RU2187248C2 - Method for introducing an epigastral trocar at laparoscopic cholecystectomy - Google Patents

Abstract

FIELD: medicine, endoscopic surgery. SUBSTANCE: a stylet is introduced into abdominal cavity through a linear alba and peritoneum leftwards against falciform and round ligaments of liver. Trocar is directed obliquely towards cholecystic cervix. In case of dorso- and mesopetal position of liver trocar should be directed from the left to the right through a falciform ligament. In case of ventropetal position of liver trocar should be introduced under a round ligament of liver. The method enables to optimize the access at different topographoanatomic variants of hepatic and cholecystic disposition. EFFECT: higher efficiency of operation. 3 dwg, 2 ex

Description

 The invention relates to medicine, namely to surgery, is used when performing laparoscopic cholecystectomy.

 A typical LCE is performed from four accesses.

 The most important functionally is the location of the second (epigastric) trocar, since through this access all the main steps of LCE are carried out: mobilization and ligation of the cystic duct and artery, isolation of the gallbladder from the liver bed.

 There is a method of introducing a second (epigastric) trocar in LCE: the trocar is introduced into the epigastric region as close as possible to the xiphoid process, so that the angle between the laparoscope and the trocar approaches 90 degrees; the abdominal wall is punctured in an oblique direction at an angle of 45 degrees so that the trocar stylet appears in the field of view to the right of the round ligament of the liver (Endoscopic surgery: Fedorov I.V., Sigal E.I., Odintsov V.V.-M .: GEOTAR MEDICINE, 1998. S.158).

 The disadvantage of this (“classical”) method of administering the epigastric trocar is that the access used is not adapted to various topographic and anatomical options for the anatomy of the gallbladder, liver and its ligamentous apparatus, which is extremely individual and variable (Surgical Anatomy of the Abdomen under the editorship of A.N. Maksimenkova.- L .: "Medicine", 1972. S. 303, 306).

 In addition, holding a trocar to the right of the round ligament of the liver due to the peculiarities of its anatomy (located 4-9 cm to the right of the midline) is possible only through the zone of the right rectus muscle of the abdomen, which is quite traumatic and may be accompanied by the development of bleeding, and in the postoperative period - inflammatory complications from the side of the wound (suppuration, infiltration, etc.).

 Similar difficulties arise when it is necessary to expand this transrectal access in case of extraction of a thick-walled gallbladder or large calculi.

 In addition, the desire to hold a trocar to the right of the round ligament of the liver reduces the range of instruments due to the reduction of the distance between the manipulation trocars.

 Less traumatic is access to the epigastrium through the white line of the abdomen, the direction of which corresponds to the midline of the body. In this case, only 4 layers of tissues of the anterior abdominal wall are overcome - skin, subcutaneous tissue, white line aponeurosis and peritoneum, excluding the rectus abdominis muscle.

 In addition, if necessary, epigastric access is easily expanded along the midline.

 Despite these advantages, access along the white line of the abdomen for the introduction of a second trocar with LCE is practically not used, since the sickle and round ligaments of the liver located in this case between the trocar and the gallbladder interfere with surgical procedures.

 In the literature there are references to the introduction of manipulation trocars along the midline in the epigastric region, in particular when performing laparoscopic cholecystectomy in children; however, no indications of any particular features of access are provided (A.F. Dronov, I.V. Poddubny, D.V. Zalikhin et al. Experience of the first 100 laparoscopic cholecystectomies in children. / Endoscopic surgery.-2000.- 1 .-C.29).

 The objective of the proposed method for the introduction of the epigastric trocar is to reduce trauma to the tissues of the anterior abdominal wall, reduce complications from the postoperative wound, optimize access to various topographic and anatomical options for the anatomy of the liver and gall bladder.

