently, stool retention occurs,
numbness, dysuric phenomena. As pus accumulates, the pain intensifies,
become twitching and pulsating. If not done in a timely manner
When an abscess is opened, it breaks into adjacent cellular tissues
wanderings, rectum, out through the skin of the perineum.
The breakthrough of an abscess into the rectum is a consequence of its melting
walls with pus, pelviorectal paraproctitis. Formed
communication between the cavity of the abscess and the lumen of the rectum (incomplete internal
Renal fistula).
When pus breaks out (on the skin of the perineum), an external
fistula The pain subsides, body temperature decreases, general health improves
the patient's condition.
Breakthrough of an abscess into the lumen of the rectum or outward is very rare when
leads to complete recovery of the patient. More often a direct fistula is formed
intestines (chronic paraproctitis).
Recurrent paraproctitis manifested by the presence of remis
this, when the patient seems to have completely recovered (disappeared
there is no pain, body temperature normalizes, the wound heals). Then there is
exacerbation with clinical picture acute pararectal abscess.
Subcutaneous paraproctitis- the most common form
ma of the disease (up to 50% of all patients with paraproctitis). Characterized by sharp
twitching pain, aggravated by movement, straining, defecation;
dysuria is observed. Body temperature reaches 39 "C, often occurs
chills. On examination, hyperemia, swelling and bulging of the skin are revealed.
limited area near the anus, deformation of the anal canal. At
palpation of this area is marked by sharp pain, sometimes it is determined
fluctuation. Digital examination of the rectum causes increased
pain. However, it is advisable to carry it out under anesthesia, since this
makes it possible to determine the size of the infiltrate on one of the walls of the
my intestines near the anal canal and decide on the method of treatment.
Ishiorectal paraproctitis pain occurs in 35-40%
nykh. Appear first general signs purulent process, characteristic
for systemic response to inflammation syndrome with a sharp increase in temperature
body temperature, chills, tachycardia and tachypnea, high content
leukocytes in the blood. Along with this, weakness is noted, sleep disorder,
signs of intoxication. Dull pain in the depths of the perineum becomes
sharp, pulsating. They get worse with coughing, physical
load, defecation. When the abscess is localized in front of the rectum
dysuria occurs. Only after 5-7 days from the onset of the disease is it noted that
real hyperemia and swelling of the skin of the perineum in the area of the
abscess. Noteworthy is the asymmetry of the gluteal regions,
smoothness of the semilunar fold on the affected side. Soreness
on palpation medially from the ischial tuberosity, moderate. Very valuable in
Diagnosis of ischiorectal ulcers is a digital examination
rectum. Already at the beginning of the disease, pain can be detected
and compaction of the intestinal wall above the recto-anal line,
smoothness of the folds of the rectal mucosa on the pore side
Submucosal paraproctitis observed in 2-6% of patients with
acute paraproctitis. Pain in this form of the disease is very moderate
severe, somewhat intensified during defecation. Body temperature subfebrile-
Naya. Palpation determines the bulge in the intestinal lumen, in the area of purulent
ka, sharply painful. After a spontaneous breakthrough of the abscess in the pro
Gut light recovery comes
Pelviorectal paraproctitis- the most severe form
disease, occurs in 2-7% of patients with acute paraproctitis. Vna
Initially, general weakness, malaise, and fever are noted.
la to low-grade fever, chills, headache, loss of appetite, aching pain
in the joints, dull pain lower abdomen. With abscess formation of infiltrate
pelviorectal tissue (7-20 days from the onset of the disease)
body temperature becomes hectic, symptoms of purulent inflammation are expressed
toxicity. The pain becomes more intense, localized, from
tenesmus, constipation, dysuria occur. Pain on palpation between
there is no news. The diagnosis can be confirmed by ultrasound, computer or magic
nitrous resonance tomography. Without instrumental studies di
The diagnosis is difficult to make until purulent melting of the pelvic muscles
the bottom will not lead to spread inflammatory process on se-
far-rectal and subcutaneous fatty tissue with the appearance
swelling and hyperemia of the skin of the perineum, pain when pressing on the
this area. During digital examination of the rectum, you can
detect infiltration of the intestinal wall, infiltration in the surrounding intestine
tissues and its protrusion into the intestinal lumen. Upper edge of the bulge with your finger
not achieved
Retrorectal paraproctitis observed in 1.5-2.5% of all
patients with paraproctitis. Characterized by intense pain in the rectum and
sacrum, worse with defecation, in a sitting position, with pressure
on the tailbone. The pain radiates to the thighs and perineum. At
digital examination of the rectum reveals a sharply painful
the swelling of her back wall. From special methods research using
They use sigmoidoscopy, which is informative for pelviorectal pas-
rapproctite. Pay attention to hyperemia and slight bleeding
mucous membrane in the ampoule area, smoothing folds and infiltration
tion of the wall, internal hole fistula tract when an abscess breaks through
intestinal lumen. For other forms, endoscopy is not needed.
