RU2221607C2 - Method for treating gallbladder bed in performing cholecystectomy - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves carrying out cholecystectomy. Treatment with Uracyl solution and laser coagulation of areas distinguished by most intensive hemorrhages and/or with retained fragments of posterior gallbladder wall under marked infiltration and commissure formation process. The laser beam moves at a speed of 1-2 mm/s. Next to it, bed laser coagulation is twice administered at a speed of 2-3 mm/s and 5-7 mm/s, respectively. Laser treatment is carried out in performing circular movements on spiral trajectory beginning from fixed posterior gallbladder wall fragments or from the boundary of gallbladder bed towards its center from 1-2 cm large distance. Furacin solution treatment is carried out after each laser coagulation treatment during a time period enough for cooling tissues under treatment. The treatment is carried out diode laser radiation at 0.805 mcm wavelength in quasi-continuous mode with radiation power equal to 7-15 W. EFFECT: enhanced effectiveness of treatment.

Description

 The invention relates to medicine, in particular to surgery, and can be widely used for laparoscopic cholecystectomy for the treatment of the gallbladder bed during its implementation.

 Known methods for treating the gallbladder bed, such as plugging, suturing, thermo and electrocoagulation (Lasers in clinical medicine. A guide for doctors. M: Medicine, 1996, p. 114).

 However, these methods are not radical. In addition, such a well-known method for coagulation of the gallbladder bed, as electrocoagulation, has disadvantages: thermal burns of the liver of various degrees, the phenomenon of "tunneling" of the current with damage to the tubular structures of the hepatoduodenal ligament and neighboring organs, the phenomenon of demodulation of current with electric damage to the patient with a low-frequency current, burn patient in the area of the passive electrode. In addition, electrocoagulation involves contact of the instrument with the wound surface, which leads to "sticking" of the working part of the instrument to the liver tissue, followed by separation of the coagulation scab and the resumption of blood and bile ducts.

 A known method of laser coagulation of the gallbladder bed during cholecystectomy, selected as the closest analogue, providing for the preliminary drying (sanitation) with a gauze swab of the gallbladder bed and subsequent treatment of the bed with a defocused beam of a CO laser with a power density of about 400 W / cm from a distance of 10-15 see (Lasers in surgery. Edited by O.K. Skobelkin. - M.: Medicine, 1989, pp. 100-101).

 Processing of the gallbladder bed is carried out by parallel movements of the beam in the transverse direction, gradually moving from the edge of the liver to its gate. According to the authors of this technique, this avoids blood flow from the upper parts of the bed to the point of exposure to the laser beam.

 The surface of the bed is covered with a thin brown film of coagulation necrosis and only at the points of active bleeding, where it was necessary to slow down the movement of the beam, a dark scab of charred shaped blood elements is formed.

 After coagulation, a wet towel is pressed onto the laser-treated wound for 2-3 minutes, which tightens the scab, increases its adhesion to the underlying tissues.

 After removing the wipes in the treated area, as a rule, there remain bleeding vessels of at least one with a diameter of more than 1.5 mm. In this situation, this bleeding vessel is stitched with a ligature, followed by ligation.

 Thus, the known method cannot provide sufficiently reliable hemostasis. In addition, the known method cannot be used for laparoscopic cholecystectomy, since it requires the fiber to be pointed away from the wound by a considerable distance of 10-15 cm, as well as pressing a wet towel and flashing blood vessels with a ligature, which is impossible due to the lack of open access to the treated place.

 Thus, the technical result to which this invention is directed is to significantly increase the efficiency of treatment of the gallbladder bed during cholecystectomy and increase its versatility.

 The specified technical result is achieved by the fact that in the known method for treating the gallbladder bed during cholecystectomy, which includes debridement and laser coagulation of the gallbladder bed with a defocused laser beam, according to the invention, sanitization with furatsilin solution and laser coagulation of areas with the most intense bleeding and / or left fragments is carried out the back wall of the gallbladder with a pronounced infiltrative-adhesive process with a speed of movement of the laser beam of 1-2 mm / s, after it is performed by double laser coagulation of the bed with a beam moving speed of 2-3 and 5-7 mm / s, respectively, the laser action is carried out in circular movements along a spiral path from the edges of fixed fragments of the posterior wall of the gallbladder or from the edges of the gallbladder bed to its center and from a distance 1-2 cm, after each laser coagulation, sanitation is carried out with a solution of furatsilin for a time sufficient to cool the treated tissues, and the treatment is carried out by radiation of a diode laser with a wavelength of 0.805 km in a quasi-continuous mode and 7-15 W output power.

 Reconstruction with a solution of furatsilin before laser coagulation allows you to free the surgical field from blood, which contributes to more efficient identification of sources of intense bleeding and improves the conditions for further laser coagulation of the wound surface, as well as reduces the risk of missing certain areas requiring laser treatment with intense bleeding and / or fragments left back wall of the gallbladder.

