RU2169528C2 - Method and device for preparing a patient to laparoscopic intervention - Google Patents

Abstract

FIELD: medicine; medical engineering. SUBSTANCE: method involves laying and fixing patient on operation table in dorsal position and subjecting to general anesthesia. Pierces into the abdominal cavity are made on the abdomen, abdominal wall traction is carried out by capturing tissues in the umbilical region and space is created in the abdominal cavity between abdominal wall and viscera. To do it, elastic deformable rods are introduced through one of pierces, brought to opposite pierce and taken out from the abdominal cavity. The rods are bent as arcs to enable one to stretch the abdominal wall from inside. The rods are separated inside of the abdominal cavity to build fan-like structure by rotating the about a conditional axis passing through the pierces. Each rod is manufactured from elastic deformable material being not less than 0.4 mm in length and having elliptic cross-section. Rod ends are coverable with protection caps and fixable in elevator holder. EFFECT: enhanced effectiveness of treatment; wide range of surgical applications; improved control quality. 5 cl, 8 dwg

Description

 The invention relates to the field of medicine and veterinary medicine. It can find application in diagnostic and surgical endosurgery.

 Endosurgery is an alternative to open operations performed through a traditional incision. It is known that actions performed on organs (using special endosurgical instruments and a miniature video camera inserted into the operating space — the body cavity) are carried out by accessing the organs through punctures and small (2-5 cm) incisions on the patient’s body. The endosurgeon controls its actions in the body cavity on the monitor screen, to which the video camera transmits a several-fold enlarged image.

 Punctures on the body are made with a sharpened stylet inserted inside a tube of small diameter - a trocar. After performing the puncture, the stylet is removed, and the trocar is left in the thickness of the tissues, creating a message between the external environment and the body cavity. Subsequently, the necessary endosurgical instrument is inserted into the body cavity through trocars.

 Known methods of preparing a patient for diagnostic and surgical laparoscopic endosurgical intervention. For free and safe manipulation of tools inside the abdominal cavity, an operating space (cavity) is created by lifting the anterior abdominal wall above the internal organs.

 Known methods for creating operating space.

According to one of the known methods [1] of laparoscopic surgery, a gas is introduced into the abdominal cavity - air or carbon dioxide CO ₂ (forming the so-called pneumoperitoneum) through a Veress needle or trocar passing through the thickness of the tissues of the abdominal wall and connected via air pipes to the compressor. Purified CO ₂ or air is pumped into the abdominal cavity under pressure up to 2 kPa (15 mmHg) in a volume of about 1.5-2.5 liters. The incoming gas, exerting uniform pressure in all directions, inflates the abdominal cavity and raises the front abdominal wall above the internal organs, creating an internal operating space (cavity) - for action in it by endosurgical instruments.

 During a surgical operation, which usually lasts several hours, the gas is gradually lost from the artificially created cavity, it leaks through existing punctures and incisions, trocars and during the replacement of instruments. Part of the gas is absorbed into biological tissues. The artificially created operating space is maintained by constant compensatory pumping of gas into the abdominal cavity and the use of trocars with valve-sealing devices.

With gas laparoscopy, the created operating space is most optimal in shape - dome-shaped. But her (gas laparoscopy) is characterized by “congenital” defects [1 - 4]:
- gas injected into the operating space compresses the large venous vessels of the retroperitoneal space with circulatory disorders in the organs of the retroperitoneal space and in the lower extremities, with a tendency to stasis (stagnation) of blood and thrombosis, with the development of DIC - syndrome;
- there is a violation of organ circulation (ischemia of internal organs);
- diaphragm pressed by gas pressure displaces the heart to a non-physiological position with subsequent violation of cardiac activity;
- a compressed diaphragm compresses the lungs, increases the "dead" zone of the pulmonary parenchyma, impairs pulmonary ventilation and disrupts the respiratory process;
- CO ₂ is absorbed into the bloodstream with the development of hypercapnia;
- unwanted hypothermia (cooling) of the internal organs develops;
- there is a non-zero probability of developing pneumothorax and pneumomediastinum, subcutaneous emphysema and gas embolism;
- the first puncture of the anterior abdominal wall - for gas supply - is carried out “blindly” in the area of vital anatomical formations and this is fraught with an increased risk of damage to these structures;
- the need to maintain a stable volume of operating space for a long time in the presence of gas leaks necessitates the use of complex sealing devices that complicate the work of the surgeon;
- the created space is poorly regulated in elderly and senile persons or with severe concomitant pathology. The increase in gas pressure in the abdominal cavity above 15 mm Hg to increase the internal volume is accompanied by a violation of the functions of vital organs, even in young and physically healthy individuals.

