JP2018038453A - Paravertebral block set apparatus - Google Patents

Abstract

PROBLEM TO BE SOLVED: To provide a paravertebral block set apparatus capable of performing safe and sure placement of a catheter by using a thoracic cavity port without using a puncture needle when placing the catheter in a paravertebral cavity for a paravertebral block after thoracoscopic operation.SOLUTION: A paravertebral block set apparatus includes: a guide catheter 2 to be introduced, under thoracoscopic observation, to a paravertebral cavity through a thoracic cavity; a stylet 3 attachably/detachably sliding in a lumen of the guide catheter and having flexibility; an injection catheter 1 to be introduced into the guide catheter in replacement of the stylet, where a tip end is disposed at the paravertebral cavity and the rear end, at the outside of the body; and a connector 4 for connecting the rear end of the injection catheter to a drug solution supply route. The tip end of the guide catheter 2 is subjected to drawing, where an inside diameter of a drawn part is formed slightly larger than the outside diameter of the injection catheter. The stylet 3 is preferably formed by including an annealed stainless steel wire.SELECTED DRAWING: Figure 1

Description

  The present invention relates to a set device for a paravertebral block that continuously injects an anesthetic into the paravertebral space for postoperative pain relief during thoracoscopic surgery.

  Thoracic paravertebral block, which is performed to continuously relieve pain after thoracic surgery, administers local anesthetics to the paravertebral space (hatched area in FIG. 6), where the spinal nerve exits the intervertebral foramen With a nerve block that blocks the spinal nerve and sympathetic nerve on one side of the body, there is no significant difference in analgesic effect compared to continuous epidural block on the chest that is performed after many operations and surgery However, the blocking area is limited, such as the nerve blocking on one side of the body, and the risk of complications such as hypotension, nausea and vomiting is said to be low.

  A catheter insertion method is known in which a catheter is placed in the paravertebral cavity in order to implement this thoracic paravertebral block as pain management after thoracoscopic surgery. After pulmonary resection, a puncture needle (epidural needle) for inserting an epidural catheter was percutaneously punctured from the eighth intercostal space while observing the inside of the thoracic cavity with a thoracoscope. The tip of the puncture needle is placed on the outside of the wall-side pleura and advanced to the side of the sympathetic trunk, taking care not to break through the catheter. It is a technique that advances to the head side along the sympathetic nerve trunk and inserts up to the 4th intercostal space. It is intended to perform continuous pain management after surgery by continuously injecting anesthetic into the paravertebral space through the catheter placed by this technique. It has been introduced as a method with low risk of postoperative complications. (Non-Patent Document 1)

Also, as a similar procedure, the catheter insertion needle (epidural needle) was removed from the surgical wound on the posterior axillary line between the 6th and 7th ribs of the patient under thoracoscopic observation before thoracotomy after thoracoscopic lung resection Pierce the side chest wall of the site, introduce the tip of the epidural anesthesia catheter into the thoracic cavity through the insertion needle, remove the insertion needle after introduction, and on the wall side pleura near the sympathetic nerve between the seventh and eighth ribs A small hole is opened with an electric scalpel, and the tip of a surgical sonde is inserted into the thoracic cavity from the thoracoscopic port. Using the sonde, the wall side is parallel to the sympathetic trunk from the small hole of the wall side pleura toward the head side. A tunnel is created outside the pleura, and the catheter tip is inserted under the wall pleura through the small hole in the wall side pleura and advanced to the head side, and the catheter tip is generally placed in the fourth intercostal space as in the above document. . (Non-Patent Document 2)
As instruments for performing these procedures, epidural needles, epidural catheters, and instruments associated therewith are used for epidural anesthesia.

