RU160304U1 - DEVICE FOR ENDOSCOPIC REMOVAL OF HYPERTENSIVE INBRAIN HEMATOMAS - Google Patents

Abstract

A device for endoscopic removal of hypertensive intracerebral hematomas, containing a port made in the form of a tube with a working channel of 10 mm in diameter, one end of which is equipped with a washer and a platform for fixation, and on the other end there are four holes with a diameter of 1 mm for emptying the liquid part of the hematoma after its puncture , on the outer surface of the port notches are applied in 10 mm increments.

Description

The utility model relates to medical equipment, namely to instruments used in neurosurgery. This model can be used for endoscopic removal of hypertensive intracerebral hematomas (hemorrhagic stroke) or other hemorrhages not related to vascular pathology (arterial aneurysms, arteriovenous malformations, etc.).

There are several methods for removing intracerebral hematomas. Moreover, the choice of method depends on the location and size of the hematoma.

The following options for access to the hematoma are possible. For example, by means of osteoplastic trepanation, a small trepanation hole is formed and an encephalotomy is performed directly at the site of closest adherence of intracerebral hematoma to the cerebral cortex. The hematoma is removed by aspiration and washing the wound with sodium chloride solution. Dense blood clots are removed with graduated forceps. Hemostasis is carried out by coagulation of blood vessels, hemostatic gauze or sponge is placed in the cavity of the removed hematoma. Patients with severe intracranial hypertension and cerebral edema, as a rule, undergo wide trepanation of the skull, and if the edema that remains after removal of the hematoma is performed, sheath plastic surgery is performed and a bone flap is removed. mm) using special navigation systems. However, with such removal of the hematoma it is impossible to conduct a thorough hemostasis, which can lead to relapse of the hematoma.

To date, it is known that intracerebral hematomas are removed using tubular expanders, which are made of stainless steel in the form of thin-walled tubes of different lengths. The edges of the tubes are polished, a metal handle is soldered to one of the edges. After diluting the white matter of the brain with spatulas, a dilator tube of a certain length and diameter is introduced into the wound, depending on the depth of the hematoma and the width of the wound, after which the spatulas are removed. Inspection of the cavity and the evacuation of the hematoma is carried out by instruments inserted through the internal opening of the expander tube. After completing all the manipulations, the tube is removed from the brain wound (Lebedev V.V., Ioffe Yu.S., Ostrovskaya IM Surgery of acute cerebral strokes. - M., 1970, p. 223). The disadvantage of the tubular expanders used in this method is the need to use a wide osteoplastic or resection craniotomy in connection with this. When conducting encephalotomy with brain spatulas, it becomes necessary to insert dilators into the wound. This procedure leads to additional brain injury.

It is also known to remove intracerebral hematomas using a funnel-shaped cannula having a height of 40-60 mm, a diameter of a larger base - 23-27 mm, a diameter of a smaller base - 13-17 mm, and a restriction flange of the funnel-shaped cannula expander tube is installed on a larger base. A funnel-shaped cannula is inserted into the hematoma cavity until its smaller base is placed in the hematoma cavity, and the larger base is fixed in the trepanation hole, the dilator tubes are removed and the hematoma is removed (RU 2336030 C1, 10.20.2008). However, the use of such wide cannulas (23-27 mm) is traumatic for the cerebral cortex, which is of fundamental importance in patients who already have a neurological deficit due to destruction of the hematoma tissue. The specified method is adopted by us as a prototype.

The technical result of the claimed utility model is to reduce operational trauma due to the complete elimination of the need for extensive osteoplastic access and the need for extended trepanation for microsurgical access. Reducing the time of surgical intervention by reducing access time and the absence of the need to close a bone defect and suturing large skin incisions (the length of the incision does not exceed 2 cm), which is very important for patients in serious condition and having a concomitant pathology. Ensuring the removal of intracerebral hematomas regardless of their location by any access, due to the optimal diameter and length of the device.

The technical result of the utility model is achieved in that the device for endoscopic removal of hypertensive intracerebral hematomas contains a port made in the form of a tube with a working channel with a diameter of 10 mm, one end of which is equipped with a restrictive washer and a platform for fixation, and at the other end there are four holes with a diameter 1 mm for emptying the liquid part of the hematoma after its puncture, incisions are made on the outer surface of the port with a pitch of 10 mm, a stylet with a diameter of 9.9 mm is located inside the port, one end of which It is in the form of the handle and the other has a blunt conical tip.