 The disadvantages of gas laparoscopy limit its scope, and the processes accompanying it can have fatal consequences.

 Other methods of laparoscopy are known - using low-pressure gas (2-4 mm Hg) in the abdominal cavity [5], as well as gas-free laparoscopy (BGL), which has been developed since the late 80s [2, 5]. With BHL, the surgical space in the abdominal cavity is created by lifting the abdominal wall using various mechanical devices inserted into the abdominal cavity or directly into the thickness of the abdominal wall.

 Gasless laparoscopy is free from the disadvantages of gas laparoscopy and is therefore attractive for practical surgery.

 The present invention relates to a variety of methods and devices for gas-free laparoscopy.

 Known [6] is a method of fixing an isolated volume in the abdominal cavity as needed for pneumoperitoneum and a tool for implementing the method.

 The patient is placed in a supine position on an operating table equipped with special racks. Conduct general anesthesia. Perform the actions necessary to create pneumoperitoneum (described above). A separate abdominal wall incision is made in the umbilical region to insert an endoscopic T-shaped retractor.

This T-shaped retractor is made of a strong metal rod 30 cm long. A longitudinal groove is made at one of the ends of the rod, where a 7.5 cm long blade is fixed on the axis with 360 ^o rotation. Through the separate umbilical incision, the end of the retractor is inserted with a blade. In the abdominal cavity, the retractor blade is rotated 90 ^° with respect to the axis of the rod, forming a T-shaped structure. Manually pull the free (outside the abdominal cavity) end of the retractor and thus lift the abdominal wall above the internal organs, forming the operating space. The free end of the T-shaped retractor is fixed on special racks of the operating table. The described analogue has the following main disadvantages:
- the need for additional cuts for the introduction of T-shaped retractors and the associated additional invasiveness and leakage;
- the need for additional time for installation;
- the created space is suboptimal in form and non-physiological, has a regional character, thereby restricting the review;
- clutter of the operative space above the stomach operated by retractors and special racks for their fixation, interferes with the work of the surgeon;
- the formation of hematomas (bruising) at the points of contact of the retractor blade to the abdominal wall from the inside;
- very limited mobility;
- the need to dismantle the structure during x-ray monitoring of the progress of the operation (metal rods have a radiopaque - opaque);
- the formation of zones of tissue ischemia in places where the narrow retractor lobe fits to the peritoneum from the inside.

 There is another [7] similar method and device for its implementation, simplifying the work of the endosurgeon.

 The patient is placed in a supine position on the operating table with special fastening devices, given general anesthesia and performed the actions necessary to create pneumoperitoneum (described above). At the same time, low-pressure gas is supplied to the abdominal cavity as an auxiliary tool - a small space is preliminarily created for visual inspection and elimination of damage to internal organs during the introduction of a mechanical device - instrument - into the abdominal cavity. The tool for raising the abdominal wall is a U-shaped retractor - a needle 40 cm long and 0.5 cm in diameter, made of stainless steel. Through a puncture in the right hypochondrium, a U-shaped retractor is inserted into the abdominal cavity. Having passed at the end of the crescent ligament, the needle is pushed up and the abdominal wall is pierced so that both ends of the needle are outside the abdominal cavity. Having fixed the ends of the U-shaped retractor in special fastening devices on the operating table, the abdominal wall is lifted, forming an operational volume in the abdominal cavity for further work of the endosurgeon.

After fixing the U-shaped retractor, the pressure of the gas pumped into the abdominal cavity is reduced to prevent the pathophysiological consequences of pneumoperitoneum (described above). But this method also has disadvantages:
- the operating space formed inside the abdomen has a small volume and a concave dome, thereby restricting the movement of surgery during manipulations of surgical instruments over the operated organ;
- difficult and limited the ability to inspect the lateral abdomen;
- the presence of fastening devices over the abdomen of the operated interferes with the manipulation of the surgeon;
- lifting the abdominal wall with a U-shaped retractor stretches the muscles and skin in a non-physiological manner, leading to damage to biological tissues and postoperative complications;
- requires the dismantling of the structure during x-ray monitoring of the course of the operation, after which reassembly is necessary, that is, the expenditure of additional time, which adversely affects the patient (the duration of anesthesia);
- when the abdominal wall rises, soft tissue is squeezed between the U-shaped retractor and the rib - with subsequent complications.