Shuhei Akari, 4 others, "Catheter insertion method for intercostal nerve and thorax paravertebral block in thoracoscopic surgery", [online], 53rd Annual Meeting of the Japanese Lung Cancer Society, November 2012, Japanese Lung Cancer Society, [ Search on July 27, 2015], Internet <URL: http://www.haigan.gr.jp/journal/am/2012a/12a_gvl0200V2-1.html> Hiroshi Sugimura, 7 others, “Study on usefulness of continuous paravertebral nerve block in pain management after thoracoscopic pulmonary resection”, Journal of Japanese Society of Respiratory Surgery, May 2012, Vol. 26, No. 4, p373 (11 ) -P379 (17)

  As in the above literature, in thoracoscopic surgery, it is possible to puncture while observing with a thoracoscope a puncture needle (epidural needle) that serves as a guide when placing a catheter in the paravertebral space. A relatively safe puncture can be expected due to the high visibility compared to the puncture performed under an ultrasonic guide as an indwelling means. However, the puncture is performed percutaneously, and of course, the sharp tip of the puncture needle tip is provided, so that concerns such as visceral pleural puncture cannot be completely eliminated.

  Therefore, in thoracoscopic surgery, a port for inserting an endoscope or treatment tool is provided in the chest cavity during the operation, and attention is paid to the fact that routes already exist outside the body and inside the chest cavity. By using this port to place a catheter in the spinal cavity, a technique that does not use a puncture needle (epidural needle) and an instrument therefor have been studied.

  The present invention is adapted to a procedure in which a catheter is placed in the paraspinal cavity by being introduced into the thoracic cavity through a port introduced into the thoracic cavity from outside the body in thoracoscopic surgery, and tunneling through the thoracic cavity. The objective of this study was to provide a paravertebral blockset device that can be safely and reliably treated.

  The paraspinal block set device of the present invention has a guiding catheter that is introduced into the paravertebral space through the thoracic cavity under thoracoscopic observation, and has flexibility that slides in the lumen of the guiding catheter and is detachable. Having a stylet, an infusion catheter that is introduced into the guiding catheter by replacing the stylet, the distal end is placed in the paravertebral space, and the rear end is disposed outside the body, and the connector that connects the rear end of the infusion catheter to the drug supply route And a drawing process is performed on the distal end side of the guide catheter so that the inner diameter of the distal end side is slightly larger than the outer diameter of the infusion catheter.

  Further, the stylet preferably includes a stainless steel wire having enhanced ductility by annealing, and a part thereof is preferably formed in a curved shape and the tip is formed in a spherical shape. Furthermore, it is more preferable that the front end side of the stylet is formed of a stainless steel wire and the rear end side is formed of a stainless steel wire.

(Function)
According to the paravertebral blockset device of this means, an injection catheter for anesthetic injection can be placed in the paravertebral space by the following procedure.
1. A guide catheter with a stylet set is introduced into the thoracic cavity under thoracoscopic observation from a thoracic cavity port installed in the axilla for thoracoscopic surgery. Here, a puncture needle is not required for setting the introduction route by using the thoracic cavity port installed at the time of surgery for introduction of the catheter.
2. Advance the guide catheter, advance through the thoracic cavity under thoracoscopic observation, puncture the wall side pleura with the tip of the stylet, and further advance under the wall side pleura so that the tip side of the guide catheter becomes the paravertebral space Set to. Here, since the tip of the stylet has a spherical shape, pleural puncture and catheter introduction can be safely advanced.
3. The stylet is removed from the guide catheter, the infusion catheter is inserted through the guide catheter lumen, and the tip is introduced to the same paravertebral space as the tip of the guide catheter.
4). While maintaining the position of the injection catheter, the guide catheter is removed, a connector is attached to the rear end of the catheter, and an anesthetic is injected. Here, the distal end side of the guiding catheter is drawn to a small diameter so that the rear end side with a large outer diameter is easy to insert a stylet or catheter, and includes the abutment portion with the pleural puncture portion. Is reduced in diameter and close to the outer diameter of the infusion catheter to keep the perforation small and prevent leakage of the medicinal solution into the thoracic cavity due to the injection of anesthetic solution.

