RU2655887C1 - Method of sealing of centesis of the abdominal wall after deletion of the troakar during the laparoscopic surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely laparoscopic surgery, and can be used to seal the wound of the abdominal cavity during laparoscopic operations. To do this, a Foley catheter is inserted through the canal of the wound from the punctures to the abdominal cavity. End of the catheter is cut distal to the border of the inflatable cuff of the catheter. Catheter cuff is inflated to a diameter of 10–15 mm and the catheter is pulled out from the abdominal cavity to the outside until a full hermetic contact to the parietal peritoneum. Then, the surgical clamp is applied to the catheter until the skin is fully sealed.

EFFECT: method ensures reliable fixation of the trocar in the tissues of the anterior abdominal wall, allowing to completely seal the abdominal cavity during laparoscopic operations, including when it is necessary to remove or move the trocar to another area of the abdominal wall.

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Description

The invention relates to medicine, namely to laparoscopic surgery, and can be used to close punctures of the abdominal wall after removing the trocar or moving it to another area of the abdominal wall during laparoscopic operations in order to maintain abdominal tightness and save carbon dioxide.

The emergence of complex non-standard intraoperative situations forces the surgeon to increase the efficiency of manipulations to transfer the trocar for endosurgical instruments during laparoscopic interventions to other areas of the abdominal cavity more convenient for manipulations. The wound hole left at the trocar removal site passes carbon dioxide out of the abdominal cavity, which contributes to depressurization of the abdominal cavity, lower pressure of carboxyperitoneum, increase carbon dioxide consumption, worsen video review and conditions for continued intervention, increase the duration of operations, and subcutaneous emphysema forms when the skin is sutured, extending to the upper torso and face. Extraperitoneal insufflation involves the ingress of gas into various tissues besides the abdominal cavity (sc, preperitoneally, retroperitoneally, into the tissue of the greater omentum or mesentery) or the development of complications such as pneumomediastinum or pneumothorax. Subcutaneous emphysema is manifested in the form of swelling and crepitus in subcutaneous fat. The frequency of its occurrence during laparoscopy varies from 0.43 to 2% (Fedorov I.V., Sigal E.I., Slavin L.E. Endoscopic surgery. - M.: GEOTAR-Media, 2009. - 542 p.). The most common cause of gas entering the skin from the abdominal cavity through the trocar openings after accidentally extracting poorly fixed trocars or as a result of incomplete desufflation at the end of the operation. The prevalence of subcutaneous emphysema depends on the volume of gas injected extraperitoneally. Emphysema can reach the tissues of the neck, face, or advance in the caudal direction (pneumoscrotum). However, more often it surrounds the area of introduction of the trocar. Pneumomediastinum - the ingress of gas into the mediastinum. Preperitoneal administration of CO ₂ can lead to its propagation in the sternum in the anterior mediastinum and higher, towards the neck, where the gas forms a dense “collar”. The anesthetist is the first to signal this. The frequency of this complication is 0.03-0.08% (Fedorov I.V., Sigal E.I., Slavin L.E. Endoscopic surgery. - M.: GEOTAR-Media, 2009. - 542 p.).

Pneumomediastinum can occur after dissection of the peritoneum in the area of the esophageal opening of the diaphragm during laparoscopic fundoplication, cardiomyotomy, or selective proximal vagotomy. These operations should be performed under low pressure PP (10-12 mm Hg).

Analogs

Known methods of sealing the abdominal cavity using various pneumatic fixators: Fedorov I.V., Valiullin I.N., Agliullin A.F. At the Department of Endoscopy, General and Endoscopic Surgery GOU DPO KGMA of Roszdrav developed the “Pneumofixer of the trocar” - a device for fixing the trocar in operative laparoscopic access (patent for utility model No. 70113 of January 20, 2008). Balloon fixation trocar, hold-down type Balloon cannula (Origin; USSC) consists of a trocar fixed on it in the distal section of the elastic cuff and a clamping mechanism that fixes the trocar in the immediate access.

Criticism of analogues

A disadvantage of the known methods of sealing is that the tightness of the abdominal cavity is provided only in the presence of a trocar. When a trocar is moved to another area of the abdominal wall, a trocar wound remains, which must be sealed to preserve carboxyperitoneum. The device left on the abdominal wall interferes with the manipulation of the surgeon. Tightness of the abdominal cavity is provided only in the presence of a trocar. When the trocar is moved to another area of the abdominal wall, it leaves a trocar wound, which must be sealed to preserve carboxyperitoneum.

Prototype

The prototype is a method of fixing and sealing the abdominal wall using a laparoscopic trocar placed inside a polymer carrier tube, on which there are two inflatable polymer cuffs. Source of information: Textbook Kazan. Publisher, 2010, p. 54. "Prevention of trocar complications in laparoscopy." Section "Method of fixation of the trocar in the abdominal wall", p. 22-25.

Prototype criticism

An unremoved trocar creates certain inconveniences for the surgeon to manipulate during laparoscopic surgery, especially in a limited area of the abdominal wall. In order to maintain pressure of the carboxyperitoneum in the abdominal cavity, the wound closes with a finger after removing the trocar, which distracts the assistant from the operation. It does not allow to create a stable tightness of the abdominal cavity, causes an excess consumption of carbon dioxide, an increase in the duration of the operation and anesthesia, an increase in the financial costs of the operation, several trocars are used.