 Performing laser coagulation of areas of the gallbladder with the most intense bleeding and / or left fragments of the posterior wall of the gallbladder with a pronounced infiltrative-adhesive process also contributes to a significant increase in the efficiency of the method.

 This is due to the fact that due to this treatment, the amount of blood entering the surgical field is significantly reduced, and the source of a possible infection is removed. In addition, coagulation of intensely bleeding vessels in these areas significantly reduces blood loss. This ultimately significantly improves the conditions for further treatments of the wound surface and significantly reduces the risk of postoperative complications.

 The implementation of laser irradiation precisely in circular movements along a spiral path from the edges of fixed fragments of the posterior wall of the gallbladder or from the edges of the gallbladder bed to its center allows an even greater increase in the efficiency of the method.

 This is due to the fact that performed by the claimed method, laser coagulation allows you to completely eliminate the omission of individual sections of the gallbladder bed due to the consistent, uniform processing, performed first from its safest areas - the edges of the fixed fragments of the posterior wall of the gallbladder or from the edges of the gallbladder bed moving to the center of the gallbladder bed, gradually reducing bleeding and, as a result, ultimately improving visibility and processing of the central most dangerous area, p positioned in close proximity to the main vessels of the liver.

 The authors experimentally established that the implementation of laser coagulation of areas with the most intense bleeding and / or left fragments of the posterior wall of the gallbladder with a pronounced infiltrative-adhesion process with a laser beam moving speed of 1-2 mm / s and then performing double laser coagulation of the gallbladder bed with a beam moving speed of 2-3 and 5-7 mm / s, respectively, it also significantly improves its efficiency.

 This is due to the fact that areas with left fragments of the posterior wall of the gallbladder are most dangerous, since they are sources of possible infection and intense bleeding. Therefore, these areas should be treated with a laser beam most carefully. It is the stated speeds that provide the required quality of processing these areas, more reliable hemostasis and elimination of the source of infection.

 The remaining surface of the gallbladder bed also requires initial surface treatment with a defocused laser beam with special care, which, as established experimentally, is achieved by moving the laser beam with an insignificant speed of 2-3 mm / s.

 And the final treatment of the gallbladder bed helps to consolidate the effectiveness of gallstasis and hemostasis and, as revealed experimentally, is achieved by moving the laser beam at a speed of 5-7 mm / s.

 Moreover, it is during this double laser coagulation of the areas of the gallbladder bed with the most intense bleeding and / or left fragments of the posterior wall of the gallbladder that the effectiveness of hemostasis and gallstasis achieved during their initial laser coagulation is achieved, which completely eliminates the risk of infectious inflammation and, as a result, increases the efficiency of the method.

 The authors also experimentally established that the implementation of laser exposure is most effective from a distance of 1-2 cm. It was experimentally established that it is from this distance that high-quality coagulation of the gallbladder bed is achieved and at the same time, defocused radiation does not penetrate deep into the liver parenchyma, which queue significantly reduces the risk of damage to blood vessels and bile ducts, as well as the possibility of burns to the tissues of the liver itself.

 Performing after each laser coagulation of sanitization of the gallbladder bed with a solution of furatsilin for a period of time sufficient to cool the treated tissues, further improves the efficiency of the method. This is due to the fact that the probability of a burn of the parenchyma is almost completely eliminated.

 The authors also experimentally established that the highest efficiency of the method is achieved by processing the gallbladder bed with radiation from a diode laser with a wavelength of 0.805 μm in quasi-continuous mode and a radiation power of 7-15 watts.

 The method is as follows.

 Cholecystectomy is performed laparoscopically under continuous instrumental monitoring.

 After separation of the gallbladder from the bed using endoscissors through the subxiphoid port and the port located in the right hypochondrium, the right lobe of the liver rises along the front axillary line with retractors and the gallbladder bed is widely exposed.

 With a pronounced infiltrative-adhesive process in the gallbladder bed with destructive cholecystitis, scleroatrophic gallbladder, cirrhosis of the liver, in the process of separation of the gallbladder from the liver, fixed fragments of the posterior wall of the gallbladder are left.

 After the gallbladder bed is released through a laparoscope, its surface is examined and areas with the most pronounced bleeding and / or left fragments of the posterior wall of the gallbladder are revealed.

 Then, through the port located in the right hypochondrium, an aspirator-irrigator with a working channel for the fiber is introduced along the midclavicular line.

 Sanitation of the wound surface with a solution of furatsilin and its removal after rehabilitation is carried out.

 After that, a tool is prepared for treating the wound surface with laser radiation.

 For processing, a quartz monofilament fiber in a polymer shell with a diameter of 1 mm is used. The end of the fiber is removed from the working channel of the aspirator-irrigator to a distance of 1-2 cm, laser radiation is applied and the laser beam is irradiated with a defocused to 4-7 mm laser beam of the most bleeding areas and / or areas with left fragments of the posterior wall of the gallbladder. The speed of the laser beam during this pre-treatment is 1-2 mm / s.