  In addition, the annealing process increases the ductility of the stainless steel wire, so that it can be provided with flexibility that is advantageous for introduction while maintaining the required strength. By increasing the flexibility, it is possible to adapt to the bending of the insertion path. In addition, when the stylet is formed in a curved shape in advance, the shape can be anatomically adapted to the introduction route from the chest cavity port located in the axilla through the chest cavity to the paravertebral cavity. Furthermore, when the stylet tip is formed in a spherical shape, there is little risk of damaging the tissue during insertion into the thoracic cavity or paravertebral cavity, and the wall side pleura can be pierced.

  According to the paravertebral blockset device of the above means, the placement of the anesthetic injection catheter to be introduced into the paravertebral space in thoracoscopic surgery does not require a puncture needle for percutaneous puncture, and this catheter introduction It can be set as the safe instrument which can perform a procedure under thoracoscopic observation. Then, after a thoracoscopic operation, a set device suitable for a procedure that is introduced into the thoracic cavity through a port installed in the thoracic cavity from outside the body and tunnels through the thoracic cavity to place a catheter in the paravertebral cavity is provided. be able to.

The whole block diagram of the paraspinal block set instrument of embodiment of this invention. The block diagram which shows the guide catheter and stylet of the said form. The tip side partial enlarged view of the guide catheter of the said form. The front end side partial enlarged view of the stylet of the said form. The enlarged view of the front-end | tip part which shows the stylet of the type which curved the front-end | tip. The schematic diagram which shows the position of a paraspinal cavity.

Hereinafter, embodiments of the paraspinal block set device of the present invention will be described in detail with reference to the drawings.
FIG. 1 shows a guide catheter and a stylet, an infusion catheter, and a connector set in the overall configuration diagram of the present embodiment, and FIG. 2 shows a guide catheter and a stylet in a separated state.

  The paraspinal block set device of this embodiment tunnels the intrathoracic cavity 6 using the thoracic cavity port provided in the axilla after pulmonary resection surgery to continuously relieve postoperative pain in thoracoscopic surgery, and the ribs It is used to place a catheter for continuously injecting anesthetic into the paravertebral space 5 (hatched portion in FIG. 6) existing as a wedge-shaped gap on the dorsal side of the wall-side pleura 61 between the head and the radial neck.

  The paraspinal block set device includes an infusion catheter 1 for injecting the anesthetic and a guide catheter for forming a passage serving as a guide for introducing the infusion catheter 1 from the thoracic cavity port into the paravertebral space 5 through the intrathoracic cavity 6. 2, a stylet 3 that is detachably inserted in the lumen of the guide catheter 2, reinforces the guide catheter 2, and integrally forms a passage for introducing the injection catheter 1, and a rear end portion of the injection catheter 1 Is constituted by a connector 4 for connecting the liquid crystal to the chemical solution supply route.

  The infusion catheter 1 may be the same as a general-purpose epidural anesthesia catheter formed of a flexible resin, the distal end 11 is closed to form a spherical surface, and a medical solution discharge port is provided on the distal side surface. A plurality of side holes 12 are provided. Although the size is not specified, in this example, a fluororesin having an outer diameter of 1 mm and a length of 950 mm was used, and an X-ray opaque tube was used so that the indwelling position could be confirmed.

FIG. 3 shows an enlarged view of the distal end portion of the guide catheter.
The guide catheter 2 includes a guide catheter main body 21 and a catheter base 22 serving as a gripping part and an operation part. The catheter main body 21 is made of a relatively stiff fluororesin, and the inner diameter of the catheter tip side is injected by a drawing process 212. The diameter is reduced to be slightly larger than the outer diameter of the catheter 1. The size is not particularly specified as long as it is selected according to the size of the infusion catheter 1, but in this example (outlet catheter outer diameter 1 mm), the outer diameter of the portion without drawing is 1.78 mm, and the total length is At 350 mm, the rear end portion was subjected to opening processing to form a connection portion with the catheter base 21. The distal end side of about 57 mm is narrowed to a diameter that allows the infusion catheter 1 to pass through the lumen as the small diameter portion 213. In this example, the drawing portion 212 was processed with a 1.37 mm die and a 1.05 mm core, and the tip portion 211 was rounded.

