RU195088U1 - Surgical access extension device - Google Patents

Abstract

The utility model relates to medicine, namely to surgery - devices for expanding operative access when performing transcutaneous puncture-draining interventions mainly in patients with acute destructive pancreatitis. The technical result solved by the claimed utility model is to simplify the design of the device, ease of use in the process of timely replacement drainage of cavity formations into larger ones in diameter or installation of two drainages simultaneously. The device contains an expander with tapering working end, the outer tube and conductor, made in such a way that the expander has a through channel for conducting the conductor, a cross-shaped handle at the proximal end, and its distal part has a threaded conical end, the outer tube has a distal end sharpened around the perimeter at an angle of 30 ° and a grooved surface on 1/4 of the proximal end.

Description

The utility model relates to medicine, namely to surgery - devices for expanding operative access when performing transcutaneous puncture-draining interventions mainly in patients with acute destructive pancreatitis.

Currently, minimally invasive technologies are becoming more common in the surgical treatment of acute destructive pancreatitis, due to the less traumatic nature of these interventions and the possibility of their use in the most severe patients. At the same time, acute destructive pancreatitis is a process proceeding in time, during the evolution of which a regular change in the phases and periods of the disease is observed, which have important pathomorphological and pathophysiological features. In accordance with this, the requirements for surgical treatment of acute destructive pancreatitis, in particular, minimally invasive interventions, vary significantly depending on the period and phase of the disease. So, in the 1st phase of the disease (phase-pancreatogenic toxemia), transcutaneous punctures and drains under ultrasound navigation are best suited to remove acute fluid accumulations from the abdominal cavity, since even minimal in volume and duration laparoscopic and traditional open surgical interventions under anesthesia are accompanied by extremely high mortality reaching 30-60% in the most severe patients. (Surgical technologies for minimally invasive treatment of acute severe pancreatitis: guidelines No. 9 / edited by M.Sh. Khubutia. - M., 2017. - 40 p.)

For this purpose, tubular catheters of small caliber (from 8 - 12Fr) are most often used. However, the further transition of the pathological process into the 2nd phase - the phase of destructive complications (7-10th day from the onset of the disease), characterized by sequestration of pancreatic infiltrate and / or the formation of immature (unformed) pseudocysts, requires the use of larger-caliber drains (up to 20 mm) . This is especially important during the development of purulent-destructive complications of acute pancreatitis (approximately from the 2-3rd week of the disease), when on average in 40-70% of patients infection of aseptic zones of necrosis occurs, which can be delimited (infected unformed pseudocyst, pancreatogenic abscess) or unlimited (retroperitoneal pancreatogenic phlegmon) purulent inflammation. In such conditions, the main task in the treatment of this category of patients is also the creation of conditions for the adequate removal of purulent exudate from the lesion.

According to most clinicians (Surgical technologies for minimally invasive treatment of acute severe pancreatitis: guidelines No. 9 / edited by M.Sh. Khubutiya. - M., 2017. - 40 pp.), From the point of view of the possibility of radical rehabilitation of the foci of destruction, one extensive access, which opens all the purulent-necrotic foci into one large wound, at the present stage does not have visible advantages over local limited accesses, sequentially performed in the projection of the foci of destruction as they "mature". Therefore, at present, the use of transcutaneous puncture-draining interventions under radiation control is associated with such a problem as the need for subsequent expansion of surgical access if it is necessary to replace tubular catheters with larger ones in diameter.

A device for drainage is known, comprising a tube and a rod placed in its lumen with a sharp working end and with a handle on the outer end, the tube being made shorter than the rod, characterized in that the second tube is placed on the rod, while the tubes are joined by ends with lateral perforations, and the rod consists of two parts with the possibility of separating them and removing them from the tubes, moreover, an external thread is made at the back of the rod, on which a nut is placed between the handle and the tube, and a cone is made at the working end of the rod ovidnoe extension of the rear support plate, the diameter of which is not smaller than the outer diameter of the tube (Russian patent №2329833, published 27.07.2008).

2. The device according to claim 1, characterized in that a longitudinal groove with an internal thread for the external thread of the protrusion made at the abutting end of the other part of the rod is made on the abutting end of one part of the rod.

3. The device according to p. 1, characterized in that the metric divisions on the surface of each tube are counted from the end that is joined to another tube.