 This task is achieved by introducing a trocar in LCE under the control of a laparoscope along the white line of the abdomen below the xiphoid process (reducing trauma and, as a consequence, complication of wounds); after the stylet passes into the abdominal cavity through the white line of the abdomen and the peritoneum to the left of the crescent and round ligaments of the liver, the trocar is carried out obliquely to the neck of the gallbladder from left to right through the crescent ligament in the case of the dorso- and mesopetal location of the liver or under the round ligament with the ventropetal position of the liver ( optimization of access to various topographic anatomical variants of anatomy).

 The difference between this method of introducing the epigastric trocar in LCE is that after the stylet passes into the abdominal cavity through the white line of the abdomen and the peritoneum to the left of the crescent and round ligaments of the liver, the trocar is carried out in an oblique direction to the neck of the gallbladder from left to right through the crescent ligament in case of dorso- and mesopetal location of the liver or under the round ligament with ventropetal position of the liver.

 The method is as follows: after the introduction of the first trocar in the paraumbilical region and the creation of pneumoperitoneum, diagnostic laparoscopy is performed, the localization of the gallbladder and its neck is clarified (if necessary, after the introduction of manipulation trocars in the right hypochondrium and fixation with gallbladder instruments), the location of the liver and its ligamentous apparatus (course and severity of the round and sickle-shaped ligament). A skin incision is made 1-2 cm below the xiphoid process in the projection of the midline of the body and, under the control of the laparoscope, an 11 mm trocar is inserted into the abdominal cavity in the vertical direction (2). After the stylet passes through the white line of the abdomen and the peritoneum to the left of the crescent and round ligaments of the liver (Fig. 1), the trocar is carried out obliquely to the neck of the gallbladder from left to right through the crescent ligament in the case of the dorso- and mesopetal arrangement of the liver (Fig. 2) or under the round ligament with the ventropetal position of the liver.

 After passing the crescent ligament, the end part of the trocar is located to the right and from the round ligament of the liver, which makes it possible to easily carry out the necessary manipulations - the stylet is removed, the working instruments are inserted through the trocar and the operational phase of LCE is performed (Fig. 3).

 In those anatomical cases, when there is a maximum displacement of the crescent and circular ligaments to the right (7–9 cm) or its width exceeds the length of the working part of the trocar (95–105 mm), a window sufficient for free manipulations (up to 1 cm).

 The proposed method of introducing an epigastric trocar has been used by the authors in LCE since February 1999. Modification of the epigastric access was performed in 82 patients with acute and chronic calculous cholecystitis, aged 19 to 74 years, who were treated in the surgical departments of the city hospital 1 and the medical part of the Stoilensky mining and processing plant in Stary Oskol, Belgorod Region.

 Previously, when using the classical method of introducing the epigastric trocar (to the right of the round ligament), we had to deal with the need to shift the puncture point 4-6 cm to the right of the midline, which limited the possibilities of manipulation due to the reduction of the distance between the instruments; the risk of bleeding from the wound also increased, since the direction of access in this case was in close proximity to the projection of the epigastric artery.

 When conducting 216 LCE in the period from 1996 to 1998, with the traditional method of introducing the second manipulation trocar, we observed in 4 cases (1.8%) bleeding from the right rectus muscle of the abdomen (eliminated during the operation). Difficulties in expanding access to extract the gallbladder were in 6 of 14 cases (42.9%), while in 3 patients (1.3%) due to bleeding from the right rectus muscle of the abdomen, we were forced to expand the edges to provide reliable hemostasis wounds up to 4 cm, which led to an increase in the duration of the operation and significantly reduced the cosmetic effect of the intervention. In the postoperative period, wound complications in the epigastric region were noted in another 5 (2.3%) patients (inflammatory infiltrate-2, seroma-1, hernia-2).

 When using the proposed method of administering an epigastric trocar in 82 patients with laparoscopic cholecystectomy, intra- and postoperative complications were not observed during the observation period up to 12 months. The proposed access is convenient for manipulation, allows you to perform all stages of LCE.

