RU2493804C1 - Method of stopping hemorrhage from presacral venous plexus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery. Hemorrhage from sacral venous plexus is stopped by means of tamponade. Tamponade is carried out with thin elastic plates, made from porous-permeable titanium nickelide.

EFFECT: method makes it possible to reduce hemorrhage, increases reliability of hemorrhage stopping, as well as to reduce operation duration, due to application of plate from biocompatible titanium nickelide.

3 ex, 2 dwg

Description

The invention relates to medicine, specifically to surgical means for absorbing or blocking cavities in the human body during surgery.

Presacral venous plexus is one of the most difficult places in terms of stopping intraoperative bleeding. The main nosologies in the treatment of which surgeons experience bleeding from the presacral venous plexus are locally advanced rectal cancer and non-organ retroperitoneal tumors.

With comprehensive access to the resection area, intraoperative bleeding, as a rule, can be stopped by stitching tissues. However, comprehensive access is severely limited if the tumor process affects the sacral fascia, as well as the anterior longitudinal ligament of the sacrum covering the sacral bone. At the same time, stitching becomes ineffective, since the crossed veins are reduced and go deep into the sacral openings. Electrocoagulation also becomes equally ineffective. Meanwhile, damage to the veins of the presacral plexus (also referred to as the sacral or sacral plexus in various sources) is quite common. So, according to the source [Intraoperative stop of profuse bleeding from the sacral veins during extirpation of the rectum // A.I. Abelevich, G.A. Seropyan, E.N. Patzenker // State Medical Academy, Nizhny Novgorod. 1999 (see http://www.medicum.nnov.ru/nmj/2002/1/27.php)], damage to the veins during extrusion of the rectum occurs in 1-1.5% of cases. According to the source [Direct results of surgical treatment of non-organ retroperitoneal tumors // Stilidi I.S., Gubina G.I., Nered S.N., Klimenkov A.A., Selchuk V.Yu., Tyurin I.E., Melikov S.A., Bolotsky V.I., Kakiashvili N.N. (Russian Cancer Research Center named after NN Blokhin) // Bulletin of the Moscow Cancer Society, meeting No. 528 May 25, 2006 (see http://oncodome.narod.ru/society/v06-5.htm)], with surgical treatment of retroperitoneal tumors in 132 patients recorded 6 cases of bleeding from the presacral venous plexus, which is 4.5%. These statistics are the basis for finding an effective way to ensure hemostasis.

Among the known methods of stopping bleeding from the presacral venous plexus, the most effective is the mechanical tamponade of the bleeding zone [Intraoperative stop of profuse bleeding from the sacral veins during extirpation of the rectum // A.I. Abelevich, G.A. Seropyan, E.K. Patzenker // State Medical Academy, Nizhny Novgorod. 1999 (see http://www.medicum.nnov.ru/nmj/2002/1/27.php)]. Tight tamponade is carried out with gauze tampons. This method is closest to the claimed.

However, the known method is not without drawbacks, the main of which is low reliability, great blood loss and a long duration of the procedure. For example, according to the source [Retroperitoneal giant schwannomas: Report on two cases and review of the literature // Schindler OS, Dixon JH, Case P. // Journal of Orthopedic Surgery, 2002, 10 (1), pp 77-84.] , when stopping bleeding from the presacral venous plexus, a tight tamponade was maintained for 48 hours, after changing tampons until the bleeding stopped completely for another 48 hours, the total blood loss was 24 liters, more than 100 packages with blood and plasma were used to compensate for it. In the same source, cases of refusal of surgical intervention due to the risk of bleeding are mentioned.

The technical result of the invention is to increase reliability, reduce blood loss, reduce the duration of the procedure.

The claimed result is achieved by the fact that when implementing the method of stopping bleeding from the presacral venous plexus, including tamponade of the bleeding zone, the difference is that the tamponade is produced by thin elastic plates made of porous-permeable titanium nickelide.

The invention is illustrated by figures 1 and 2:

Figure 1 - appearance of porous-permeable plates of titanium nickelide.

Figure 2 (a-c) - radiographs of patients with implanted clipping plates of porous-permeable titanium nickelide

The attainability of the technical result is illustrated by the following. Porous-permeable titanium nickelide [Biocompatible porous permeable materials // Khodorenko V.N., Yasenchuk Yu.F., Gunther // in the book. Biocompatible materials and shape memory implants. - Tomsk: Northampton, 2001. - S.9-24], is characterized by a number of properties that provide the necessary effect if used as a tamponing material. These properties include: biocompatibility, a wide range of reversible deformations, high adhesive ability and natural surface roughness. The appearance of the plates used in the inventive method is shown in figure 1. Thanks to easy deformability and roughness, thin plates easily adapt to an uneven surface and are fixed in a given position. The material can be molded (if necessary) using scissors. Having a pore size distribution controlled during the synthesis, the material is well wetted by body fluids, allowing tissue fluid and red blood cells to quickly penetrate deep into. In this case, blood clots are formed directly in the porous structure of the plate, thus additionally fixing the implant to the tissues, which ensures high reliability. It has been experimentally confirmed that the clipping effect is manifested simultaneously, with minimal blood loss. Subsequently, the plates remain implanted. They behave and deform in accordance with the laws of elastic behavior of body tissues, which is important on concave, uneven surfaces of the sacrum. Unlike gauze swabs, plates of biocompatible titanium nickelide do not need subsequent extraction, which could lead to a relapse of bleeding.

