RU2199962C2 - Device for temporally reducing blood circulation and draining the abdominal cavity when performing surgical operations on spleen - Google Patents

Abstract

FIELD: medical engineering. SUBSTANCE: device has hollow silicon rod and ligature. The ligature comes through the rod and forms loop outside of its working end. The working rod end introduceable into the abdominal cavity has two through draining openings. The openings are positioned one above the other and oriented along the longitudinal rod axis. The opposite end of the rod enables one to bring the cannula with tube for carrying out passive draining. Opening for bringing outside the free ends of ligature with clamping unit being mounted on the ligature of the clamping unit. EFFECT: enhanced effectiveness of treatment; avoided cuts of blood vessels. 2 cl, 1 dwg

Description

 The invention relates to medicine, namely to pediatric surgery.

 State of the issue: with closed injuries of the abdominal cavity, spleen rupture is detected in 24-33% of cases [Pugachev AD, Baramiya N.N. Surgical treatment of closed abdominal injuries. Clinical Surgery, 1991, 4, p. 34-37, Ruppel G.G., Lazar A.M., Tarabarin S.A. Diagnostic laparoscopy for injuries of the abdomen. Surgery, 1997, 6, p. 26-28, Cywes S, Bass DH. Blunt liver trauma in children. Injury. 1991. Jul; 22 (4); 310-314]. After splenectomy, a condition called "hyposplenism" develops. Immune resistance is violated, the hematopoiesis system. Typical manifestations of postsplenectomy syndrome are a decrease in the phagocytic activity of neutrophils and monocytes, a violation of the ratio of T and B lymphocytes, a decrease in the level of immunoglobulins, as well as reticulocytosis and persistent leukocytosis. The most common complications after surgery are purulent-septic (21.6%), which lead to the death of 7.2% of patients [Koshelev V.N. Complications and mortality in spleen injury. Clinical Surgery, 1991, 9, p. 49-50]. Therefore, the feasibility of organ-preserving treatment of closed injuries of the spleen is not in doubt [Rozinov VM, Saveliev SB Ultrasound diagnostics in obstetrics and pediatrics. 1992, 1, pp. 65-69].

 A device is known for segmental intra-splenic blood flow reduction in spleen ruptures [RF Patent 2112433, BI 16, 1988, p. 246]. The design of the device is made of metal with shape memory, contains four pointed legs connected in pairs by a jumper, in the form of a bracket fastened with a similar bracket in the middle of the jumper with an S-shaped plate, and the distal pointed ends of the legs are angled towards each other.

 The disadvantage of this device: it is completely made of metal with shape memory, which complicates the manufacture and eliminates widespread use. In the presence of several gaps, the use of 2-3 or more structures is necessary, which takes a lot of time and causes difficulties in conditions of ongoing bleeding. It is used to reduce blood flow through the arteries and veins of the spleen located in the organ parenchyma, which is accompanied by additional trauma to the organ tissue during puncture of the spleen with the legs of the device. After application, the spleen is not removed from the parenchyma, acquiring the status of a foreign body.

 A device for applying a ligature loop [US Patent 5300078, M. cl. A 61 B 17/00, priority 09.10.92, publ. 04/05/94. "Method and device for applying a ligature loop"].

 The design of the device consists of a hollow rod and a thread having a free end and the other end with a loop. The loop is on the working end of the rod, and the free end of the thread passes through the hollow rod to the opposite end. A handle is attached to this end of the shaft, having a movably mounted actuator and a device connecting this mechanism to the free end of the thread so that this end stretches at a faster speed than the actuator, as a result of which the loop is tightened. The connecting device has a pulley system mounted rotatably in the handle. This system contains a large and small pulleys and a connecting element between the small pulley and the actuator, the free end of the thread is connected to a large pulley.

 The disadvantage of this device: a device for applying a ligature loop is used to finally stop bleeding after constriction and dissection of blood vessels, which does not allow organ-preserving surgery in case of damage to the spleen. After use, the device is removed from the abdominal cavity without performing the drainage function of controlling possible rebleeding.

 The objective of the invention is to provide a device for the final stop of bleeding and drainage of the abdominal cavity in case of damage to the spleen without dissecting arteries and veins in the mode of temporary reduction of blood flow and the possibility of orthotopic preservation of the organ.