 The laser beam is moved during this treatment in a circular motion along a spiral path from the edges of the fixed fragments of the posterior wall of the gallbladder to its center.

 As a source of laser radiation, the radiation of the ALTO semiconductor diode laser with a wavelength of 0.805 μm in a quasi-continuous mode with a power of 7-15 W is used.

 After performing this treatment, the wound surface is sanitized with a solution of furatsilin in order to control the effectiveness of hemostasis and cool the treated surface of the liver.

 After that, the first of the two subsequent treatments of the gallbladder bed is carried out with a defocused laser beam from a distance of 1-2 cm, moving the laser beam in a circular motion along a spiral path from the edges of the wound to the center of the wound surface from a distance of 1-2 cm.

 The speed of the laser beam during this first treatment is 2-3 mm / s.

 After the initial treatment, the next re-sanitation of the wound surface is carried out in order to control the effectiveness of hemostasis and at the same time to cool the treated tissues. The used solution is removed from the cavity through an aspirator-irrigator.

 Then, the final, second of the two subsequent treatments of the wound surface with a defocused laser beam from a distance of 1-2 cm is carried out. The speed of the laser beam during this treatment is 5-7 mm / s. The laser beam is also moved in a circular motion along a spiral path from the edges of the wound to the center of the wound surface.

 And finally, after this treatment also carry out the final rehabilitation of the wound surface.

 After the above treatments of the gallbladder bed, the instrument is removed from the abdominal cavity. The control silicone drainage tube is brought to the bed.

 The above treatment of the gallbladder bed with cholecystectomy is also possible if it is performed with open access.

 The method is illustrated by examples.

 Example 1. Patient D. - 55 years. Diagnosis: chronic calculous cholecystitis. Disabled scar-wrinkled gall bladder.

 Under intubation anesthesia, a laparoscopic cholecystectomy from the neck was performed with separate processing, clipping and intersection of the cystic duct and arteries after separation of the gallbladder with the help of endoscopic shears. A fixed fragment of the posterior wall of the gallbladder is left.

 After sanitation of the gallbladder bed, an instrumental examination of the wound surface and the left fixed fragment of the posterior wall of the gallbladder was performed. Areas with the most intense bleeding were identified.

 These sections were processed using laser radiation (ALTO semiconductor diode laser, wavelength 0.805 μm, in a quasi-continuous mode with a power of 15 W from a distance of 1 cm with a movement speed of 1 mm / s in circular motions along a spiral path from the edges of the left fragment of the posterior bile wall the bubble to its center.The following sanitation was carried out with a solution of furatsilina followed by suction of the spent solution, followed by two times treatment (with intermediate sanitation) of the wound surface with per rooms, respectively, 2 and 5 mm / s. Moving the laser beam during subsequent processing: in circular motions along a spiral path from the edges of the wound to its center.

 After the final treatment, sanitation was completed. The tool is removed from the abdominal cavity. The control silicone drainage tube is brought to the bed.

 The postoperative period was uneventful. The patient was discharged from the hospital a few days later.

 Example 2. Patient K. 48 years. Diagnosis: chronic calculous cholecystitis. Viral hepatitis C.

 Cholecystectomy was performed according to example 1 without leaving a fragment of the posterior wall of the gallbladder.

 The sequence of processing the bed of the gallbladder with a defocused laser beam according to example 1. The distance from which the processing is carried out, 2 cm. The speed of preliminary and subsequent treatments is 2, 3 and 7 mm / s, respectively.

 Laser and processing modes according to example 1.

 Example 3. Patient N. 62 years. Diagnosis: Acute phlegmonous calculous cholecystitis.

Cholecystectomy in example 1
The sequence of laser processing of the gallbladder bed according to example 1 with the exception of distance, speeds and radiation power, which are respectively: 1.5 cm; 1.5, 2.5, 6 mm / s and 10 watts.

Claims (1)

A method of treating a gallbladder bed during a cholecystectomy, including debridement and laser coagulation of the gallbladder bed with a defocused laser beam, characterized in that sanitation is carried out with a furatsilin solution and laser coagulation of areas with the most intense bleeding and / or left fragments of the posterior wall of the gallbladder with a pronounced infiltration -soldering process with a speed of movement of the laser beam of 1-2 mm / s, after which conduct double laser coagulation of the bed at a speed of the beam is 2-3 mm / s and 5-7 mm / s, respectively, the laser action is carried out in a circular motion along a spiral path from the edges of fixed fragments of the posterior wall of the gallbladder or from the edges of the gallbladder bed to its center and from a distance of 1-2 cm , after each laser coagulation, sanitation is carried out with a solution of furatsilin for a time sufficient to cool the treated tissues, and the treatment is carried out by radiation of a diode laser with a wavelength of 0.805 μm in quasi-continuous mode and a radiation power of 7-15 watts.