  The catheter base 22 has a configuration in which the base end of the catheter main body 21 subjected to the opening process is sandwiched and fixed by the catheter base body 221 and the catheter base cap 222, and the rear end of the catheter base body 221 is attached to the stapler 223. The structure is formed and fitted with the stylet base 34.

FIG. 4 shows an enlarged view of the tip portion of the stylet.
The stylet 3 is composed of a stylet main body 30 and a stylet base 34 serving as a gripping portion. The stylet main body 30 is made of a metal such as stainless steel having an outer diameter substantially the same as the outer diameter of the infusion catheter 1, and the guide catheter 2. When set in the lumen of the guide catheter 2, the guide catheter 2 is formed with a length slightly projecting from the distal end 211 (2 mm in this example), and the distal end side is adapted to the introduction route from the chest cavity 6 to the paravertebral cavity 5. An annealed wire 31 obtained by annealing a stainless steel wire that has a strength for exfoliating the tissue and is annealed is used, and a stranded wire 32 of a stainless steel wire is used on the base side, giving priority to flexibility. And in this example, in order to connect the annealing wire 31 and the twisted wire 32, it connected by crimping using the connection pipe 33. In addition, the anneal line 31 is graduated 312 at intervals of 10 mm to serve as an index of the length of projection from the pleura to the paravertebral space 5 after the puncture of the wall-side pleura 61, and the tip 311 has a hemispherical shape for pleural rupture and separation Formed. Here, the size in this embodiment is applied to the length of the narrowed portion (small diameter portion 213) of the guide catheter 2, and the length of the annealed wire 31 portion on the distal end side is 65 mm, which is slightly smaller than the small diameter portion 213. The entire length including the stranded portion 32 was formed so that the tip 311 slightly protrudes when set on the guide catheter 2 as described above. In addition, in this example, the twisted wire 32 of the stainless steel wire giving priority to flexibility is used on the base side of the stylet 3, but the whole is functional as a single annealed wire 31 without using this. This is advantageous in terms of cost.

  The stylet base 34 is connected by bonding at the base end portion of the stylet 3, and is configured to be fitted by the catheter base 22 and the male taper 341 when setting the guide catheter 2 and the stylet 3.

  FIG. 5 shows a stylet of a type whose tip is curved in advance. In this type, a curvature of R300 is formed in advance on the annealed wire 31 portion of the stylet 3 (about 65 mm from the tip). By applying this curvature, the guide catheter 2 is introduced into the paravertebral space 5 from the thoracic cavity 6 to facilitate the anatomical operation.

  The connector 4 for connecting the rear end portion of the infusion catheter 1 to the drug solution supply route is not particularly specified as long as the connector similar to the connector for connecting to the epidural catheter is used. The tightening ring 43 having rubber elasticity having a hole 431 penetrating the infusion catheter 1 is sandwiched between the clamp body 41 and the clamp cap 42 and crushed to reduce the inner diameter of the through hole 431 and tighten the infusion catheter 1 In this case, one that can be fastened with one touch by rotating the clamp lever 44 is used.

  FIG. 6 is a cross-sectional view around the vertebra showing the approximate position of the paravertebral space that is the site of anesthesia during thoracoscopic surgery to which the present instrument is applied. The hatched portion in the figure is the range of the paravertebral space 5, and the space between the wall-side pleura 61 and the visceral pleura 62 is the thoracic cavity 6 and serves as a catheter introduction passage. The range of the paravertebral space 5 is between the external intercostal muscle 72 and the wall side pleura 61 and the internal intercostal muscle 71, from the vertebral body including the spinal cord 9 between the vertebral body 91 and the vertebral arch 92 through the intervertebral foramen. It exists in a wedge shape where the spinal nerve comes out.

