RU2195182C2 - Method for operative treatment of closed hepatic lesions in children - Google Patents

Abstract

FIELD: medicine, juvenile surgery. SUBSTANCE: from the edge of right rectus muscle of abdomen towards the upper external spina of ilium's wing 3 cm below the edge of the 12th rib one should made a cutaneous incision of 3.5-4 cm length. Parallel to the edge of right rectus muscle of abdomen 2-2.5 cm apart one should made an incision of aponeurosis of external, internal oblique and cross- sectional muscle of abdomen at its length being 4 cm. The blade of retroperitoneoscope is introduced into the obtained cross-shaped access by placing above hepatic parenchymous rupture. Then one should observe I, II, III, IV, V, VI, VII and VIII hepatic segments by inserting the blade of retroperitoneoscope into abdominal cavity towards the left hypochondrium perpendicularly the rectus muscle of abdomen. After that the handle of retroperitoneoscope is turned in an anti-clockwise direction parallel to hepatic surface up to the right hypochondrium. EFFECT: decreased traumaticity of operation. 1 dwg, 1 ex

Description

 The invention relates to medicine, namely to pediatric surgery.

 With closed injuries of the abdominal cavity in children, liver rupture is detected in 27.6% of cases [Pugachev AD, Baramiya N.N. Wedge. surgery. 1991. - 4. S. 34-37]. In all cases of liver rupture, treatment can only be operative. However, the available experience shows that in children operated on for blunt abdominal trauma with liver damage, in 45% of cases the “classic” wide surgical access is not practical due to the fact that only drainage is required during surgery.

 Known operational access [Kozlov I.Z., Gorshkov S.Z. et al. Abdominal injuries. M., Medicine, 1988. - S. 64., Bairov G.A. Urgent surgery of children. St. Petersburg, 1997. - C. 267] in case of liver damage - upper median laparotomy. When the localization of liver rupture using computed tomography, ultrasound or laparoscopy is accurately established, more convenient approaches are used by using incisions of Kocher, Petrovsky, Pochechuev, etc. The known method [Isakov Yu.F., Stepanov E.A., Krasovskaya T.V. Abdominal surgery in children: a guide. M .: Medicine, 1988. - S. 361, Hakobyan V.G. Pediatric surgical hepatology. M .: Medicine, 1982. P. 112, Matyashin I.M., Gluzman A.M. Handbook of surgical operations. Kiev, Zdorov'ya, 1979. - P. 179] surgical treatment of closed liver injuries with right oblique hypochondrium in accordance with Fedorov, chosen as a prototype, in which a 3-5 cm long incision starts from the xiphoid process down the white line of the abdomen, then rotate to the right, parallel to the costal margin and, departing from it by 3-4 cm, cross the right rectus abdominis muscle.

 The disadvantages of the method: when performing access, the right rectus abdominis muscle is crossed, tissues located in the operating area undergo swelling and inflammation, which in the postoperative period lengthens the healing process of the wound and can lead to purulent complications. The intersection of the rectus muscle threatens with the formation of a postoperative hernia of the anterior abdominal wall and reoperation for this reason.

 The objective of the invention is to reduce the invasiveness of the operation and reduce the treatment time due to the early active regimen of patients.

 The task is achieved in that a skin incision of 3.5-4 cm in length is performed from the edge of the right rectus abdominis muscle towards the upper outer spine of the wing of the right iliac bone 3 cm below the edge of the 12th rib, and the aponeurosis incision of the external, internal oblique and transverse abdominal muscles 4 cm long is performed perpendicular to the skin incision and parallel to the edge of the right rectus abdominis muscle, deviating from it 2-2.5 cm, a retroperitoneoscope blade is inserted into the obtained access, placing it above the rupture of the liver parenchyma, and for examination I, II, III, IV, V, VI, VII and VIII segments of the liver wedge retroperitoneoskopa administered to the peritoneal cavity in a direction perpendicular to the left subcostal rectus and its handle is rotated counterclockwise direction parallel to the surface of the liver to the right hypochondrium. To suture liver ruptures, instruments are inserted into the gutter of the retroperitoneoscope blade.

 The method solves the problem due to access obtained by performing variable cruciate incisions of the skin and aponeurosis, which allows you to perform the surgical task due to the optimal spatial relationships in the wound of a sufficiently large angle of surgical action, small depth of the wound and a small angle of inclination of the axis of the surgical action.