A similar Laparolift method and device is known [8 - 10], which are most widely used in the USA for auxiliary purposes in intracavitary surgical operations using gas laparoscopy methods. The use of this equipment allows to minimize the pressure of CO ₂ injected into the abdominal cavity and to reduce the associated pathophysiological effects.

 The device consists of a working tool - a retractor inserted into the abdominal cavity to lift the abdominal wall and mounted on the tool holder.

 The retractor consists of two metal rods L-shaped at right angles, the vertical arms of which are rotatably inserted into a common hollow body. The horizontal shoulders of both rods (about 12 cm long) at the ends are flattened in the form of horizontal blades 0.9 cm wide. By rotating and subsequently fixing the position of the L-shaped rods in the body, the horizontal shoulders of the rods can be folded together (like scissors), bringing their blades into parallel position, or fan-shaped to expand, forming a V-shaped (top view) design.

 The retractor with its body is fixed at the end of the telescopic boom (about 60 cm long) with swivel-hinged and locking units. The other end of the boom is connected to a lifting mechanism mounted on the edge of the operating table.

 The device is used in the following way. The patient is laid in a supine position on the operating table and undergo general anesthesia and pneumoperitoneum. A through-hole puncture of the anterior abdominal wall is performed with a trocar. The ends (in the form of lobes) of the retractor folded together are introduced into the abdominal cavity through the resulting puncture. In the abdominal cavity, the previously folded ends are fan-shaped bred in a horizontal plane, the free external ends are fixed and vertically lifted by a lifting mechanism. The horizontal ends of the retractor (in the form of blades) abut against the abdominal wall from the inside and raise it. By hanging the abdominal wall on the retractor, the pressure of the gas pumped into the abdominal cavity is reduced.

The main disadvantages of the described analog are as follows:
- the inability to work without the use of pneumoperitoneum;
- the presence of an operated retractor on the telescopic boom and a lifting mechanism above the stomach limits the freedom of movement of the surgeon;
- lack of mobility - the ability to move the retractor in the abdominal cavity without dismantling;
- the lack of retractor mobility limits the ability of x-ray monitoring of the operation;
- the created space is not optimal in form and non-physiological;
- limited ability to examine the lateral abdomen;
- the rise of the abdominal wall is accompanied by muscle strain in a non-physiological manner with damage to biological tissues and possible complications;
- the presence of complex technical elements in the design complicates the operation.

 These disadvantages limit the scope of this analogue - it is applicable only as an adjuvant in combination with pneumoperitoneum.

 Closest to the proposed invention in meaning and content is the development of Japanese specialists [11].

 The device consists of four flexible rods made of stainless steel, similar to a fishing rod (with a diameter of 0.3 cm, a length of 60 cm, thinned to one end to a diameter of 0.2 cm, according to the developers' terminology - such as a “fishing rod”) or two bent like a bow rod (with a uniform diameter of 0.3 cm over the entire length, 70 cm long - according to the terminology of the developers - such as "bow"). The device also contains 4 or 2 (according to the number of rods used) metal holder - a lift with rotary-locking elements for fixing and holding the rods, changing and fixing the length of the working parts of the rods. Holders - lifts are installed on the side rails (rails) of the operating table.

The described device is used to raise the abdominal wall as an adjuvant in gas laparoscopy, allowing surgery to be performed with extremely low pressure of CO ₂ injected into the abdominal cavity to reduce the pathophysiological consequences of using gas. Carry out this in the following way. The patient, laid on his back on the operating table, is subjected to general anesthesia, followed by muscle relaxation. Pneumoperitoneum is performed using carbon dioxide CO ₂ (described above) and the abdominal wall is raised. Incise the skin of the patient in the required places. Through the incisions under the skin with a thin end, rods are inserted forward and push them under the skin of the abdomen towards each other. The free ends of the rods are fixed in the respective holders - lifts. Acting with rods as a fishing rod when lifting a load, the abdominal wall is properly lifted by the skin and in this position the rods are fixed in the hoist holders.