 The task is achieved by the fact that when using a hollow silicone rod and a ligature that extends inside the rod to form a loop, two through drainage holes are made on the working end of the rod inserted into the abdominal cavity, located one above the other and oriented along the longitudinal axis of the rod, and at a distance from the opposite end of the rod, made to bring the cannula with a tube for passive drainage, there is a hole for the output of the free ends of the ligature, followed by installation on these ends of the clamp of devices. The ligature is made in the form of an elastic silicone tube.

Device novelty
1. The combination in one rod of perforation holes for drainage of the abdominal cavity at its working end, made to bring the cannula with a tube for passive drainage, and a perforation hole located at a distance from the opposite end for withdrawal and fixation of the free ends of the ligature by the clamping device, provides the final hemostasis during operations on the spleen and allows you to perform a drainage function in order to qualitatively and quantitatively monitor the discharge from the abdominal cavity in the postoperative period.

 2. Fixing the free ends of the ligature with a clamping device outside the rod allows you to completely remove the device from the abdominal cavity after temporary reduction of blood flow and healing of spleen wounds without the use of surgical instruments.

The positive effect of the use of this device:
1. The possibility of pre- and intraoperative manufacturing of the device without the use of special equipment in a short period of time.

 2. The device facilitates the use of other methods of surgical treatment (suturing wounds, applying clips, braces, the use of biological glue, etc.) in conditions of the final stop of bleeding from wounds of the spleen parenchyma.

 3. It can be used in patients of any age, with any form of damage to the spleen, which contributes to orthotopic preservation of the organ.

 4. Does not require additional drainage of the operation area with tubes.

 The invention is illustrated by the drawing, which shows a General view of the device, where 1 is a silicone rod, 2 - through perforations for drainage of the abdominal cavity, 3 - perforation hole for outputting the free ends of the ligature, 4 - ligature loop formed when it is drawn through the inner cavity of the rod 5 - the inner cavity of the rod, 6 - the working end of the rod, 7 - the free ends of the ligature, 8 - clamping device.

 A device for temporary reduction of blood flow and drainage of the abdominal cavity (see drawing) consists of a hollow elastic silicone rod 1 for introducing and holding a ligature loop compressing the spleen vessels, the inner diameter of which is 10 mm. At the working end of the rod, introduced into the abdominal cavity, there are two perforations 2 located one above the other along the longitudinal axis of the rod 1. The distance of the outermost hole from the tube end is 20 mm, the distance between the holes is 10 mm and the diameter of these holes is 5 mm. At a distance of 20 mm from the opposite end of the rod, another hole 3 with a diameter of 6 mm is made. Loop 4 is formed from a ligature material, which is an elastic silicone tube with a diameter of 3 mm and a length of 30 cm. The ligature, folded in half, is inserted with its free ends into the inner cavity 5 of the rod 1 with the formation of a loop 4 at the working end 6 of the rod 1. The free ends 7 of the ligature are displayed from the hole 3, where they, after adjusting the size of the loop are clamped by any clamping device 8.

 A device for temporarily reducing blood flow to the spleen and draining the abdominal cavity works as follows: for the audit of the spleen, the upper median laparotomic access is used. The position of the patient on the back. A longitudinal incision is made from the xiphoid process to the paraumbilical region, 4 cm indent from the umbilical fossa towards the pubic joint. The skin, subcutaneous fat, aponeurosis, peritoneum are sequentially dissected. The edges of the wound divert laterally with a retractor. The spleen for the gastrolienal ligament is removed to the wound. Using a billroth clamp and gauze tupfer, an artery and a spleen vein are isolated. After which the ligature with one of the free ends 7 (see drawing) is carried out behind the vessels of the spleen. Through an incision in the anterior abdominal wall 1-1.5 cm long, made from the middle axillary line towards the midline of the abdomen, parallel and lower than the edge 12 of the rib by 3 cm, silicone rod 1 is inserted into the abdominal cavity with the working end 6. Into the internal cavity 5 of the rod, both free ends 7 of the ligature are inserted in such a way that a loop 4 is formed at the working end of the rod, covering the artery and veins of the spleen. Both ends of the ligature are led out through the hole 3. By pulling on the free ends and sliding the ligatures in the cavity of the rod, the loop is tightened. Squeeze the vessels of the spleen until the cessation of bleeding from the gap. The free ends of the ligature are fixed at hole level 3 with any removable clip 8. If necessary, the parenchyma rupture is sutured, the spleen is placed in its bed, pulling the device from the abdominal cavity. The device does not require fixing beyond the edges of the skin. A cannula with a tube for passive drainage from the abdominal cavity is brought to the outer end of the rod. Laparotomic wound is sutured in layers. Hemostasis is monitored by the quality and quantity of discharge from the abdominal cavity through openings 2 and cavities 5 of rod 1. Using ultrasound in the postoperative period, the healing of the rupture of the spleen parenchyma is monitored. After 3-5 days, remove the clamp 8, fixing the ends 7 of the ligature, and weaken the compression of the vessels of the spleen. In the absence of blood flow through the holes 2 through the inner cavity 5 of the rod from the abdominal cavity, the rod and the ligature are sequentially pulled. The wound after removal of the suturing device does not require healing by secondary intention.