Treatment. At acute paraproctitis surgical treatment is performed.
The operation consists of opening and draining the abscess, eliminating
entrance gate of infection. The operation is performed under general anesthesia
I eat. After anesthesia (anesthesia), the localization of the affected area is established.
sinuses (inspection of the intestinal wall using a rectal speculum after insertion
injection of methylene blue solution and peroxide solution into the abscess cavity
hydrogen). If the abscess breaks out through the skin, then
As a rule, further drainage does not occur. With subcutaneous para-
proctitis it is opened with a semilunar incision, the purulent cavity is well
inspect with a finger, separate the bridges and eliminate purulent leaks.
A button probe is passed through the cavity into the affected sinus and excised.
there is an area of skin and mucous membrane that together form the wall of the cavity
with sinus (Gabriel's operation).
With subcutaneous-submucosal paraproctitis, the incision can be made in
radially - from the pectineal line through the affected
anal crypt ( entrance gate infections) on the perianal skin. Then
excise the edges of the incision, the affected crypt along with the internal opening
I eat fistula. A bandage with ointment is applied to the wound, a gas outlet is introduced,
tube into the lumen of the rectum.
For ischiorectal and pelviorectal paraproctitis similar hi
Surgical intervention is impossible, since it will intersect
Most of the external sphincter is covered. In such cases, produce
opening the abscess with a semilunar incision, carefully examining the cavity
it and open all purulent leaks, the wound is washed with peroxide solution
hydrogen and loosely tamponed with a gauze swab with dioxidine
The pancreas is adjacent to spinal column and large vessels of the retroperitoneal space, inflammation is a common lesion of the organ. Emergency operations for acute pancreatitis are carried out in the first hours or days of the disease, delayed surgical interventions are indicated 2 weeks after the development of the pathology. Planned operations are performed to prevent relapses of acute pancreatitis and only in the absence of a necrotic component.
Inflammation is a common organ damage.
Indications for surgical intervention are:
Surgical treatment makes the pathological process stable, pain decreases 2-3 days after surgery. Key manifestation of severe concomitant disease- lack of enzymes.
Before surgery, the extent of damage to the pancreas is determined. This is necessary to select the method of performing the operation. Hospital surgery includes:
The therapy improves blood properties, minimizing microcirculatory disorders is observed.
IN postoperative period the patient must follow special dietary rules. After the operation, complete fasting is required for 2 days. Then you can introduce into the diet:
For the first 7-8 days after surgery, meals should be fractional. Food should be taken up to 7-8 times during the day. The serving size should not exceed 300 g. Dishes should be boiled or steamed. The porridge is cooked only in water; the crackers need to be soaked in tea. Useful vegetable purees, puddings and jelly.
From 2 weeks after surgery, the patient must adhere to the diet prescribed for pathologies of the digestive system. It is recommended for 3 months. Can be used:
Drinking alcoholic beverages after surgery is contraindicated.
Recovery in hospital lasts up to 2 months, during which time digestive tract must adapt to other operating conditions, which are based on the enzymatic process.
After surgical treatment of the pancreas, some consequences cannot be excluded:
The most common complication after surgery is purulent pancreatitis. Its signs:
Exacerbation of Hirschsprung's disease (excision of fragments of the pancreas) leads to persistent constipation. Pancreatic shock promotes necrosis of the remaining part of the gland.
Late complications appear after 12-14 days when the infection enters the body and develops secondary pathological process. Among them are:
As a result of cardiotonic therapy, blood clotting disorders may occur. With moderate interstitial pancreatitis, symptoms of intrasecretory insufficiency appear.