The novelty of the method
1. Performing a skin incision 3.5-4 cm long from the edge of the right rectus abdominis muscle towards the upper external awn of the ilium wing 3 cm below the edge of the 12 rib and aponeurosis incision of the external, internal oblique and transverse abdominal muscles 4 cm long, made perpendicular to the skin incision and parallel to the edge of the right rectus abdominis muscle, deviating from it 2-2.5 cm, provides optimal access to the right hypochondrium during rupture of the liver parenchyma without cutting the right rectus abdominis muscle.

 2. The use of a retroperitoneoscope in this access allows you to increase the area for surgical procedures on the surface of the liver in the zone I, II, III, IV, V, VI, VII and VIII segments, which ensures high-quality performance of a hemostatic suture, brackets on the edges of the wound, defect tamponade oil seal, etc.

 The invention is illustrated in the drawing, which shows a diagram of the access.

The method is as follows:
1. When a patient is admitted with suspected liver damage in parallel with antishock measures, a blood sample is taken for laboratory tests (general blood test, blood group, Rh factor, coagulogram), hemodynamic parameters monitoring (blood pressure, heart rate) . Ultrasound, computed tomography of the abdominal cavity and diagnostic laparoscopy are indicated. When an isolated rupture of the liver parenchyma is established, the child on a gurney is urgently transported to the operating room.

 2. In the operating room, using endotracheal anesthesia after treatment of the right hypochondrium with an antiseptic solution, a skin incision is made 3.5-4 cm long from the edge of the right rectus abdominis muscle towards the upper external spine of the wing of the right iliac bone 3 cm below the edge of the 12 rib, and a section of the aponeurosis of the external, internal oblique and transverse muscles of the abdomen 4 cm long is performed perpendicular to the skin incision and parallel to the edge of the right rectus abdominis muscle, deviating from it 2-2.5 cm.

 3. A retroperitoneoscope is inserted into the incision obtained, to the left and perpendicular to the rectus abdominis muscle, so that the gutter of the retroperitoneoscope blade is located above the surface of the left lobe of the liver. An illuminator is connected to a retroperitoneoscope through a light guide. Inspect the left lobe of the liver (I, II, III segment), turning the blade of the retroperitoneoscope by its handle counterclockwise, and parallel to the surface of the liver examine its right lobe (IV, V, VI, VII, VIII segment), and to suture the liver ruptures the retroperitoneoscope blade gutter introduces the instruments and carries out a hemostatic suture of the wound, stapling, tamponade of the defect with the omentum, draining the abdominal cavity with silicone tubes, tampons, etc. After that, the apparatus for retroperitoneoscopy is removed from the abdominal cavity. The wound is sutured in layers with separate sutures.

 The proposed method allows you to perform the necessary amount of surgery for ruptures in the zone I, II, III, IV, V, VI, VII and VIII segment of the liver in children with minimal invasiveness. Significantly reduces treatment time due to the early active regimen of patients.

Clinical example
Izgarshev Oleg entered the clinic for 11 years at 21.40. 11/17/1999, discharged 10/12/1999, medical history 10170. Complaints upon receipt of abdominal pain, vomiting. An. morbi: At 9 p.m., playing on the roof, the child fell from a height of 7-8 m. An ambulance team. help after 20 minutes delivered to the children's surgical department. Upon receipt, the condition is extremely serious. Body temperature 36.7. The skin and visible mucous membranes are pale. Shortness of breath up to 26 per minute. Pulse up to 154 per min. HELL 125/75. In the area of the scalp, face, limbs, multiple abrasions. The abdomen is swollen, the anterior abdominal wall is not involved in the act of breathing. On palpation, pronounced tension of the anterior abdominal wall and sharp pain in all departments. Symptoms of peritoneal irritation are positive. Complete blood count: erythrocytes - 4.18MIL, hemoglobin - 10.8 g / dl, white blood cells - 39.5TNOU, ESR - 5 mm / hour. General urine analysis, biochemical blood parameters within the age norm. Examination of a neurosurgeon is a severe open craniocerebral injury. A linear fracture of the frontal bone to the right with a transition to the anterior cranial fossa. A severe brain contusion. Inspection of a traumatologist - a fracture of the right and left pubic bone. Diagnosis at admission: Polytrauma. Severe traumatic brain injury. A linear fracture of the frontal bone to the right with a transition to the anterior cranial fossa. A severe brain contusion. Fracture of the right and left pubic bone. Closed abdominal damage. Liver rupture? Traumatic shock of the I-II degree.

 From the reception and diagnostic department, the child was taken to the operating room, where an operation was performed under endotracheal anesthesia: diagnostic laparoscopy, suturing the wounds of the right lobe of the liver.