Device Usage Example
Kireev Kirill, 13 years old, was admitted to the clinic at 22.50 on 07/21/98, was discharged on 08/03/98, medical history 5655.

 Complaints of pain in the left abdomen.

 An. morbi: At 9 p.m., the child fell from a height of 1.5-2 m, hit his left side. There was abdominal pain. After 90 minutes, the ambulance team was delivered to the children's surgical department. Upon receipt, the condition is serious due to injury. Body temperature 36.0. The skin is pale. Forced position - sitting with hands brought to the stomach. Shortness of breath up to 21 per minute. Pulse up to 110 beats. in minutes HELL 100/65. The abdomen is not 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 on the left along the flank. Symptoms of peritoneal irritation are sharply positive. Complete blood count: erythrocytes - 4.1 MIL, hemoglobin - 11.8 g / dl, hematocrit - 35.5%, leukocytes - 16.1 THOU, ESR - 7 mm / hour. General urine analysis, biochemical blood parameters within the age norm.

 Diagnosis at admission: Closed abdominal damage. Rupture of the spleen.

 From the reception and diagnostic department, the child was taken to the operating room, where an operation was performed under endotracheal anesthesia: diagnostic laparoscopy, upper median laparotomy, suturing wounds of the spleen, and lavage of the abdominal cavity.

After treatment of the skin with a chlorhexidine solution, the incision is up to 1.0 cm at a point above the umbilical fossa by 3 cm and to the left of the midline of the abdomen by 4 cm. A Verishi needle is inserted into the abdominal cavity through the incision. The abdominal cavity is filled with CO ₂ , after which a trocar and a laparoscope are inserted through the described access. Examination of the abdominal cavity revealed liquid blood in a volume of 300 ml, spreading along the left flank and small pelvis. Upon further examination, the source of bleeding was revealed - rupture of the spleen in the projection of the lower pole with ongoing bleeding. Laparoscope is disconnected from the illuminator. After additional treatment with a skin antiseptic in the midline from the xiphoid process to the umbilical fossa, the skin incision is up to 15 cm. The muscles are bluntly dilated to the peritoneum. The peritoneum is opened, a retractor is introduced into the abdominal cavity. The spleen is visualized in the projection of the bottom of the surgical wound. After vascular pedicle of the spleen, after its isolation, one end summed up the ligature of the device for temporary reduction of blood flow. Through an incision in the anterior abdominal wall up to 1.5 cm, made to the left of the middle axelar line towards the midline of the abdomen, a hollow silicone rod with two perforations at the working end of the device was introduced into the abdominal cavity parallel to and below the edge of the 12th rib by 3 cm. Both free ends of the ligature are inserted into the canal with a diameter of 10 mm, a loop is formed that completely covers the artery and veins of the spleen. Both ends of the ligature are brought out through an opening located 20 mm from the edge of the opposite end of the rod and having a diameter of 6 mm. Due to pulling on the free ends and sliding of the ligature in the cavity of the rod, the loop is tightened until the bleeding stops from rupture of the spleen. The free ends of the ligature are fixed with a mosquito clip. After suturing the gap with separate catgut sutures, the spleen is laid in its bed. The device is stored in the abdominal cavity. A cannula with a tube for passive drainage from the abdominal cavity is brought to the outer end of the rod. Control of hemostasis. Layer-by-layer stitches on the wound.

 Diagnosis after surgery: Closed abdominal damage. Rupture of the lower pole of the spleen. Intra-abdominal bleeding.