The utility model is illustrated by the drawings shown in figures 1-3.

The figure 1 presents a General view of the device in assembled form. In figure 2 - presents the port in the form of a tube. The figure 3 presents a view of the stylet.

A device for endoscopic removal of hypertensive intracerebral hematomas contains a port (1) made in the form of a tube with a working channel with a diameter of 10 mm and a length of the main part of 102 mm. One end of the port (1) is equipped with a washer (2) and a platform (3). Rigid fixation of the port (1) is carried out in the area of its platform (3), which has an uneven surface around the circumference. In this part of the device, fixation is performed using clamps from the standard Karl Storz endoscopic surgery kit. At the other end of the port (1) there are four holes (4) with a diameter of 1 mm for emptying the liquid part of the hematoma after its puncture. Port (1) together with platform (3) has a length of 112 mm. On the outer surface of the port (1), notches (5) are applied in the form of a graduated scale of 10 in increments of 10 mm. This scale is used to visualize and control the depth of the port (1) in relation to the bone landmarks of the skull. Inside the port (1) there is a stylet (6) with a diameter of 9.9 mm and a length of 183 mm, one end of which is made in the form of a handle (7) for a more comfortable grip by hand, and the other has a conical blunt tip (8), which provides atraumatic puncture installation of port (1) in the medulla. Using the stylet (6) allows you to set the port (1) without cutting the brain tissue, through its anatomical non-acute dissection and separation of the fibers.

The presence of a platform (3) at the end of the port ensures the use of any devices currently available for rigid fixation.

The essence of the utility model consists in the possibility of endoscopic removal of hypertensive intracerebral hematomas with the possibility of using a minimum set of microsurgical instruments sufficient to evacuate acute hematoma with minimal risk of damage to the surrounding tissue. An internal diameter of 10 mm at the distal end of the port is sufficient for the simultaneous use of endoscopes of various diameters and suction of sufficient size, for efficient and quick removal of hematomas with minimal trauma to the surrounding brain tissue, and the port length together with the 112 mm platform provides access to the hematoma at any location. Hematoma-type hemorrhages in 85% of cases based on autopsy materials have a typical localization in the subcortical nuclei, cerebral hemispheres and cerebellum. With hemorrhage like a hematoma, its dimensions far exceed the volume of the destroyed tissue. Diapedesic hemorrhages are much less common, being a consequence of primary ischemia of the vascular wall and an increase in its permeability. Such hemorrhages are located mainly in the thalamus or brain bridge.

The device operates as follows.

An incision is made either in the frontal region or in the parietal length of 2 cm, after skeletonization of the bone and the application of a traction hole (diameter 1.2 mm), the port installation trajectory is calculated (1). After that, the dura mater (TMT) is opened and inserted by pushing the device with a blunt stiletto (6) inserted into the port (1) to the hematoma cavity. The external surface of the device is smooth, so when it is installed, the fibers and paths are pushed apart, without the risk of damage. The installation of the port (1) is carried out in a blunt way with the use of a stylet (6) inserted into the port (1) and having no gaps at the distal end in assembled form, which ensures its puncture atraumatic installation at any dissection depth. This type of installation allows for encephalotomy without dissection, with a tomia area not exceeding 10 mm. Existence of the platform (3) for fastening allows to combine port (1) with any fixing systems. If necessary, a navigation system is connected to the distal part of the stylet (6), for more accurate positioning of the port (1) relative to the hematoma cavity. The notches (5) in the form of a graduated scale of 10 and in increments of 10 mm when immersing the port (1) control the depth of its immersion, duplicating the calculations of the navigation system. Given the anatomy of the brain tissue and the average distance to the target point is not more than 100 mm. At the end of the port (1), there is an expansion in the form of a washer (2), with a diameter of 1.4 mm, which prevents the device from submerging more than 100 mm. Next, the stylet (6) is removed from the cavity of the port (1), while, due to the four holes (4) of the port (1), the liquid part of the hematoma is drained to the outside. Then the cavity of the port (1) is used for the unhindered and safe for the brain tissue delivery of instruments (endoscopes, microsurgical suction and bipolar coagulators for endoscopic surgery) to the hematoma cavity and its subsequent removal. In our work, we used the Karl Storz endoscopic complex, which includes ⌀1.9, ⌀2.7, ⌀4.0 mm endoscopes, with an angle of view of 0 °, 30 ° and 70 °, a set of instruments for microsurgery. A rigidly installed port (1) with the help of a platform (5) does not injure the surrounding tissue, except for the surgical course and allows, if necessary, to examine the entire hematoma cavity without additional brain traction. After removal of the main part of the hematoma, the mass effect of the hematoma decreases and the dislocation and compression syndromes regress. Given the port mobility (1), it is possible to inspect the entire hematoma cavity, with control of hemostasis along its periphery. Evacuation of blood leads to the normalization of intracranial relationships: regression of edema, restoration of blood circulation, the creation of the necessary conditions for the restoration of brain functions.