 In this case, the flexible rods are bent according to the shape of the abdomen, and the abdominal wall rises, forming a cavity for subsequent manipulations of the surgeon.

With all its advantages, the prototype has the following main disadvantages that limit its use:
- due to the natural limitation (elastic limit) of the mechanical strength of the material of the rods, their (rods) lifting capacity is very limited - this property explains the auxiliary role of the method and device only as an addition to gas laparoscopy;
- exposure (lifting and fixing) of the anterior abdominal wall is small and limits the needs and possibilities of the surgeon during manipulations with surgical instruments in the abdominal cavity;
- subcutaneous insertion of the rods during lifting leads to the regional nature of the created exposure, limiting the view inside the abdominal cavity;
- subcutaneous insertion of the rods complicates the exposure of the abdominal wall in obese patients - it is impossible to properly raise the entire thickness of the adipose tissue, muscles and other formations under the skin - due to the elongation of the latter;
- the skin experiences increased deformation (tension) near the inner ends of the rods in the thickness of the abdominal wall, which is accompanied by the formation of local hematomas (bruising) with the occurrence of postoperative complications;
- subcutaneous insertion of the rods is accompanied by the formation of subcutaneous rod channels in which the rods are fixed, completely excluding their movement (if necessary) in the transverse direction, and the lack of rod mobility creates interference during x-ray monitoring of the operation;
- the introduction of rods under the skin, produced "blindly", is accompanied by uncontrolled damage to blood vessels in the thickness of the abdominal wall with subsequent hemorrhage along the entire length of the rod channel;
- the clutter of the operating space above the stomach and to the side of the patient creates inconvenience to the surgeon's work, restricting the freedom of his movements;
- the presence of a large number of structural elements increases the duration of installation of the device, leading to premature fatigue and reduce the operability of the surgeon;
- the presence of postoperative scars from additional incisions on the anterior abdominal wall is not cosmetic.

 These disadvantages limit the use of the prototype.

Common disadvantages for all known analogues and the best of them - the prototype of the invention are:
- only 1-2 quadrants (out of 4 existing) of the abdominal cavity are available for visual inspection, which is clearly not enough to examine the lateral canals during the operation of the surgeon;
- the space created inside the abdomen is suboptimal in volume and nonphysiological in form;
- it is difficult to lift the abdominal wall in obese patients.

 Therefore, they (analogues and prototype) do not meet the needs of practice and are used only as adjuvants in combination with gas laparoscopy (pneumoperitoneum) - to reduce the negative effects of the latter.

 The best solution would be to create an operating space similar to that obtained with pneumoperitoneum, but without pumping gas into the abdominal cavity.

The present invention is aimed at overcoming the disadvantage of known methods and devices used in laparoscopic surgery, and aims to:
- the exclusion of pneumoperitoneum from the process of endosurgical surgery;
- the creation in the abdominal cavity of the patient of the operating space of an adjustable shape and volume;
- improvement of the review and X-ray television control during the operation and diagnosis;
- accelerating the diagnostic process and improving its quality;
- expanding the range of surgical interventions;
- improving the reliability of the surgeon by eliminating interference in the form of clutter of the surgical field over the abdomen of the operated;
- reduction of intra- and postoperative complications;
- improvement of the cosmetic effect;
- improvement of working conditions and reduction of surgeon fatigue;
- reduction of the postoperative period of recovery of the patient's disability after surgery;
- providing the ability to use general surgical instruments and a combination of conventional surgical and endosurgical operations;
- providing the ability to perform surgical interventions in elderly people or with severe concomitant pathology.