The effectiveness of the proposed method is confirmed by a number of clinical examples.

1. Patient K., 47 years old, was treated in the surgical department of the Tomsk Regional Oncology Center with a diagnosis of non-organ retroperitoneal pelvic tumor. According to the MRI of the pelvic organs retroperitoneally in the small pelvis was determined education, with a diameter of up to 4.5 cm, without communication with the surrounding organs. Under combined anesthesia, the lower median laparotomy was performed. After opening the peritoneum and mobilizing the posterior and right lateral walls of the rectum, it was found that the tumor is located under its own fascia of the sacrum. Education on a broad basis, the right ureter is “flattened” over its surface - phased out, taken to the turnstile. In an acute way, the tumor is separated from the periosteum of the sacrum. Bleeding from her bed and sacral veins was initially stopped by tight tamponade (blood loss 250.0-300.0 ml). After extracting the compresses, the ongoing bleeding was stopped by pressing 3 plates (in area) of porous titanium nickelide to the bed of the removed tumor (Fig. 2a). The postoperative period was satisfactory, healing by primary intention. An extract from the hospital for 14 days.

2. Patient S., 71 years old, was treated in the surgical department of LLPD with a diagnosis of Cancer of the upper ampullar part of the rectum. Upon further examination, a tumor of the upper ampullar part of the rectum with stenosis.

Under combined anesthesia, a lower-median laparotomy was performed .. Tumor of the upper-ampullar part of the rectum, palpation-circular; all the layers of the wall grow on the front surface. Along the length of the intestine up to 6-7 cm. The lower pole of the tumor at the level of the pelvic peritoneum. The rectum is mobilized to the muscles of the pelvic floor. Along the lines of the proposed resection, the intestine is stitched with UO-60 devices. The drug is removed. Through the formed “window” in the anterior abdominal wall of the left ileal region, the sigmoid colon is withdrawn in the form of a single-barrel anus praeternaturalis. (Operation Hartmann). When controlling for hemostasis, bleeding from the sacral vessels was detected. Temporary hemostasis with a hot compress. After removing the compress, bleeding continues. Performed hemostasis by pressing plates of porous titanium nickelide (fig.2b). The postoperative period was satisfactory. Primary healing. Extract from the hospital on the 13th day.

3. Patient A. - 71 years old. 02/16/2011 Diagnosis: Tumor of the upper ampullar part of the rectum, palpation-circular; all layers of the wall grow on the front surface. Along the length of the intestine up to 6-7 cm. The lower pole of the tumor at the level of the pelvic peritoneum. After performing a “lyre-shaped” incision along the sigma mesentery and the peritoneum of the small pelvis in the acute way and bluntly the rectum is mobilized to the muscles of the pelvic floor. The main vessels intersected between the clamps with their double ligation. Along the lines of the proposed resection, the intestine is stitched with UO-60 devices). The drug is removed. After an additional assessment, the application of an inter-intestinal anastomosis was deemed technically impossible. The sigmoid colon through the formed “window” in the anterior abdominal wall of the left iliac region is brought out to the anterior abdominal wall and is fixed by a double-row suture - in the form of a single-barrel anus praeternaturalis. When controlling for hemostasis, bleeding from the sacral vessels was detected. Temporary hemostasis with a hot compress. The mechanical suture on the resected rectum is additionally immersed in two half-sutured sutures (vikril). After removing the compress, bleeding continues. Hemostasis was performed by pressing the plates of porous titanium nickelide (Fig. 2c) - with repeated control “dry”. An ointment swab was brought into the pelvic cavity through a presacral contraperture. Through an additional incision in the anterior abdominal wall of the right iliac region, a tampon with a drainage tube is brought. With repeated controls on hemostasis - dry. Control on foreign bodies with napkin counting. The defect of the pelvic peritoneum with separate sutures was restored. After repeated control on hemostasis and foreign bodies, the abdominal wall is sutured in layers. Aseptic dressing.

These cases clearly demonstrate the effectiveness and simplicity of the method for stopping bleeding from the presacral venous plexus using plates of porous titanium nickelide.

This method not only prevents massive blood loss that occurs when trying to stop the bleeding in other ways, often alternating with each other and taking longer, but also makes it possible to complete the operation in full, planned volume, even if bleeding occurred at the beginning of the mobilization of the tumor process.

Claims (1)

A method of stopping bleeding from the sacral venous plexus, including tamponade of the bleeding zone, characterized in that when it is carried out, tamponade is produced by thin elastic plates made of porous permeable titanium nickelide.

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