 EXAMPLES of a specific implementation.

 Patient S., born in 1976, was admitted to the surgical department of MSCh SGOK on 02/14/2000 for surgical treatment with a diagnosis of cholelithiasis, chronic calculous cholecystitis (medical history 219/149). The patient is a brachymorphic physique; weight 102 kg, height 186 cm. Anamnesis of the disease for more than a year, the last exacerbation of cholecystitis - two weeks before going to the hospital.

 With ultrasonography, the gallbladder is not enlarged in size, in its lumen there is a large calculus up to 2 cm. With ultrasound, the round ligament of the liver is located 4 cm to the right of the midline of the body.

 Operation (A. A. Bondarev) 02.16.00 - laparoscopic cholecystectomy under endotracheal anesthesia (Fig.1-3).

 In diagnostic laparoscopy: the liver is not enlarged, located mesopetally, its edge is above the costal arch; the gallbladder is of usual color, in the neck area it is soldered to the omentum, it is usually located. The round and crescent ligaments are shifted to the right of the midline by 4 cm.

 In the epigastrium 2 cm below the xiphoid process along the midline vertically inserted 11 mm trocar (Fig. 1), which is then drawn through the crescent ligament in the direction of the neck of the gallbladder (Fig. 2).

 Introduced manipulation trocars in the right hypochondrium.

 The gallbladder is fixed, the neck is isolated from the adhesion process by a hook electrode held through the epigastric trocar.

 The cystic duct and artery are mobilized, separately terminal through the epigastric access, and crossed.

 The gall bladder is allocated subserosally (figure 3), removed with a calculus after expansion to 2 cm of umbilical access.

 The duration of the operation is 55 minutes.

 The postoperative period is smooth - discharged in satisfactory condition 02/20/00 on the 4th day after LCE.

 Patient I., born in 1966, was admitted to the surgical department of MSCh SGOK 02.03.2000 for surgical treatment with a diagnosis of cholelithiasis, chronic calculous cholecystitis (medical history 347/203). The patient is a brachymorphic physique; weight 95 kg, height 165 cm.

 03.03.00 a laparoscopic cholecystectomy was performed. On examination: the liver is not enlarged, located ventropetally; w / bubble of normal color, collapsed, usually located, two large calculi are determined in the lumen. The round and crescent ligaments are displaced to the right of the midline by 5 cm.

 The epigastric trocar was inserted 2 cm below the xiphoid process in the midline, the manipulation tools were then carried out to the gallbladder under the round ligament. After mobilization, the gallbladder was freely removed through an expanded up to 2 cm epigastric access. The duration of the operation was 55 minutes.

 The postoperative period is smooth - discharged in satisfactory condition on 03/06/00 on the 3rd day after LCE.

 Thus, the proposed method of introducing an epigastric trocar in case of laparoscopic cholecystectomy allows achieving the objective of the invention due to the fact that after passing the stylet into the abdominal cavity through the white line of the abdomen and peritoneum to the left of the crescent and round ligaments of the liver, the trocar is carried out in an oblique direction to the neck of the gall of the bladder from left to right through the crescent ligament in the case of the dorso- and mesopetal location of the liver or under the round ligament with the ventropetal position of the liver.

Claims (1)

 A method for administering an epigastric trocar with laparoscopic cholecystectomy along the white line of the abdomen below the xiphoid process under the control of the laparoscope, characterized in that, in order to reduce trauma to the tissues of the anterior abdominal wall and reduce complications from the surgical wound, as well as optimize access to various topographic anatomical options for the location of the liver and gallbladder, after passing the stylet into the abdominal cavity through the white line of the abdomen and peritoneum to the left of the crescent and round ligament of the liver trocar carried out in an oblique direction to the neck of the gallbladder from left to right through the crescent ligament in the case of the dorso- and mesopetal location of the liver, or under the round ligament with the ventropetal position of the liver.

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