Pancreatic surgery for pancreatitis: consequences, diet, nutrition
Pancreatitis: treatment + diet. Effective treatment pancreas without drugs or with drugs.
Acute pancreatitis is one of the most serious diseases, accompanied by a high mortality rate.
CLASSIFICATION
In Russia they usually use the classification proposed Shalimov(1971).
Acute interstitial pancreat (edema).
Acute hemorrhagic pancreatitis.
Acute pancreatic necrosis.
Acute purulent pancreatitis.
Acute cholecystopancreatitis.
Chronic pancreatitis.
In the USA (Atlanta) in 1992, a new classification of acute pancreati was proposed - -
Acute pancreatitis.
♦ Light form proceeds with minimal disruption of organ function and is easily stopped. The main morphological features of this form are macroscopically - interstitial edema, microscopically - saturation of pancreatic tissue with leukocytes (mainly neutrophils) With small foci of necrosis of acinar cells and peripancreatic adipose tissue.
♦ Severe form (develops in 20-25% of cases) - acute pancreatitis with the development of complications (in the early stages, organ failure, in the late stages - pancreatic infection, accompanied by necrosis of more than 30% of the pancreatic tissue). Macroscopically - extensive necrosis of the surrounding adipose tissue, accompanied by the formation of a turbid hemorrhagic effusion in the abdominal cavity. Microscopically - plaques or confluent zones of necrosis of the pancreatic parenchyma with necrosis of the vascular walls, foci of hemorrhage with rupture of the pancreas
reatic ducts. An important feature is also fat necrosis inside the pancreas and severe inflammation.
Acute fluid accumulation is an accumulation in the tissue or area of the pancreas of exudate rich in pancreatic enzymes (without a tendency to form granulations or capsules), occurring during the first 4 weeks of the development of acute pancreatitis. Infection of accumulated fluid occurs rarely (2.7%), mainly with the development of combined cholecystitis and cholangitis or with large-focal pancreatic necrosis.
Pancreatic necrosis is a diffuse or limited area of non-viable pancreatic parenchyma, usually with concomitant necrosis of peripancreatic tissue and a tendency to infection. Microscopically, the disease is manifested by damage to the parenchymal network of pancreatic capillaries, acinar and islet cells, the ductal system and necrosis of peridolbular fat.
♦ Sterile pancreatic necrosis.
♦ Infected pancreatic necrosis is a common purulent-necrotic lesion of pancreatic tissue and/or peripancreatic tissue by pathogenic microorganisms. It often develops in the early stages of the disease and has a dubious prognosis due to the development of systemic complications (renal failure, bleeding disorders). Systemic complications arise due to the release of toxins and vasoactive substances (endotoxin, trypsin, phospholipase, etc.) from non-viable tissue. The production of these endotoxins depends on the extent of necrosis and the degree of bacterial contamination.
Pancreatic false cyst is an accumulation of pancreatic juice delimited by a pseudocapsule in the pancreas or in the peripancreatic region, resulting from acute pancreatitis 4 weeks or more from the onset of the disease.
Pancreatic abscess is a limited (more than 5 mm in diameter) accumulation of pus inside or in the area of the pancreas, formed as a result of the melting of necrotic tissue or secondary infection of a false cyst. Occurs more often in
relatively late stages diseases after stopping the main process and therefore has a relatively good prognosis. It differs from infected pancreatic necrosis in that the exudate contains little or no non-viable pancreatic tissue. The validity of such a scheme has been confirmed clinically: it has both therapeutic and prognostic significance. Based on this classification, acute pancreatitis is considered as an aseptic inflammation of the pancreas with possible involvement of adjacent tissues, which is based on the processes of necrobiosis of pancreatic cells and enzymatic autoaggression with the subsequent development of necrosis, degeneration of the gland and the addition of a secondary infection.
SURGICAL INTERVENTIONS FOR ACUTE PANCREATITIS
In case of acute destructive pancreatitis, the following surgical interventions are performed (diagnostic laparotomy is not taken into account).
Lumbotomy as an independent access for drainage of the retroperitoneal space (see above).
Laparotomy with drainage of the pancreas
gland through lumbotomy.
