RU2066123C1 - Method for performing cholecystectomy from miniaccess - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves performing miniaccess to the gall bladder, introducing retractor manipulator into the wound and moving it in the vertical plane with the abdominal wall reducing the depth of the operation wound. The retractor manipulator with two pivotally connected bars with automatic lock is used. The bars have handles at one end and working mirrors at the other end bent at an angle of 60 deg to the bars. EFFECT: reduced depth of the operation wound; increased operation action angle. 3 dwg

Description

 The invention relates to medicine, namely to surgery, and can be used in the surgical treatment of gallstone disease, chronic calculous cholecystitis.

 Other options for using this method are possible overlaying cholecystostomy, cholecystejunostomy, choledochostoma, gastroenterostomy, gastrostomy, in gynecology in the surgical treatment of cysts and benign ovarian cysts, for biopsies.

 The speed, radicalism, and most importantly the non-invasiveness of manipulations with any abdominal intervention depend on a successful choice of operative access.

 In operations on the gallbladder, this condition is of particular importance.

 Currently, more than 60 different surgical approaches have been proposed for interventions on the gallbladder and extrahepatic bile ducts (B.V. Petrovsky, 1972) [3] Such a large number of accesses is caused not only by the localization and nature of the pathological process and the volume of the proposed intervention, but also physique and chest shape of the patient.

 It is known that with a brachiomorphic physique, the magnitude of the epigastric angle and the distance between the extreme points of the costal arches are greater than with a dolichomorphic physique. In individuals with a dolichomorphic physique, the liver and gall bladder can be completely covered by ribs, which makes it difficult to access these organs. Conversely, with a brachiomorphic physique, the liver may protrude from under the costal arch for several centimeters.

 Spatial relationships to the surgical wound are determined by well-known parameters, of which the so-called accessibility zone, that is, the area accessible to the surgeon, is the main one.

 This parameter is of particular importance in case of cholecystectomy, when the area on which it is necessary to manipulate during the operation is in the depth of the wound and is limited on all sides by walls of a certain height, that is, the operation has to be carried out in the depth of the abdominal cavity insitu. Another important parameter is the axis of the operational action. The axis of the operational action is understood as the line mentally drawn from the eyes of the surgeon to the deepest point of the surgical field.

 If, for manipulation of the gallbladder, the depth of the wound can be reduced using special techniques (pulling the liver by the crossed circular ligament, the introduction between the diaphragm and the liver and the subsequent inflating of the rubber pelota, however, this in turn can lead to inflection of the inferior vena cava and death of the patient ), then a decrease in the depth of the wound during manipulation in the region of the Kahlo triangle is possible only by the patient’s position on the operating table with large lumbar-thoracic lordosis. This is achieved using a roller, but also in some cases leads to a deterioration in the hemodynamic parameters of the patient, to a violation of the blood flow through the inferior vena cava, to a decrease in the vital capacity of the lungs, minute ventilation, respiratory rate and oxygen consumption, and even to long-term pain in the spine .

 Finally, the last parameter that determines the accessibility of the object that is subject to the main manipulation, the so-called angle of operational action, in other words, the angle at which the surgeon's instruments and fingers can move in the wound. It depends, of course, not only on the above measurements, but also on how well the mirrors and retractors are selected.

 The difficulties associated with operative access to the liver and gall bladder are evidenced by the fact that there is no other organ in the abdominal cavity for which such a large number of access methods have been proposed.

Recently, in abdominal surgery in general, and in biliary tract surgery in particular, there has been a reasonable tendency to small incisions (E. I. Galperin, D. M. Dederer, 1987 [1] B.A. Korolev, D.L. Pikovsky, 1990, [2]
The “shortening” of the incision is advisable, since a large incision is primarily a big injury. The listed sensory and motor nerve fibers of the right half of the abdominal wall are reflected in the postoperative period by the restriction of its mobility and significant pain.

In 1982, Dr. Ismael R. Goco [6] introduced the term “mini-cholecystectomy” in the United States to the 50th annual Assembly of the Surgical Society and reported that cholecystectomy was performed in 50 patients through a 4 cm incision. A laparoscopic cholecystectomy was successfully performed using a tool kit and devices Richard Wolf, Karl Storz / 8 [5]
The prototype of our invention [7] is the performance of "mini-cholecystectomy" and intraoperative cholangiography [7] CHARLES E. MORTON. Cost Containment with the Use of "Mini-Cholecystectomy" and Intraoperative Cholangioqraphy.