 After treating the skin with a chlorhexidine solution, the incision is up to 1.0 cm at a point above the umbilical fossa by 5 cm and to the left of the midline of the abdomen by 3 cm. A Verishi needle is inserted into the abdominal cavity through the incision. The abdominal cavity is filled with nitrous oxide, after which a trocar and a laparoscope are introduced through the described access. Examination of the abdominal cavity revealed liquid blood in a volume of 200-250 ml, spreading from the subphrenic space to the right, along the right flank and to the pelvis. A further examination revealed a gap in the zone V of the segment of the right lobe of the liver up to 3.5-4 cm with ongoing bleeding. Other injuries of the liver, spleen, mesentery of the intestine and intestinal tube were not detected. Laparoscope is disconnected from the illuminator. After treatment of the skin with an antiseptic in the right hypochondrium, a skin incision was made 3.5 cm long from the edge of the right rectus abdominis muscle towards the upper outer spine of the wing of the right iliac bone 3 cm below the edge of the 12th rib, and the aponeurosis incision of the external, internal oblique and transverse abdominal muscles 4 cm long is made perpendicular to the skin incision and parallel to the edge of the right rectus abdominis muscle, deviating from it 2-2.5 cm. The peritoneum is opened. A retroperitoneoscope was introduced into the obtained access, with a blade to the left and perpendicular to the rectus abdominis muscle. The retroperitoneoscope blade gutter is located above the surface of the left lobe of the liver. An illuminator from a laparoscope is connected to a retroperitoneoscope through a light guide. The left lobe of the liver was examined - there were no injuries of the II-III segments. Moving the blade of a retroperitoneoscope counterclockwise and parallel to the surface of the liver, the right lobe is examined. Two ruptures of the liver parenchyma were revealed in the zone V of the segment 4: 1 cm and in the zone VI of the segment 1.5: 0.5 cm. A clamp was introduced through the gutter of the retroperitoneoscope and a needle holder made a hemostatic catgut suture of the wound in zone V of the segment and thermal hemostasis of the wound in zone VI segment. Under the control of a retroperitoneoscope, a drainage silicone tube is brought to the rupture site through a separate puncture in the anterior abdominal wall. Control of hemostasis. A retroperitoneoscope is removed from the abdominal cavity. The aponeurosis of the external, internal oblique and transverse muscles of the abdomen, and then the skin, is sutured separately. Aseptic dressing.

 Diagnosis after surgery: Polytrauma. Severe traumatic brain injury. A linear fracture of the frontal bone to the right with a transition to the anterior cranial fossa. A severe brain contusion. Fracture of the right and left pubic bone. Closed abdominal damage. Rupture of the right lobe of the liver. Intra-abdominal bleeding. Traumatic shock of the I-II degree.

 From the operating room, the child was transferred to the intensive care unit, where anti-shock measures and standard symptomatic therapy were continued. A repeated examination of the neurosurgeon and traumatologist was performed.

 11/18/99. The condition of the child is extremely serious. Consciousness is absent. From 22.00 on the background of the restoration of independent breathing, extubation was performed. Body temperature during the day from 36.4 to 37.5. Pulse - 120 rpm. AD-130/65. The abdomen is not swollen, with palpation a motor reaction to pain in the wound area. Post-traumatic intestinal paresis of the II degree remains. Auscultatory sluggish peristalsis. From the abdominal cavity through the drainage tube to 100 ml of hemorrhagic discharge. According to the probe from the stomach, 50 ml of stagnant contents. Diuresis - 2000 ml. Stool on the background of intestinal stimulation of 0.05% r-rum proserin after an enema 2 times.

 11/19/99. The condition is the same. Medically loaded. Contact not available. Body temperature from 36.7 to 38.1. The stomach is soft. Clinically, intestinal paresis is preserved up to grade I. Auscultatory satisfactory peristaltic murmurs. There is no discharge from the stomach from the probe; the latter has been removed. Diuresis - 1200 ml. Once on the background of intestinal stimulation, an independent stool and twice after an enema. Ultrasound of the abdominal cavity - there is no free fluid in the abdominal cavity, there are no structural changes in the liver, spleen, or kidneys. Control biochemical blood tests without pathology. Complete blood count: erythrocytes - 2.9 MIL, hemoglobin - 8.1 g / dl, leukocytes - 21.2 THOU, the formula remains shifted to the left, ESR - 25 mm / hour.

 11/20/99. Severe condition due to traumatic brain injury. Well-being does not suffer. Relatively accessible to contact. There are no complaints. Nausea, vomiting is absent. Body temperature - 36.6. Skin and visible mucous membranes of normal color and moisture. Hemodynamics is stable. Pulse - 90-100 per min. HELL - 120/70. The abdomen is not swollen when palpated soft. Moderate wound pain persists. Edema, no wound infiltration. From the abdominal cavity through the drainage tube to 20 ml of serous discharge. Correction of homeostasis continued. Treatment of a neurosurgeon.