The disadvantage of this technical solution is the impossibility of its use in the intra-abdominal localization of the pathological lesion, as through drainage in this case is accompanied by an extremely high risk of damage to the abdominal organs.

A known tool for expanding a wound with a cut, containing a handle, characterized in that it consists of a metal rod with a diameter of not more than 4 mm, curved at a distance of 1/3 from the distal end in an arc of 40-45 mm radius and ending with a spherical thickening, the diameter of which is 1 mm larger than the diameter of the rod, while the handle is ring-shaped and located at the proximal end of the metal rod, and the plane of the handle ring is perpendicular to the plane of the arc of the distal end of the rod and the plane of the cutting blade lying in the plane the speed of the arc and attached to the straight part of the rod before the start of the arc (RF patent No. 2393791, published July 10, 2010).

The disadvantage of this technical solution is the inability to use this device in the conditions of ultrasonic navigation surgery, since there is a risk of damage to internal organs when performing this manipulation.

A device is known as a retractor comprising a housing and a detachable tube, characterized in that the housing is made in the form of two coaxially arranged rings mounted for rotation relative to each other, and is equipped with an element for fixing the position of the rings made in the form of a screw, the tube is made of three parts, each of which is equipped with two opposed brackets, one end of one of the brackets placed in the socket of the inner ring, and the end of the other bracket passing through the grooves of the inner and outer th rings, it is made of a biologically and chemically inert material (RF Patent №103290, published 10.04.2011).

This device, designed for use with videoassisted mini-laparotomy for operations from mini-access, consists of a large number of parts, which makes it technically difficult and its use labor-intensive.

A device for monitoring the abdominal cavity, containing a port in the form of a pipe with a channel for introducing a tool, divided by a flange into the intracavitary part and the handle, characterized in that it is equipped with a tee with a cylindrical outer surface having a central circular hole with a side outlet, and a lid having a central an opening with a sealing collar, while on the handle there is a landing hole for a tight and detachable connection with a tee, moreover, on the outer surface of the tee and handle polyene annular groove for sealing releasable connection with flange lid, and the inner part of the port is provided with a metal or plastic reinforcement in the form of a helical spring which generates undulating inner surface nozzle intracavitary portion of the device (RF patent №2542370, published 06.20.2014).

The disadvantage of this technical solution is the impossibility of its use if it is necessary to perform transcutaneous drainage of the pathological lesion under ultrasound control.

From the existing level of technology, the closest technical solution, in our opinion, is a device for percutaneous drainage of cavity formations (RF patent No. 118854, published 10.08.2012), containing a needle with a holder, a mandrin installed inside the needle, an outer tube with a holder, while the needle made with a sharpened cut of the working end, characterized in that it is equipped with an expander located on the outer tube and a trocar placed on it, while the outer tube and expander have tapering working ends, the outer tube is shorter than the length of the needle and the mandrel, but greater than the length of the trocar and dilator, the tapered end of the dilator has a working surface that ensures its smooth entry into tissue. The device according to claim 1, characterized in that the surface providing a smooth entry of the expander into the fabric is made in the form of either a tapered thread or a tapered surface.

This method is chosen by us for the prototype.

The disadvantages of the prototype device are the technical complexity and the complexity of manufacturing and use.

These shortcomings are eliminated in the claimed technical solution.

The objective of the utility model is to develop a device that is easier to use, which will not allow time sharing of the introduction of larger diameter catheters when draining fluid abdominal cavity formations under radiation control in patients with acute destructive pancreatitis.

This problem is solved due to the fact that the device for expanding surgical access contains an expander with a tapering working end, an outer tube and a conductor made in such a way that the expander has a through channel for the conductor, a cross-shaped handle is made at the proximal end, the distal part of the expander has a threaded conical end, the outer tube has a distal end sharpened around the perimeter at an angle of 30 ° and a corrugated surface on 1/4 of the proximal end.

The technical result solved by the claimed utility model is to simplify the design of the device, the convenience of its use in the process of timely replacement of drainage of cavity formations with larger ones in diameter or installation of two drainages at the same time.