Laparotomy, drainage and tamponade
stuffing bag:
♦ only with dissection of the capsule in front of the gland or in combination with surgery on the biliary tract and gallbladder (external drainage of the extrahepatic biliary tract and gallbladder, cholecystectomy);
♦ only without dissecting the capsule in front of the gland or in combination with surgery on the bile ducts and gallbladder.
Laparotomy and omentopancreapexy with deep
chemical suture of the abdominal cavity.
Laparotomy and omentobursopancreatostomy.
Pancreatic resection.
Laparotomy with drainage of the pancreas through lumbotomy
As a rule, this operation is indicated for deep pancreatic abscess or pancreatic necrosis.
270 ♦ TOPOGRAPHIC ANATOMY AND OPERATIVE SURGERY ♦ Chapter 12
Technique. An upper-median laparotomy is performed, mobilizing the splenic angle of the colon and displacing it downwards. By pressing with a finger from the side of the parietal peritoneum between the spleen and kidney, a protrusion is formed along the posterior axillary line in the tenth intercostal space and a layer-by-layer incision of soft tissue is made above it. Moving forward towards the omental bursa, the parietal layer of the peritoneum and the gastrocolic ligament are dissected successively. The drainage tube passed through this channel is placed along the axis on the anterior wall of the pancreas and brought out. The operation is completed by suturing the parietal layer of the peritoneum and the opening in the gastrocolic ligament. Layer-by-layer sutures are applied to the wound.
The drainage channel through the gastrocolic ligament is usually longer and directed obliquely upward, while with lumbar drainage it is straight, short and directed downward (Fig. 12-303).
Laparotomy, drainage and tamponade of the omental bursa
This method is the oldest and most common operation.
Drainage of the omental bursa is carried out by inserting drainage tubes into the opening of the hepatogastric ligament (lig. hepatogastricum) followed by laying them on the front wall
ku of the pancreas without dissecting the cat-sula, since it is sufficiently penetrating
precious and tender, and any manipulation with it can cause bleeding (see Fig. 12-307)
However, before draining the omental bursa, many authors recommend dissecting the pancreatic capsule (in the area of the gland, dissecting the peritoneum is not recommended due to the possibility of vascular damage). According to supporters of this method, decapsulation reduces compression of intraorganic vessels and prevents further destruction of the gland, and drainage of the abdominal cavity promotes excretion from the body toxic substances and prevents the formation of streaks and phlegmons in the retroperitoneal tissue.
Körte(1898) dissected the pancreatic capsule in a checkerboard pattern with 4-5 longitudinal cuts from the head to the tail of the gland. Yeletskaya(1971) recommends cutting the capsule 3 cm from the tail of the pancreas and extending no more than 2 cm towards the head. Ivanov, Molodenkov(I960) after dissection of the capsule, it was additionally peeled off, freeing the anterior and, if possible, other surfaces of the pancreas. The circumferential release of the pancreas prevents the spread of exudate through the retroperitoneal tissue and the formation of phlegmon. Bakulev, Vinogradov(1951) proposed before drainage of the omental bursa in order to limit the pathological focus from the free abdominal cavity
fix the edges of the opening of the gastrocolic ligament to the parietal peritoneum of the wound. If there are necrotic areas, they must first be removed at the border with viable tissues. Protruding droplets of blood indicate the correctness of this manipulation.
Laparotomy and omentopancreapexy with blind suture of the abdominal cavity
Technique. A superomedial paw-rotomy is performed, the gastrocolic ligament is dissected, and the omental bursa is opened. The parietal layer of the peritoneum in front of the pancreas is not dissected. Two flaps of the omentum are cut out on a wide pedicle and covered with them the anterior surface of the pancreas. A drainage tube is left in the omental bursa and the wound is sutured tightly.
Laparotomy and omentobursopancreatostomy
IN recent years This operation is widely used for pancreatic necrosis.
Technique. A superomedian laparotomy is performed and the gastrocolic ligament is dissected for omentobursopancreatostomy. After opening the omental bursa and dissecting the parietal layer of the peritoneum in front of the pancreas, a transverse wedge-shaped incision of the pancreatic tissue is made in the center across its entire width. From the transverse incision, two longitudinal wedge-shaped incisions are made to the sides towards the head and tail of the pancreas until bleeding areas appear (Fig. 12-304).