 The essence of the invention consists in the fact that punctures or small (1-2 cm) cuts penetrating into the abdominal cavity are performed on the patient’s body, laid in a supine position on the operating table, for example, contralateral (symmetrically located on opposite sides of the body) , in the lumbar region at the level of the navel in the mid axillary line. Then traction (lifting upward by pulling) of the abdominal wall is performed by grabbing the tissues beyond the navel, for example, with bullet forceps. By diverting the abdominal wall from the internal organs, auxiliary space is created in the abdominal cavity. Then, through a puncture, rods are inserted into the abdominal cavity (one or more - the quantity is determined by the need) made of elastically deformable material, for example, stainless steel. At the end of the rods, protective caps are fixed in the form of a streamlined body - to prevent damage to internal organs. The inserted rods, pushing inside the abdominal cavity, lead to a puncture on the opposite side of the patient’s body and out through the puncture so that the free ends (outside the body) are approximately the same length. After that, the ends of the rods protruding from the body are pressed downward, as a result of which the arched rods are bent. Then each rod separately, simultaneously for both free ends, is lifted upward, maintaining the arcuate shape of the rod. In this case, the rods from the inside abut against the abdominal wall and raise it. Arched bent rods fan-shaped apart in the required amount (determined by the needs of the surgeon) by rotating them around a conditional axis passing through the contralateral punctures. Having lifted the abdominal wall properly, the ends of the rods are fixed in the hoist-holders with rotary-locking devices located on the surface of the operating table.

 The essence of the invention is illustrated by the following illustrations (see Fig. 1 - 8).

In FIG. 1 shows a patient lying on an operating table, where:
1 - patient, 2 - operating table, 3 - puncture or small incision on the left side of the body, 4 - navel, 5 - middle axillary line (conditional).

 In FIG. 2 shows a patient with the abdominal wall raised up, pulled by bullet forceps, where: 1 - patient, 2 - operating table, 3 - puncture, 4 - navel, 5 - middle axillary line, 6 - bullet forceps, 7 - anterior abdominal wall.

 In FIG. Figure 3 shows a patient with rods inserted into the abdominal cavity through the left puncture and brought out through the right puncture, where: 1 - patient, 2 - operating table, 3 - left puncture, 4 - rods, 5 - protective cap, 6 - right puncture.

 In FIG. 4 shows a cross-section A-A of the patient’s body with the abdominal wall raised by bullet forceps and rods inserted into the abdominal cavity, where: 1 - the patient's anterior abdominal wall, 2 - operating table, 3 - counter lateral punctures, 4 - rod, 5 - auxiliary space for holding rods, 6 - bullet forceps, 7 - internal organs.

In FIG. 5 shows the sequence of actions with the rods, where:
1 - patient, 2 - operating table, 3 - contralateral punctures, 4, 5 - left and right ends of the rods. The arrows show the direction of movement of the ends of the rods under the action of the surgeon's hands (hands are not indicated in Fig.).

In FIG. 6 shows a patient with inserted into the abdominal cavity, bent, raised and fan-shaped rods, where:
1 - patient, 2 - operating table, 3 - left puncture, 4 - rods, 5 - holder-lift with rotary-locking elements.

In FIG. 7 shows the patient’s body in cross section AA in FIG. 6, where:
1 - anterior abdominal wall of the patient, 2 - operating table, 3 - punctures, 4 - rod, 5 - holder-lift, 6 - operating space in the abdominal cavity, 7 - internal organs.

 In FIG. 8 shows the rods and the protective cap used for implementing the method, where: 1 - the rod; 2 - section AA of the rod, where a is the small axis of the ellipse; b is the major axis of the ellipse; k = a: b is the compression coefficient of the ellipse; 3 - a protective cap.

 The present invention is implemented, for example, as follows. As shown in FIG. 1, patient 1 with their backs laid on the operating table 2, subjected to general anesthesia. On the side walls of the patient’s abdomen, a trocar performs 3 punctures (or small ones up to 2 cm, cuts) penetrating into the abdominal cavity - for example, counter lateral, in the lumbar region at the level of the navel 4, along the mid-axillary line 5 (conditional line).

 Further (Fig. 2) with a special tool, for example, bullet forceps 6, grab the skin of the abdomen by the navel 4 and perform traction (lifting up by pulling) of the anterior abdominal wall 7. In this case, the abdominal wall departs from the internal organs and space forms in the abdominal cavity ( see Fig. 4).

 Then (Fig. 3), through one of the contralateral punctures, for example, the left 3, one or more rods 4 are inserted into the abdominal cavity with a protective cap 5 at the ends. The rods 4 introduced into the left puncture 3 are carried out in the abdominal cavity to the opposite puncture 6 (on the right side of the patient’s body 1) and removed from the puncture 6. The rods 4 are inserted into the patient’s body so that the free ends (outside the body) of the rods are approximately the same length. FIG. 4 illustrates the situation after completion of insertion of rods 4 into the abdominal cavity of patient 1.