After removal of the main part of the hematoma and cavity inspection, hemostasis is performed using standard coagulation for endoscopic techniques, port (I) is removed, a hemostatic sponge is introduced into the cavity of the channel for the prevention of repeated bleeding. Using the utility model allows to reduce the invasiveness of access, to simplify the technique of removing intracerebral hematomas.

The utility model is illustrated by the following clinical example:

Patient A., 56 years old, was admitted to the center with a diagnosis of acute cerebrovascular accident by hemorrhagic type. Putamennaya hematoma on the left (V = 84 cm ³ ). Right hemiplegia, hemianesthesia, sensory aphasia.

The level of consciousness is stupor (Glasgow Coma Scale 10 points). The patient underwent endoscopic removal of the putamenal hematoma.

Through the incision in the left frontal region, 2 cm long, after skeletonizing the bone and applying the traction hole (diameter 1.2 mm), after calculating the trajectory of the port installation, TMT was opened. Installation of the port in the hematoma cavity was carried out bluntly using a stylet. In this case, using the notches, the immersion depth of the device was controlled, and the washer prevented the immersion of the device by more than 100 mm. The size of an encephalotomy is 10 mm. Through four port openings, the liquid part of the hematoma was drained to the outside. The liquid part of the hematoma was obtained, then the stylet was removed, and the port using the platform was rigidly fixed by the Mitaka fastening system. Under the control of an endoscope, an acute hematoma was removed using a standard 3.5 mm suction. At the end of the operation, the cavity of the removed hematoma was repeatedly washed with physiological 0.9% solution; hemostasis was made in the wound using bipolar endoscopic coagulation. The average operation time is 35 minutes. The hematoma bed is lined with hemostatic gauze. The port is deleted. TMT is sealed tightly. Layered closure of the wound (length 2 cm). Dry dressing.

In the neurological postoperative period, the patient has a restoration of the level of consciousness to a clear one. Hemisymptomatic regression: recovery to a small paresis in the arm and proximal leg. At the time of discharge, elements of motor aphasia are preserved. In this patient, both during the operation and in the postoperative period, the use of a device for the endoscopic removal of hypertensive intracerebral hematomas made it possible to reduce the time of surgery and significantly reduce the trauma of the surrounding brain substance.

Thus, the claimed utility model completely eliminates the need for large, traumatic osteoplastic trepanation in this group of patients. Reduces the time of surgical intervention by reducing access time and the absence of the need for suturing the wound, which is very important for patients in serious condition and having a concomitant pathology. Moreover, the device ensures the removal of intracerebral hematomas regardless of their location by any access, due to the optimal diameter and length of the device, as well as due to its universality of attachment (the ability to use all available rigid fixation systems) and an inner diameter sufficient for adequate minimally invasive access to intracerebral hematomas. The device also reduces the time of surgical intervention by reducing access time and the absence of the need for suturing the wound, which is very important for patients in serious condition and having concomitant pathology.

Claims (1)

A device for endoscopic removal of hypertensive intracerebral hematomas, containing a port made in the form of a tube with a working channel of 10 mm in diameter, one end of which is equipped with a washer and a platform for fixation, and on the other end there are four holes with a diameter of 1 mm for emptying the liquid part of the hematoma after its puncture , on the outer surface of the port notches are applied in increments of 10 mm.

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