The technique of performing a 4–5 cm incision in the upper right quadrant (transrectal) performed a laparotomy. Using the Richrdson retractor [4] and subsequently the “luminous retractor (analog of our device) Harrington, extra dcep with fluted handle. Blade 2 1/4" (5.7 cm) (width. Depth 7 "(17.5 cm) N 34 1790 PiLLiNG ^® DRG 1167 Ronte 22, Fast Monntainside, NJ 07092 USA p. 67 [4] the colon and the liver, its right lobe were pulled out, then the gall bladder and the hepatoduodenal ligament were resected and the cystic duct and artery were dissected and identified. The latter are pinched by brackets and intersect, the gall bladder is excised and removed (if necessary, and indications are performed cholangiography i). The abdominal cavity is drained by a small closed suction system and the wound closes. Drainage is removed on the 1st or 2nd postoperative days and the patient is usually discharged on the 2nd postoperative day. 96 operations were completed, operation duration min. 25 min. max 1 h 5 min averaged 45 min.

 The purpose of the invention is the use of an extender-manipulator, which allows more than 3 times to reduce the depth of the surgical wound and 4 times to increase the angle of surgical action when performing cholecystectomy using mini-laparotomy.

This goal is achieved by the fact that a retractor-manipulator is used, the action of which is carried out in two mutually perpendicular planes: horizontal, increasing the accessibility zone with a section of 4 cm due to the elasticity of the tissues of the anterior abdominal wall and the fixing device on the instrument up to 6 cm ² , and in the vertical plane, invaginating the anterior abdominal wall to the posterior one, the wound depth decreases by 17.5 cm / Harrington, Charles E. Morton, 1985 [7] and all traditional cholecystectomy methods to 5 cm in our method.

It is this ratio of the sizes of the wound parameters that leads to an increase in the angle of surgical action from 15 to 65 ^o , i.e. more than 4 times (figures 1 and 2).

 This greatly facilitates the work of the surgeon and allows you to perform all stages of cholecystectomy in reliable ways (ligation of the cystic arteries and duct, subserous removal of the bladder, suturing of the bed of the bladder, revision of the extrahepatic bile duct, intraoperative cholangiography).

The retractor-manipulator (figure 3) has two shoulders 1, moving on one common axis 2 and in the same plane. One shoulder contains a handle 3 located at one end and a wound “mirror” 4 at the other, opposite end. The specified "mirror" is located in a plane making up an angle of 60 ^o with the total plane of movement of the shoulders. On the shoulder from the axis, closer to the handle on the axis 5 is a plate element 6 with a slot for the fixing screw of the other shoulder. The other shoulder also has a handle at the first end and a wound "mirror" at the second, also at an angle of 60 ^o to the general plane of movement of the shoulders. On the shoulder there is a fixing screw 7 for manual tightening, which passes into the slot of the plate element, and when the screw is tightened, it fixes the plate element, as well as both shoulders in the diluted position.

The wound "mirror" has a hemispherical shape with two protrusions: proximal 8, more pronounced, and distal 9, less pronounced. Both protrusions are located at an angle of 90 ^o to the working surface of the "mirror".

 Mirror dimensions: width 4 cm, depth 3.8 cm.

 The maximum wound size in diameter is 8.3 cm.

 The method is as follows: under aseptic conditions under endotracheal anesthesia or epidural anesthesia after processing the surgical field according to the generally accepted technique, a pararectal section of the Lauson-Tate type or an oblique parallel to the right costal arch, but without crossing the rectus muscle with a 4 cm length, the abdominal cavity is opened. A retractor-manipulator is inserted into the wound, its branches are bred (hemostasis of the operational wound is carried out by pressing the edges of the wound with “mirrors”) and is fixed with a screw in the set position.

The elasticity of the tissues of the anterior abdominal wall allows you to bring the wound to a round or oval shape, the diameter of which is 4-5 cm. The access area in this case ranges from 12.56 to 19.31 cm ² .