The technical result is provided by the given set of features: the expander has a cruciform ergonomic handle at the proximal end, which ensures reliable performance of rotational movements when it is screwed into the pathological cavity. The path of the "entrance" of the tool is defined by a rigid metal conductor with a diameter of 5.2 mm, which is introduced into the through channel of the expander, thereby ensuring the accuracy and reliability of the input device. Uniform spreading of the tissues is provided by the distal threaded conical end of the expander and the distal end of the outer tube sharpened around the perimeter at an angle of 30 °, and its smooth entry with a smooth surface. The corrugated part 1/4 of the length of the outer tube provides a more reliable fixation in the hands of the surgeon, prevents the device from sliding and falling out of the cavity during surgical manipulation.

The essence of the proposed device for expanding surgical access is illustrated by the following description and drawings, where:

In FIG. 1 - shows the conductor, outer tube, expander;

In FIG. 2 - shows a General view of the inventive device for expanding surgical access;

Detailed description of utility model

части наружной трубки 1 имеется рифленая поверхность длинной 4 см, что обеспечивает ее надежную фиксацию в руках хирурга и предупреждает выскальзывание при извлечении самого устройства для расширения доступа из тканей в условиях работы в стерильных перчатках. Дистальная (нижняя) часть наружной трубки 1 имеет заточенный по периметру под углом 30° конец, что облегчает беспрепятственное прохождение инструмента через ткани.A device for expanding surgical access consists of a metal outer tube 1 up to 16 cm long and 15 mm in diameter for conducting large-caliber drainage tubes. In the proximal (upper)

part of the outer tube 1 has a corrugated surface 4 cm long, which ensures its reliable fixation in the hands of the surgeon and prevents slipping when removing the device itself to expand access from tissues in working conditions with sterile gloves. The distal (lower) part of the outer tube 1 has an end sharpened around the perimeter at an angle of 30 °, which facilitates the unhindered passage of the instrument through the tissue.

The access expander 2 is a rod up to 20 cm long with a through channel with a diameter of 5.2 mm. The distal part of the access expander 2 has a threaded conical end, providing a smooth entry and uniform advancement of the instrument in the fabric. At the proximal end of the access expander 2, a cruciform ergonomically shaped handle with protrusions of 1.5 cm each is made for a more convenient and comfortable arrangement of the surgeon's fingers when performing twisting movements to introduce the instrument into the pathological cavity through the tissue.

The through channel of the access expander 2 is necessary for conducting a rigid metal conductor 3 in the form of a hollow tube with an outer diameter of 5 mm and a length of 40 cm. The conductor 3 also has a through channel for holding a thin guide standard mandrel with a diameter of 0.038 mm.

The essence of the utility model is illustrated by drawings, which depict:

Outer tube 1 - made of stainless steel, 160 mm long with a corrugated surface in the proximal part 40 mm long. The inner diameter is 15 mm, the wall thickness is -1 mm. The distal end of the outer tube 1 is sharpened around the perimeter at an angle of 30 °.

Access expander 2 - made of stainless steel. The distal part of the access expander 2 has a threaded conical end (thread pitch - 6 mm). In the proximal part of the access expander 2 there is a cruciform handle of ergonomic shape, with protrusions 15 mm long each, with thickenings at the ends up to 10 mm in the form of a semicircle. The diameter of the access expander 2 is 14.8 mm. The access expander 2 has a through channel with a diameter of 5.2 mm for conducting the guide conductor.

A rigid metal conductor 3 made of stainless steel up to 400 mm in length with a diameter of 5 mm with a thin through channel for conducting a standard guide mandrel with a diameter of 0.038 mm.

A device for expanding surgical access is used as follows.

When draining fluid cavity formations of the abdominal cavity under radiation control in patients with acute destructive pancreatitis under general anesthesia through a previously installed drainage tube (from 8 to 12 Fr) under radiological control (using a C-arc), the pathological cavity is contrasted. A skin incision is made to the right and left of the previously installed drainage tube equal to the diameter of the outer tube 1. A guide mandrel of 0.038 mm is introduced into the lumen of the drainage tube, after which the drainage tube is removed. A hard metal conductor 3 is put on the mandrin.

The access extender 2 with the outer tube 1 mounted on it is placed on the metal conductor 3, advanced to the skin with the distal end, and gradually screwed into the pathological cavity together with the outer tube 1 by means of a threaded conical end using a cross handle in the proximal part. . Hold the outer tube 1 by the corrugated surface and smoothly remove the expander 2 by the cross-shaped handle at the proximal end. In the cavity of the wound through the outer tube 1 enter the required diameter drainage (or 2 drainage). The outer tube 1 is removed, in the wound there is a drainage tube of the desired diameter through which, in the presence of purulent contents, sanitation is performed with subsequent fixation of the drainage tube to the skin.