The use of the instrument of the present invention in thoracoscopic surgery is as described above, but will be described again in conformity with this embodiment.
1. During the thoracoscopic surgery, the guide catheter 2 with the stylet 3 set is introduced into the thoracic cavity 6 from the thoracic cavity port leading to the intrathoracic cavity 6 set in the axilla.
2. Under the thoracoscopic observation, the guide catheter 2 is advanced to the vicinity of the paravertebral space 5 using the intrathoracic cavity 6 as a passage with the support of forceps.
3. The wall side pleura 61 is punctured by the stylet tip 311 in the vicinity of the paravertebral space 5.
4). Further, the guide catheter 2 is pushed under the wall side pleura using the scale 312 of the stylet 3 as an index, and the distal end portion of the guide catheter 2 is positioned in the paravertebral space 5. At this time, care should be taken so that the small-diameter portion 213 of the guide catheter 2 is not inserted beyond the wall-side pleura 61. (The pierced part is placed in the small diameter part 213)
5. When the distal end portion of the guide catheter 2 is located in the paravertebral space 5, the stylet 3 is removed from the guide catheter 2, and the injection catheter 1 is introduced into the guide catheter 2 instead.
6). When the infusion catheter 1 is introduced for the length of the guide catheter 2 and the distal end portion of the infusion catheter 1 is located in the paravertebral space 5, the position of the infusion catheter 1 is maintained and the guide catheter 2 is removed.
7). The position of the infusion catheter 1 is confirmed by X-rays, and if confirmed, the chest port or the like is removed and a procedure such as suturing is performed.
8). The connector 4 is connected to the proximal end of the infusion catheter 1 to start continuous infusion of anesthetic.

  By using this device as described above, it is not necessary to use a puncture needle to place the infusion catheter 1 in the paravertebral space, and the guide catheter 2 and the stylet 3 that serve as a guide for introduction are sharp. Since there is no cutting edge, the procedure can be performed safely. In addition, by suppressing the outer diameter of the guide catheter that hits the puncture site of the wall-side pleura to the paravertebral space as much as possible compared to the outer diameter of the infusion catheter, there is a possibility that the injected drug solution will leak into the thoracic cavity. It is small.

1. Infusion catheter 11. Catheter tip 12. Side hole Guide catheter 21. Catheter body 211. Catheter tip 212. Drawing section 213. Small diameter part 22. Catheter base 221. Catheter basic body 222. Cap 223. Messtaper 3. Stylet 30. Stylet body 31. Annealed wire 311. Tip 312. Scale 32. Stranded wire 33. Connection pipe 34. Stylet group 341. Osteper 4. Connector 41. Clamp body 42. Clamp cap 43. Tightening ring 44. Crank lever 5. Paravertebral space 6. Thoracic cavity 61. Wall side pleura 62. Visceral pleura 71. Internal intercostal muscles 72. External intercostal muscles 8. Sympathetic trunk 9. Spinal cord 91. Vertebral body 92. Larch

Claims (5)

  A guiding catheter introduced into the paravertebral space through the thoracic cavity under thoracoscopic observation, a flexible stylet that slides in the lumen of the guiding catheter and is detachable, and replaces the stylet An infusion catheter that is introduced into the guide catheter and has a distal end disposed in the paravertebral space and a rear end disposed outside the body, and a connector that connects the rear end of the infusion catheter with a drug solution supply route. A paravertebral block set device characterized in that the distal end side is subjected to a drawing process in which the inner diameter of the distal end side is slightly larger than the outer diameter of the infusion catheter.   The paravertebral blockset device of claim 1, wherein the stylet includes a stainless steel wire having enhanced extensibility by annealing.   3. The paravertebral block set device according to claim 1, wherein a part of the stylet is formed in a curved shape.   4. The paravertebral block set device according to claim 1, wherein the stylet has a spherical tip.   5. The paravertebral block set device according to claim 1, wherein the stylet is formed of a stainless steel wire on a front end side and a stranded wire of a stainless steel wire on a rear end side.

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