The purpose of the invention

The aim of the invention is to develop a reliable system for fixing the trocar in the tissues of the anterior abdominal wall, an effective method that ensures complete tightness of the abdominal cavity during laparoscopic operations, if necessary, remove or move the trocar to another area of the abdominal wall.

The essence of the proposed method

The essence of the proposed method is given in FIG. 1, in a schematic representation of sealing a puncture of the abdominal cavity using a Foley catheter, where after removing the trocar through the remaining wound channel, a Foley catheter (item 1) of the corresponding diameter is inserted into the abdominal cavity. After that, immediately beyond the distal border of the inflatable cuff, the end (pos. 2) of the Foley catheter is cut off. Then, under laparoscopic control, the cuff (item 3) is inflated to the required diameter, but not more than 10-15 mm in diameter. After that, the catheter is pulled from the abdominal cavity outward until the surface of the inflated cuff is firmly in contact with the parietal peritoneum (pos. 4) and the puncture is completely sealed. A clamp (pos. 5) is applied directly to the outer part of the elongated catheter directly on the skin surface, or the catheter tube is ligated with a ligature (pos. 6) until completely tight, followed by fixation to the skin. If necessary, the cuff can be inflated and inflated again during the operation.

An example of a specific application of the method

Patient D., 67 years old, was admitted to the surgical department 3 days after an attack of acute calculous cholecystitis. The patient was disturbed by pain in the right hypochondrium, radiating to the right shoulder blade, nausea, and dry mouth. The pains began to disturb after eating spicy fatty foods. Conservative therapy in (antispasmodics, analgesics, infusion therapy, antibiotics) allowed to stop an acute attack. During the examination, acute calculous cholecystitis was diagnosed. With an objective examination, the abdomen is limitedly involved in the act of breathing, with palpation of the abdomen in the region of the right hypochondrium, the defanation of the muscles of the abdominal wall, positive symptoms of Kera, Murphy and the phrenicus symptom are determined. Ultrasound showed that the gallbladder was enlarged, the wall thickness up to 5 mm, in the lumen there was a cloudy fluid and calculi of different gradations. 02/01/2017, an operation was performed - laparoscopic cholecystectomy. During the operation, due to the unsuccessful installation of 5 mm trocars in the right hypochondrium and the enlarged liver, the trocars crossed during the operation, impairing visualization and creating technical difficulties in manipulations. In this regard, the medial 5 mm trocar was moved slightly below normal localization. At the same time, carbon dioxide escape from the puncture wound, a drop in pressure of the carboxyperiotoneum in the abdominal cavity, worsening visualization was noted. The surgeon’s assistant covered the puncture wound with his fingertip, signs of subcutaneous emphysema of the anterior abdominal wall around the wound appeared. In this regard, through a puncture wound of a trocar previously removed and transferred to another region of the abdominal wall, the Foley catheter was inserted into the peritoneal cavity of 14 Fr. part right at the skin applied a clip. The release of carbon dioxide stopped, the pressure of the carboxyperitoneum stabilized. If necessary, this method can be used without damage to the patient to seal several wounds.

Signs of the invention, distinctive from the prototype method.

Prototype

- A trocar without a stylet is previously introduced into the polymer carrier tube, on which two inflatable polymer cuffs are fixed.

- An air fixator with a trocar is inserted into the abdominal cavity so that the lower cuff is located deeper than the aponeurosis (respectively, the peritoneum), and the lower one is superficial.

The lower cuff is inflated, a trocar with a pneumatic fixator is pulled onto itself, which ensures its fixation at the level of the lower edge of the aponeurosis.

- Then inflate the upper cuff for fixation to the abdominal wall.

Invention

- After removal of the trocar through the remaining wound channel, a Foley catheter of the appropriate diameter is inserted into the abdominal cavity.

- After that, immediately after the distal border of the inflatable cuff, the end of the Foley catheter is cut off.

- Under laparoscopic control, inflate his cuff to the required diameter, but not more than 10-15 mm in diameter.

- After that, the catheter is pulled from the abdominal cavity outward until the surface of the inflated cuff is firmly in contact with the parietal peritoneum and the puncture is completely sealed.

The positive effect of the application of the proposed method

- Provides complete stable sealing of the puncture of the abdominal wall without the participation of an assistant.

- Allows you to maintain a stable intra-abdominal pressure of carboxyperitoneum.

- Saving carbon dioxide.

- The method is convenient for the manipulation of the surgeon during laparoscopic surgery.

- Reducing the duration of surgery and anesthesia.

- Reducing the financial costs of the operation.

- Prevention of subcutaneous emphysema.

- Complete tightness of the abdominal cavity during laparoscopic surgery.

- Stable carboxyperitoneum for the entire duration of the operation.

- Excludes extraperitoneal insufflation of carbon dioxide and the development of subcutaneous emphysema.

- Overspending of carbon dioxide is excluded.

- Reduces the duration of surgery and anesthesia.

- Economic efficiency.

- The device does not interfere with the manipulation of the surgeon.

- Relieves the assistant from monitoring stable carboxyperitoneum.

- Eliminates differences in intra-abdominal pressure during laparosoccal surgery.

Claims (1)

A method of sealing the abdominal wall wound during laparoscopic operations, which consists in introducing a Foley catheter into the abdominal cavity through the puncture wound channel, the end of the catheter is cut off distal to the border of the inflatable cuff of the catheter, the catheter cuff is inflated to a diameter of 10-15 mm and the catheter is pulled out of the abdominal cavity to the outside until complete tight contact with the parietal peritoneum, then a surgical clamp is applied to the catheter near the skin until complete tightness.

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