The performance of the proposed method is confirmed by the following clinical example.

Example. Patient V-ev, 39 years old, was admitted as an emergency to the surgical department of GB No. 1 named after N.A. Semashko ”, Rostov-on-Don, with complaints of severe pain in the upper abdomen that appeared after heavy consumption of fatty foods, nausea, repeated vomiting that does not bring relief, general weakness. After a clinical, laboratory and instrumental examination, a clinical diagnosis was made: acute pancreatitis. An ultrasound examination of the abdominal cavity of the patient revealed fluid accumulation in the stuffing bag with a volume of up to 400 ml. Under ultrasonic control, simultaneous percutaneous drainage of this fluid accumulation by a 9 Fr. drainage tube was performed. At the same time, about 400 ml of hemorrhagic liquid was evacuated. Subsequently, the patient underwent complex conservative therapy in the intensive care unit, as well as daily reorganization of the cavity formation with antiseptic solutions. On the 10-12th day from the moment of the patient’s admission to the hospital, clinical signs of infection of the pancreatogenic necrosis zone appeared, which was manifested in the patient by an increase in body temperature to 39 ° C with chills, an increase in general weakness, leukocytosis up to 22⋅10 ⁹ / L with neutrophilia, an increase in the APACNEII index to 20 points and an increase in the blood C-reactive protein content to 180 mg / l. A control ultrasound examination of computed tomography on the 12th day revealed the presence of several sequesters with a diameter of 0.5 to 2.5 cm in the stuffing bag. A contrast study (by introducing contrast through the existing drainage) revealed a cavity up to 5 cm in diameter. It was decided to replace the existing drainage tube with a larger one in diameter. Under general anesthesia, a guiding standard mandrel of 0.038 mm was introduced through a previously installed drainage, after which the drainage was evacuated. A hard metal conductor 3 was introduced into the cavity along the mandrin, through which an access expander 2 with an outer tube 1, worn over the expander, was brought to the skin from above. Under ultrasonic control, the wound canal is expanded to 15 mm by twisting movements, the access expander 2 and the rigid metal conductor 3 are removed, and the outer tube 1 is left in the cavity, 2 polyvinyl chloride drainages with a diameter of 7.0 mm are installed through it. In the future, a flow-washing system of the purulent cavity was established with antiseptic solutions with active aspiration. At the same time, an inflow of purulent purulent discharge with small sequesters was noted along the drainage drainage. By the 7-8th day, the wash liquid became more transparent, purulent sediment was absent, and sequestration separation ceased. On the 9th day, the drains were replaced with smaller ones in diameter. Against the background of multicomponent intensive care, the patient's condition improved: the clinical and laboratory parameters returned to normal, the drainage discharge decreased, and then it stopped completely. The patient was discharged on the 15th day in a satisfactory condition. During the control ultrasound and computed tomography of the abdominal cavity, the presence of pathological cavities and sequestration were not detected.

The advantages of the claimed device for expanding surgical access:

- the device allows for more efficient and safe replacement of drainage tubes with larger ones in diameter and, if necessary, install 2 drainages simultaneously in one wound;

- the introduction of larger diameter catheters is not delayed, but immediately if drainage is necessary;

- the device is suitable for antiseptic processing, is reusable and can, if necessary, be used to expand the drainage hole in another operation.

- the proposed device is simple in design and reliable to use. Its use can simplify drainage and reduce the complexity of the operation.

The proposed device for expanding surgical access has been tested in the clinic and can be recommended for widespread use in surgical hospitals.

Claims (1)

A device for expanding surgical access, containing an expander made in the form of a rod with a tapering working end, an outer tube worn on the expander and a conductor, characterized in that the expander has a through channel, a cross-shaped handle on the proximal end of the expander, and its distal part has a threaded conical end; the outer tube has a distal end sharpened around the perimeter at an angle of 30 ° and a corrugated surface on 1/4 of the proximal end, while the conductor is drawn through the through channel of the expander and is made in the form of a hollow tube containing a through channel for holding the mandrel.

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