 In FIG. 5 shows the next steps. The ends 4 and 5 of the rods protruding on both sides of the patient’s body 1, pressing with their hands, are pressed downward, as a result of which the rods take an arcuate shape.

 In FIG. 6, maintaining the arcuate shape of the rods 4, each rod separately, simultaneously for both ends, push up. Then the rods are fan-shaped apart, rotating in opposite directions around a conditional axis passing through two contralateral punctures. After that, the ends of the rods are fixed in the holder-hoist 5 with rotary-locking elements.

 In FIG. 7 rests against the abdominal wall of the patient from the bottom 1 rod 4 when moving up raises the abdominal wall. Having done the described actions with each of the rods, a dome-shaped volume is created in the abdominal cavity - the operating space 6.

 Thus, the preparation of the patient for further work of the surgeon with tools is completed - in the operating space.

 If necessary, change the volume of the operating space, the rods are raised or lowered in the holders, hoists, where the rods are fixed.

 To carry out x-ray television monitoring of the course of the operation, the arcuate, bent rod lying in the projection of x-rays is removed outside the controlled rotation field at the external ends around the conditional axis passing through the contralateral punctures, and these actions are performed without removing the rods from the abdominal cavity. The described method is carried out using rods made of elastically deformable material, for example, stainless steel.

 The implementation of the rods with a length of at least 0.40 m ensures the overlapping of the range of needs of practical laparoscopic surgery, taking into account the individual characteristics of the patients.

 The implementation of the rods ellipsoidal in cross section achieve atraumatic rods in contact with the abdominal wall.

 By varying the compression ratio k of the rod cross section from 1: 1 to 1: 12, the combination of strength with flexibility and atraumaticity of the rod during installation and dismantling, prolonged compressive contact from the inside with the tissues of the abdominal wall is overlapped, taking into account the individual characteristics of the patients.

 The protective cap (see Fig. 3, pos. 5 and Fig. 8 pos. 3) is made in the form of a streamlined body and the ends of the rod or bundle of rods are closed to them before entering them into the abdominal cavity, which ensures safe movement of the rods.

 Movement of the rods inside the abdominal cavity up and down and rotational back and forth around the conditional axis of rotation passing through the contralateral punctures is performed without removing the rods from the abdominal cavity. This operation, performed by a simple movement of the hands, allows you to quickly, in the process of work, change the shape and amount of space in the abdominal cavity, and carry out X-ray television monitoring.

 Adjustability of the shape and volume of the operating space in the abdominal cavity improves visibility and improves the quality of the medical work of the surgeon, including the quality of diagnosis.

 The absence of mechanical devices over the body of the person being operated on removes restrictions on the surgeon’s movements, relieves him of the psychological stress of waiting for his hands to interfere with interference (in the form of retractors and their lifts) over the person being operated on and thus improves working conditions, reduces fatigue, speeds up the surgeon’s work and increases his quality.

 The formation of the operating space of the optimal volume and shape in the patient’s abdominal cavity without the use of gas frees from attachment to gas sources, from all the inconveniences of gas laparoscopy, expands the scope of laparoscopy and the possibility of surgical interventions. The unnecessary sealing of the abdominal cavity makes it possible to combine endosurgery with traditional (open) surgery and the use of general surgical instruments, which also expands the possibilities of surgical interventions for treating patients.

 The combination of the above positive effects of the application of the invention accelerates the recovery of the patient after surgery, reduces the time of inpatient treatment and the recovery period.

 The fact that postoperative sutures from punctures and small incisions are located on the sides of the body, and not on the anterior abdominal wall, as is observed in similar traditional cases, does not disfigure the patient's appearance, that is, improves the cosmetic effect compared to the use of analogues.

 In addition to the above, other variants of the method are possible, for example, by separate introduction of the rods - through individual punctures for each rod located on other parts of the abdominal wall, and by placing them (rods) in the abdominal cavity parallel to each other or intersecting. Using rods of various lengths, the volume and shape of the created operating space are regulated.

 The application of the proposed method and device for its implementation allows, in comparison with the prototype, to significantly improve the effectiveness of laparoscopic intervention.

