duodenal diverticulum surgery

The incidence of duodenal diverticulum is higher, accounting for the second place in the digestive tract diverticulum. Two-thirds are located in the descending duodenum. It is often very close to the duodenal papilla, and about 1/3 is located in the third and fourth segments of the duodenum. Most of the diverticulum is located inside the duodenum, close to the common bile duct and pancreatic head, and some are deeply buried in the pancreatic tissue, closely related to the common bile duct and pancreatic duct, and even the common bile duct and pancreatic duct directly open in the diverticulum. Most of the duodenal diverticulum has no symptoms or no typical symptoms. The occurrence of various symptoms is often associated with complications of the diverticulum. If there is inflammation in the diverticulum, abdominal pain may occur and bleeding may occur. Most of the duodenal diverticulum can be diagnosed by X-ray examination of the upper digestive tract. Treatment of diseases: ulceration, perforation of the stomach, duodenal ulcer, acute perforation Indication 1. The neck of the diverticulum is narrow and has symptoms of retention. The X-ray barium meal examination found that the tincture remained in the diverticulum for 6 hours and remained empty. Diverticulitis and abdominal pain often occur, and long-term medical treatment is ineffective. 2, diverticulum bleeding, perforation or the formation of abscesses. 3, the diverticulum is huge, X-ray shows > 2cm, the common bile duct or pancreatic duct is compressed, causing symptoms of the pancreatic pancreatic system. The incidence of complications in duodenal diverticulum surgery is high, and once it occurs, it is more serious. Therefore, surgical indications must be strictly controlled. Contraindications Duodenal diverticulum with asymptomatic or mild symptoms is generally not required for surgery. Preoperative preparation Surgery in the duodenal diverticulum is not a simple operation, and should not be carried out rashly. Adequate preparation should be done before surgery. In addition to general gastrointestinal surgery preparation, the following preparations should be made: 1. X-ray barium meal examination before surgery to determine the specific part of the diverticulum. The photo should include the right, lateral and oblique positions, and endoscopy and cholangiography should be performed if necessary. Understand the relationship between the diverticulum and the common bile duct and duodenal papilla. A clear understanding of the location and size of the diverticulum helps to determine the surgical procedure. 2. Place the nasogastric tube before surgery. When it is difficult to find a diverticulum during surgery, the stomach tube can be inserted into the duodenum through the pylorus for inflation test, which helps to find the diverticulum. Commonly used surgical methods for the treatment of duodenal diverticulum include diverticulum resection, internal iliac crest, and diverticulum placement. It is easy to expose and free diverticulum, and the smaller diverticulum is feasible for internal suture. Separation and excision of the duodenal diverticulum may damage the bile duct, pancreas or affect the blood flow of the intestinal wall or may cause obstruction of the intestine after internal suture. Surgical procedure 1. Incision Generally, the right upper rectus abdominis incision is used, and the right inferior oblique incision can also be used. 2. Exploring and revealing the diverticulum After entering the abdominal cavity, first explore the upper digestive tract, biliary tract and pancreas, exclude other lesions, and then look for the diverticulum, according to the preoperative examination and diagnosis of the site in different ways to reveal. The diverticulum located in the third and fourth segments of the duodenum should be cut open for the transverse mesenteric membrane. Be careful not to damage the middle cerebral artery. The diverticulum located inside the descending part of the duodenum needs to dissect the medial edge of the descending duodenum and the attachment of the pancreas. The diverticulum located in the posterior part of the descending duodenum should be cut open to the lateral peritoneum of the duodenal descending segment, and the descending segment and the back of the pancreatic head are freed, and the front is turned open to find the diverticulum. If the diverticulum cannot be found according to the above steps, the gastric tube should be inserted into the duodenum through the pylorus, the start of the jejunum should be clamped with the intestinal clamp, and the duodenal bulb should be grasped by hand, and then the right amount of air should be injected from the stomach tube. The duodenum is inflated and the diverticulum is inflated and inflated for easy identification. 3, treatment of the diverticulum After the diverticulum is found, the diverticulum is released. Use a mosquito-type vascular clamp to separate the surrounding tissue along the surface of the diverticulum. Care should be taken when separating. Do not tear the intestinal wall or damage the pancreatic duct and bile duct. After the diverticulum was completely freed, it was cut from the neck of the diverticulum. The incision on the intestinal wall can be sutured with full-layer intermittent suture with No. 0 non-absorbable line, and then sutured with the muscle layer. Note that when pulling the diverticulum, do not use too much force to prevent excessive mucosal resection, resulting in intestinal stenosis after suturing. After the diverticulum resection, the incision of the intestine wall should be horizontally sutured, and the tissue should not be overturned too much. If the neck of the diverticulum is thinner, the muscle layer of the pulp can be cut along the neck. The mucosa and the submucosa are ligated through the suture, and then the diverticulum is removed and the muscle layer is sutured. Resection of the diverticulum near the duodenal papilla or at the opening of the common bile duct and pancreatic duct may affect the anatomy and function of the site, and the cholecystectomy should be performed at the same time. The common bile duct cuts the T-tube drainage or the anastomosis of the duodenal papilla. 4, indoor suture A purse string was made on the intestinal wall around the neck of the diverticulum, and the diverticulum was inserted into the intestine by a vascular clamp, and then the purse string was ligated. 5, duodenal diverticulum A Billroth II partial gastrectomy was performed to place the diverticulum in the duodenum (see "Billroth II Gastric Resection"). 6. Duodenal diverticulum treatment deeply buried in the head tissue of the pancreas Longitudinal incision of the anterior wall of the duodenum, find the opening of the diverticulum in the duodenum, insert a vascular clamp into the bottom of the diverticulum, turn the diverticulum into the duodenal cavity, cut off at the root of the diverticulum, with No. 0 Broken sutures of the wire close the defect in the duodenal inner wall. If the diverticulum is close to the duodenal papilla, the common bile duct can be cut open, placed into the support catheter and passed through the duodenal papilla, reaching the duodenal lumen, and the diverticulum is turned into the duodenal lumen. Inside, the wall of the duodenum is cut open along the root of the duodenal diverticulum, so the duodenal papilla is swam away, and the intermittent thick line indicates the annular incision at the bottom of the diverticulum. After the diverticulum is removed, the support catheter and nipple are placed in the diverticulum. At the defect, the mucosa sutured the duodenal papilla and the duodenal posterior wall of the mucosa, and finally sutured the anterior wall of the duodenum.