 The assistant, holding the retractor by the handles, moves it together with the relaxed anterior abdominal wall from the bottom of the gallbladder to its body and neck and hepatoligamentous zone. The surgeon at the same time visually and by palpation conducts an audit of the gallbladder, extrahepatic bile ducts, pancreatic head, and, if necessary, other parts of the abdominal cavity.

 The depth of the surgical wound is equal to the depth of the “mirror” of the retractor, ie 4 cm, in rare cases more, with a thickness of the anterior abdominal wall of more than 4 to 5 cm.

The angle of operational action with the above accessibility zone and the depth of the wound 42 65 ^o .

 If there is evidence, a cholecystectomy from the neck is performed with separate ligation of the artery and duct, subserous excision of the gallbladder and simultaneous phased closure of its bed. In this case, traction behind the Gertmann pocket of the bladder is carried out by a terminal clamp introduced through contraperture, which in turn is used subsequently to conduct a control drainage tube.

 Thus, until the gallbladder is completely separated from the bed and the manipulating fenestrated clamp is located outside the accessibility zone of the surgical wound and does not impede the surgeon's actions.

 The simultaneous release of the bladder and suturing the bed can reduce the duration of the operation. The operation ends with the control of hemostasis, the introduction of a control tube and blind sutures to the wound with a subcutaneous catgut suture.

It is the claimed retractor-manipulator, which allows, without reducing the accessibility zone, 3 times reducing the depth of the surgical wound and increasing the angle of surgical action from 15 to 65 ^o, which according to the method provides cholecystectomy using mini-laparotomy and thereby achieve the purpose of the invention. This allows us to conclude that the claimed invention is interconnected by a single inventive concept.

 A comparison of the proposed solutions with the prototype made it possible to establish compliance with their criterion of "novelty."

 When studying other known solutions in this field of surgery, distinguishing the claimed invention from the prototype, were not identified and therefore they provide the claimed solution according to the criterion of "significant differences".

 Example 1. Patient Kalish Ivan Ilyich, 53 years old, was admitted to the clinic of faculty surgery in Novosibirsk on 11/14/91 for chronic calculous cholecystitis for planned surgical treatment.

Survey conducted: Er. 5.0 • 10 ⁹ , HB 153 g / l, Lake 6.5 - 10 ⁹ , E 2 = P 3, C 53, O 39, M O, ESR 5 mm / h. Bilirubin 22.9 μmol / L direct 2.7, not direct 20.2. ALT 0.8, AST 0.5. Blood sugar 4.7 mmol / L, prothrombin index 94% fibrinogen 4.44 g / L. ECG: sinus rhythm 67 per minute. Slowing in (atrial conduction, load on the right atrium. Signs of moderate left ventricular hypertrophy. Ultrasound of the abdominal cavity: liver size and echostructure unchanged. Gall bladder - the shape is correct, average size, two constrictions in the n / a and c / s of the bladder. Walls Concrements 6 7 pieces, dimensions 10 15 mm and diameter. Acoustic shadow clear, localized diffusely in the body, bottom and cervical. Intrahepatic ducts unchanged. Common bile duct normal. Pancreas: contours are not clear, equal. Right kidney in Wed . The stone zone is 3 mm in diameter.

Conclusion: calculous chronic cholecystitis, ICD, microlith of the right kidney. Blood type B / 111 /, rhesus neg. 11.19.91 operation: "Mini-cholecystectomy". Under intubation anesthesia, a 4 cm transrectal incision in the right hypochondrium, a laparotomy was performed, a retractor-manipulator was introduced, and an abdominal cavity was revised. In the gall bladder, stones, through a contra-opening, a window clamp is introduced, with which the gall bladder is taken from the Hartmann pocket, traction is performed. The access zone is 16 cm ² , the wound depth is 4 cm, the angle of surgical action is 65 ^o , and the arteries and the cystic duct are ligated with silk. The gall bladder with catgut suturing of the bladder bed was subzero removed from the bottom after hydrotreating. Hemostasis control is satisfactory. Revision of the common bile duct: duct 0.8 cm in diameter, palpation of calculi in it is not determined. A control tube was drawn through the counter-hole to the Vinslov hole. Sutures on the wound tightly, aseptic sticker.

 Macrodrug: the walls of the bladder are scarred, in the lumen, stones are 0.8 cm in diameter.

 Postoperative diagnosis: chronic calculous cholecystitis.