The application of the invention achieves:
- the exclusion of pneumoperitoneum with its attendant binding to gas sources and pathophysiological effects and complications;
- reduction of morbidity when creating an operating space for laparoscopic intervention;
- adjustable form and volume of the operating space;
- improving the quality of diagnosis;
- improvement of working conditions and reduction of surgeon fatigue;
- improving the quality of the results of surgical intervention;
- expanding the range of surgical interventions in laparoscopy;
- the ability to perform extensive surgical interventions in elderly people or with severe concomitant pathology;
- expanding the possibilities of combining endosurgery with traditional (open) surgery;
- the possibility of using general surgical instruments;
- reduction of patient suffering during diagnosis and treatment;
- reduction of the recovery period of the patient’s disability and the time spent in hospital;
- improvement of the cosmetic effect.

Used sources
1. Zh. "Herald of Surgery", Volume 155. N 2 - 1996. - S. 72.

 2. Belopukhov V. M., Fedorov I. V., Shaimuratov I. M. Features of anesthesia in endosurgery. - Kazan: "Tatpolygraph, 1996. - P.4 - 17.

 3. R.J. "Endosurgery today." - Kazan: Association ENDOSURGERY OF TATARSTAN. - 1996, N 2. - S. 4.

 4. R.Zh. "Endosurgery today." - Kazan: Association ENDOSURGERY OF TATARSTAN. - 1996, N 1. - S. 16.

 5. Fedorov I.V., Chugunov A.N. Gasless laparoscopy and operations with minimal pressure. - Kazan: Tatpolygraph, 1996.

 6. Paolucci V., Schaeff B., Gutt C.N. Gasless Laparocopy - why and how? J. "Minimally Invasive Therapy", 1995, N 4, p. 165 - 172.

 7. Kitano S., Iso Y., Tomikawa M., Oriyama M., Sugimachi K. A prospective randomized trial comparing pneumoperitoneum and U - shaped retractor elevation for laparoscopic cholecysectomy. J. "Surgical Endoscopy", 1993, 7, p. 311 - 314.

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 9. Albert K. Chin., M.D. Frederic, H. Moll, M.D., Milton B. McColl, M.D. , and Harry Reich, M.D. Mechanical Pertoneal Retraction as a Replacement for Carbon Dioxide pneumoperitoneum. The Journal of the American Association of Gynecologic Laparoscopists. V. 1. N 1, November, 1993, p. 62 - 66.

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 11. H. Nacamura, Y. Kobori, N. Goseki, H. Inoue, K. Takeshita, M. Endo, T. Nacamura. Fishing-rod-type abdominal wall lifter for gasless laparoscopic surgery. J. "Surgical Engoscopy", 1996, V. 10, N 9, September, p. 944 - 946.

Claims (5)

 1. A method of preparing a patient for laparoscopic intervention, including laying the patient with his back on the operating table, fixing it and performing general anesthesia, characterized in that the patient's abdomen is punctured by penetrating into the abdominal cavity, traction of the abdominal wall (lifting upward by pulling) by tissue grabbing beyond the navel, create in the abdominal cavity a space between the abdominal wall and internal organs, through one of the punctures, elastically deformable rods are introduced into the abdominal cavity, which conduct to a positive puncture through which the ends of the rods are removed from the abdominal cavity, the protruding ends of the rods are pressed downward, giving the rods an arc shape while maintaining an arched shape, the rods are pushed upwards and the inside of the abdominal wall is stretched, the rods are fan-shaped in the abdominal cavity by rotating their ends around the conditional axis passing through punctures, and form an operating space inside the abdomen for subsequent manipulation of tools, the ends of the rods are fixed in the holder-lifts.  2. The method according to claim 1, characterized in that the rods are introduced separately through individual punctures for each rod in the abdominal wall and the rods are placed in the abdominal cavity parallel to each other or intersecting.  3. A device for implementing the method according to claims 1 and 2, in the form of a rod, characterized in that the rod is made of elasto-deformable material with a length of at least 0.4 m and has an elliptical cross-section, the ends of the rod being made to be closed with a protective cap and for fixings in the holder elevator.  4. The device according to claim 3, characterized in that the compression coefficient k of the ellipsoidal cross-section of the rod is defined as k = a: b, where a is the small axis of the ellipse, b is the large axis of the ellipse, and k values are determined from 1: 1 to 1: 12.  5. The device according to claim 3, characterized in that the protective cap is made in the form of a streamlined body.

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