 From the operating room, the child was transferred to the intensive care unit, where anti-shock measures, blood transfusion and standard symptomatic therapy were continued.

 07/21/98. The condition of the child is serious. Against the background of the restoration of independent breathing, tracheal extubation was performed. Body temperature during the day from 37.5 to 36.9. Pulse - 100 beats. in minutes AD-120/70. The child is available to contact. There are no complaints. The abdomen is not swollen, with palpation moderate pain in the wound area. Post-traumatic intestinal paresis of the first degree is preserved. Auscultatory sluggish peristalsis. On a probe from the stomach 50 ml of mucus. Diuresis-1200 ml. Up to 30 ml of blood was obtained from the abdominal cavity through the inner cavity of the rod.

 07/22/98. The condition is the same. There are no complaints. Body temperature 36.3. The stomach is soft. Auscultatory satisfactory peristaltic murmurs. There is no discharge from the stomach from the probe; the latter has been removed. Started taking fluid per os up to 300 ml during the day. No vomiting noted. Diuresis - 1500 ml. Control biochemical blood tests without pathology. Complete blood count: erythrocytes - 3.8 MIL, hemoglobin - 10.9 g / dl, white blood cells - 22.8 THOU, ESR - 54 mm / hour. There is no detachable device in the cavity of the rod core.

 07.24.98. The condition of the child is stable to moderate severity. No complaints. Body temperature 36.6. 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 three times. Diuresis 1050 ml. Control blood test: red blood cells - 3.9 MIL, hemoglobin - 10.7 g / dl, white blood cells - 11.0 THOU, ESR - 13 mm / hour. Biochemical blood tests within the age norm. There is no detachable device for lowering the loop along the cylinder. Ultrasound of the abdomen - there is no free fluid in the abdominal cavity, there are no structural changes in the liver or kidneys. In the area of the gap - the forming scar up to 5-6 cm long. The child was transferred to the Department of Pediatric Surgery for further treatment.

 07/25/98. The child's condition is stable, to satisfactory. Relatively active. Allowed to get up. Body temperature - 36.6. Gets a common table. No vomiting. Pulse up to 90 beats. in minutes HELL 120/70. The abdomen is not swollen, palpation is soft, painless in all departments. Postoperative scar without signs of inflammation. Auscultatory peristalsis is satisfactory. The chair is independent, decorated. There is no dysuria. The cancellation of infusion, antibacterial therapy. In the dressing room, the clip fixing the ends of the ligature is removed. The pressure of the loop on the vessels of the spleen is weakened.

 Observation for 2 hours showed no signs of bleeding. There is no detachable device abdominal cavity. In the dressing room after treatment of the skin with an alcohol solution of chlorhexedine, the rod and ligature were removed. A postoperative rehabilitation course has begun.

 07.26-03.08.98. 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 spleen in dynamics without features, a scar is clearly visualized in the projection of the lower pole. The course of treatment is completed. In the dressing room, sutures were removed (on the 9th day of the postoperative period). The child was discharged home with recommendations. Blood test at discharge: red blood cells - 4.13 MIL, hemoglobin - 11.5 g / dl, white blood cells - 11.7 THOU, platelets - 183, ESR - 31 mm / h.

 Diagnosis at discharge: Closed abdominal damage. Rupture of the spleen of the lower pole of the spleen. Intra-abdominal bleeding.

 The device is used for operations on the spleen in 35 children aged 3 to 14 years. In all children during surgery, bleeding from spleen wounds was stopped 5 minutes after opening the abdominal cavity. In 17 children, the device remained in the abdominal cavity for 3 days, in 10 children - for 4 days, and in 8 children - for 5 days. All children were discharged with recovery. Outpatient observation for 1 year, ultrasound of the spleen in dynamics did not reveal any complications.

Claims (2)

 1. A device for temporary reduction of blood flow and drainage of the abdominal cavity during operations on the spleen, consisting of a hollow silicone rod and a ligature passing inside the rod with the formation of a loop outside the working end of the rod, characterized in that at the working end of the rod inserted into the abdominal cavity is made two through drainage holes located one above the other and oriented along the longitudinal axis of the rod, and at a distance from the opposite end of the rod, made to bring the cannula with a tube for passive enazha is arranged to output opening outwardly the free ends of the ligature and then installing these ends of the jig.  2. The device according to p. 1, characterized in that the ligature is made in the form of an elastic silicone tube.