 In the postoperative period, the patient received two injections of omnopon on November 19 and 20, 2011. On the second day after the operation, the drainage tube was removed. 22.11, i.e. on the 3rd day after surgery, the patient was discharged for outpatient treatment. 11/22. stitches removed, healing by first intention. 12/01/91, the condition is satisfactory, proceeded to work.

 Example No. 2. Patient Semukhin Dmitry Borisovich, 28 years old. He was admitted to the clinic of faculty surgery on 10.29.91, with a diagnosis of suspected acute cholecystitis.

 Diagnosis at admission: acute cholecystitis, diabetes mellitus, compensated mild.

Upon admission, the patient is prescribed analgesic, antispasmodic, anti-inflammatory and detoxification therapy. The condition has improved, the inflammatory process has stopped. The patient was examined: Er. 4.5 • 10 ¹² , HB 136 g / l, Lake. 16.7 • 10 ⁹ , E-6, P-10, S-78, L-E, M-Z, ESR 8 mm / h. Protein 82 g / l. Urea 6.2 mmol / L. Bilirubin 12.3 mmol / L straight O, not straight 12.3 mmol / L. ALT 0.5 μm / mol / L; AST 0.3 μm • mol / L. Blood amylase 10.0 units To pl. 4.8, sodium pl. 148.0 mmol / L. Blood sugar 3.5 mm / L. Urinalysis: negative protein, lake. 2 in s / sp. epithet. pl. units in s / sp. Salts of oxalates. Ultrasound scanning 11.11.91, the liver dimensions and echostructure are not changed. The gallbladder is medium in size, the walls are thickened, the contents are not homogeneous, the calculus is single, 11-12 mm in diameter, and the bottom of the bladder is localized. Intrahepatic ducts are not changed, the common bile duct is normal. Pancreas: average size, echo density is not changed.

 Conclusion: chronic cholecystitis, cholelithiasis. The height of the patient is 178 cm, weight 114 kg.

11/20/91 operation: "Mini-cholecystectomy". Under intubation anesthesia, a transrectal size in the right hypochondrium, the length of the incision was 6 cm, a laparotomy was performed, and a retractor-manipulator was introduced. The abdominal cavity was revised. There is a single stone in the gall bladder, the common bile duct is palpation unchanged, calculi are not determined. Accessibility zone 25 cm ² , wound depth 5 cm, angle of operational action 62 ^o . Arteries and the cystic duct were isolated and separately ligated with silk, the gall bladder with cathegut suturing of the bladder was subseriously excised. Through the counter-hole, a drainage tube is brought to the Vinslov hole. Hemostasis control is satisfactory. Seams on a wound tightly in layers. Aseptic sticker. Macro drug: the wall of the gallbladder is scarred, in the lumen there is one calculus in diameter of 0.8 cm. Postoperative diagnosis: chronic calculous cholecystitis. Histological examination of 11/26/91. In the wall of the gallbladder, sclerotic atrophic changes. Moderate histiocytic infiltration.

 Conclusion: chronic cholecystitis. In the postoperative period, the patient received one injection of omnopon on the day of surgery on November 20, 91, and an injection of omnopon the day after surgery. 11/28. stitches removed, healing by first intention. 11/29. Discharged under the supervision of a surgeon and endocrinologist polyclinic.

 An example of a specific implementation: the method was implemented during the operation of cholecystectomy in 36 patients operated in 1991 in the clinic of faculty surgery of the Novosibirsk Medical Institute. There were 3 men, 33 women.

Distribution of patients by age:
up to 30 years 2
31 40 years 2
41 50 years 4
51 60 years 6
61 70 years 20
71 and older 2
The minimum age of the patient is 28 years old, the maximum is 72 years. The weight of patients ranged from 62 to 114 kg. Ten operations were performed under intubation anesthesia, 26 under epidural anesthesia. The duration of the operation ranged from 25 minutes to 1 hour. No complications were observed.

Claims (1)

 Method of mini-access cholecystectomy, including laparotomy, insertion of a retractor into the surgical wound and removal of the gallbladder, characterized in that a retractor-manipulator is used, containing two articulated jaws with a rack, arms at one end and workers working at an angle of 60 ° to the branches mirrors on others and move it in a vertical plane with the anterior abdominal wall, reducing the depth of the wound.

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