 11/21/99. The condition of the child is stable to moderate severity. No complaints. Body temperature 36.6-37.2. Started fluid intake per os up to 250 ml during the day. No vomiting noted. Hemodynamics is stable, pulse 70-80 beats. in minutes HELL 120/70. The abdomen is not swollen, soft on palpation. Peritoneal symptoms are absent. Auscultatory peristalsis is satisfactory. Stool on the background of intestinal stimulation during the day four times. Diuresis 1500 ml. Control an. blood: erythrocytes - 3.69 MIL, Hemoglobin - 10.1 g / dl, white blood cells - 6.5 TNOU, white blood cell count unchanged, ESR - 34 mm / hour. Biochemical blood tests within the age norm. There is no discharge from the abdominal cavity through the drainage tube. At the ligation, the tube was removed from the abdominal cavity. Aseptic dressing.

 November 22-23, 1999. The condition of the child is stable. Relatively active. Body temperature - 36.6. Feeding started. No vomiting. Pulse up to 90 per min. HELL 120/70. The abdomen is not swollen, palpation is soft, painless in all departments. Postoperative wounds without signs of inflammation. Auscultatory peristalsis is satisfactory. The chair is independent, decorated. There is no dysuria. The cancellation of infusion, antibacterial therapy. A course of postoperative rehabilitation (microwave on a wound, massage) has begun.

 11/24/99. The child was transferred to the Department of Pediatric Surgery for further treatment. The condition is satisfactory. There are no complaints. Sleep, appetite is not broken. Body temperature 36.6. Somatically without features. The abdomen is soft, painless. Given the presence of head injury, fractures of the pelvic bones, bed rest is maintained. In the dressing room, sutures were removed (on the 7th day of the postoperative period).

 11/25. 12/10/99. The condition is satisfactory. There are no complaints. Body temperature 36.6. The abdomen is soft, painless. There are no signs of inflammation in the area of postoperative wounds. Healing of the latter by primary intention. Ultrasound of the liver in dynamics without features. An intensive course of treatment and rehabilitation for head injury has been completed. The child was discharged for a spa treatment with recommendations. Blood test at discharge: red blood cells - 4.37 MIL, hemoglobin - 116 g / dl, white blood cells - 9.7 THOU, platelets - 11.6%, ESR - 30 mm / h. The diagnosis at discharge: Polytrauma. Severe traumatic brain injury. A linear fracture of the frontal bone to the right with a transition to the anterior cranial fossa. A severe brain contusion. Injuries to the soft tissues of the head and face. Fracture of the right and left pubic bone. Closed abdominal damage. Gap V, VI segment of the right lobe of the liver. Intra-abdominal bleeding. Traumatic shock of the I-II degree.

 Using this method, the clinic performed 20 operations in children aged 3 to 14 years. In 9 children, gaps in the projection of the V segment, in 7-IV, in 3-VI and in I-III segment of the liver, were noted to varying degrees. All children were discharged with recovery. Outpatient observation for 1 year revealed no complications and signs of adhesive disease.

 Thus, surgical treatment of closed liver injuries in children by performing variable cruciform access in the right hypochondrium and the use of a retroperitoneoscope in this access allows any surgical hemostatic manipulation in the zone I, II, III, IV, V, VI, VII and VIII of the liver segment, and reducing surgical trauma is the prevention of possible complications. Access with intersecting rows of sutures avoids the discrepancy between the edges of the wound and eventation in the postoperative period.

Claims (1)

 A method of surgical treatment of closed liver injuries in children, including performing variable access in the right hypochondrium and suturing liver ruptures, characterized in that a skin incision of 3.5-4 cm is performed from the edge of the right rectus muscle of the abdomen towards the upper external spine of the iliac wing 3 cm below the edge of the 12 ribs, and the aponeurosis section of the external, internal oblique and transverse abdominal muscles 4 cm long is performed parallel to the edge of the right rectus abdominis muscle, deviating from it 2-2.5 cm, into the resulting cruciform access is introduced to the monk of the retroperitoneoscope, positioning it above the rupture of the liver parenchyma, then examine the I, II, III, IV, V, VI, VII, and VIII segments of the liver, introducing the blade of the retroperitoneoscope into the abdominal cavity in the direction of the left hypochondrium perpendicular to the rectus abdominis muscle and turn its handle against clockwise parallel to the surface of the liver to the right hypochondrium.