RU2254075C1 - Method for videothoracoscopic extravasal occlusion of opened arterial duct - Google Patents

Abstract

FIELD: medicine, cardio-vascular surgery.

SUBSTANCE: one should introduce three trocars into patient's thorax, perform videoendosurgical isolation of anterior, superior and inferior ductal walls followed by squeezing the duct with clips. After isolating anterior, superior and inferior ductal walls one should measure external diameter of its narrowest part and match a clip in accordance with the ratio of clips' sizes to external diameter of a vessel. At this ratio, external diameter of the vessel of 3.0 mm corresponds to clips of 5.0 mm and 6.0 mm in closed state, in case of external diameter of vessels being 3.5 mm, 4.0 mm and 5.0 mm one should match clips of 8.7 mm and 9.0 mm length, and at vessels' diameter being 5.5 mm and 6.0 mm it is necessary to take clips of 12.0 mm length. To perform clipping one should substitute instrumental trocar for that for clip-applicator in the desired point. As a result, it is possible to decrease traumaticity of operative interference, decrease cases of intraoperational hemorrhages and lesion of recurring-laryngeal nerve, save residual circulation or renew it along opened arterial duct.

EFFECT: higher efficiency.

1 cl, 1 ex, 1 tbl

Description

The present invention relates to medicine, namely to cardiovascular surgery.

The open ductus arteriosus (OAI) is one of the most common malformations of the cardiovascular system. A functioning arterial duct, even of small sizes, leads to premature death, while the average life expectancy of untreated patients with OAP is 39 ± 4 years. Early diagnosis and elimination of the defect are the only optimal way to increase the duration and improve the quality of life in patients with OAP.

There is a method of surgical treatment of OAP (Burakovsky V.I., Bokeria L.A. Cardiovascular surgery. M. 1996, p. 82-88), including left-side thoracotomy, circular excretion of the ductus arteriosus and its ligation with two ligatures. The disadvantages of the method are: significant invasiveness of the intervention; the continuing high level of operational mortality due to damage to the duct wall and the development of intraoperative bleeding; a high level of restoration of pathological blood flow through the arterial duct after ligation as a result of incomplete ligation of the duct or its recanalization.

There is a method of videothoracoscopic surgical treatment of OAP, which is less traumatic for the intervention and includes the introduction into the chest of three or four trocars, video endosurgical isolation of the anterior, upper and lower walls of the duct and compression of the duct with metal clips (Laborde F., Folliquet T., Batisse A., Dibie A., Da-Crus E., Carbognani D. Surgery for Congenital Heart Disease. Video-Assisted Thoracoscopic Surgical Interruption: The Technique of Choice for Patent Ductus Arteriosus. J. Thorac. Cardiovasc. Surg. 1995; 110: No. 6: 1681 -1685).

The main disadvantages of the method are: a high level of cases of preservation of residual blood flow or its relapse; dysfunction of the laryngeal nerve associated with damage to metal clips; intraoperative bleeding.

The technical result of the invention is to reduce the degree of invasiveness of surgical intervention, reduce cases of intraoperative bleeding, damage to the laryngeal nerve, preserve residual blood flow or resume blood flow by OAA.

The method is as follows: three trocars are introduced into the left pleural cavity, the front, upper and lower walls of the OAA from the aortic wall to the vagus nerve and the recurrent-laryngeal nerve extending from it for a length sufficient for overlaying clips are inserted from the surrounding tissues.

The high location of the aortic arch and the corresponding location of the OAA relative to the aorta make it necessary to partially isolate the posterior wall of the duct, since the tilt angle of the clip applicator with respect to the duct in this anatomical version becomes acute. This manipulation is performed in the form of a narrow rectilinear tunnel and is carried out by a palpation probe or a tool with a hemispherical tip with a diameter of 3.7-5.0 mm in the area of the intended location of the clips at a distance of 2-4 mm. As a rule, such a manipulation does not present any technical difficulties and does not cause damage to the duct wall, since the instrument moves tangentially with respect to the duct. A prerequisite is the observance of the straightness of the direction of movement of the instrument, caution and the termination of tunneling with pronounced tissue resistance. After highlighting the front, upper and lower walls of the OAP using a graduated endoscopic probe, the external diameter of the duct is measured in its narrowest part.

The technical result is achieved in that the selection of clips of the required size is made according to the table of the ratio of the sizes of the clips with the outer diameter of the vessel.

Table
The ratio of the size of the clips with the outer diameter of the vessel. Vessel Outer Diameter (mm) Atrauclip music videos size Ligaclip extra music videos size 3.0 Average LT200 3,5 Wed-large LT300 4.0 Wed-large LT300 4,5 Wed-large LT300 5,0 Wed-big LT300 5.5 Big LT400 6.0 Big LT400

To perform the clipping, the instrumental 5.0 mm trocar is replaced with an 11.0 mm trocar for the clip applicator at the selected point, and the lung retractor is replaced with a clamp - dissector with bent tips of the jaws. The dissector fixes a leaf of the prepared pleura, providing an exposure of the OAA and the laryngeal nerve.

Clips are superimposed stepping back 2.0-3.0 mm from the aortic wall so that they do not get the laryngeal nerve. To interrupt the blood flow through the OAA or any other vessel, clips and clip applicators of two leading developers are used, approved for use by the Ministry of Health of the Russian Federation:

"Atrauclip" of the company "Pilling", Germany:

- medium - 6.0 mm long in closed condition;

- medium-small - 9.0 mm long;

- large - 12.0 mm long.

"Ligaclip extra" company "Ethicon Endosurgery" company "Johnson and Johnson", USA:

- medium - LT 200 - 5.0 mm long in closed state;

- medium-small - LT 300 - 8.7 mm long;

- Large - LT 400 - 12.0 mm long.

Clipping injuries are observed provided that the jaw of the clip is strictly perpendicular to the longitudinal axis of the vessel during their closure, otherwise there may be a potential risk of damage to the OAP walls by the edges of the clips.

When the diameter of the OAP is more than 6.0 mm, its ligation is shown. For this purpose, a mini thoracotomy is performed with a length of 2.0-4.0 cm in the third intercostal space in the form of an extension of a trocar wound. Through mini-thoracotomy, standard surgical instruments are introduced, with which, under video endoscopic control, the posterior wall of the OAI is extracted, ligatures are performed around the duct and its ligation is performed. The combination of minithoracotomy with video endoscopy can reduce the degree of trauma of surgical intervention by reducing the area of injured tissues in comparison with left-sided minithoracotomy and standard thoracotomy, which leads to a decrease in the number of postoperative complications.

Example

Patient L., 6 years old and 4 months old, was admitted to the clinic with complaints of increased fatigue, frequent colds, shortness of breath during physical exertion. From the anamnesis it is known that she previously underwent surgery - plastic surgery of a ventricular septal defect (DMS) from transsternal access. During the examination: the condition of the patient of moderate severity. The skin is of normal color. In the projection of the sternum, a rough linear scar up to 12.0 cm long. Heart rate - 72 beats / min. HELL = 95/45 mm Hg General blood tests, urine tests, biochemical blood tests - without deviations from the norm. Height 110 cm, weight - 15 kg.

On an ECG: sinus rhythm; incomplete blockade of the right bundle branch block; axis-levogram; hypertrophy of both ventricles. Phonocardiography: 2nd tone on the pulmonary artery is normal, split. There is systolic-diastolic murmur at 4 points and above the aorta. Echocardiography: condition after surgery for plastic surgery of the breast - a patch without features, OAP - 2.0-3.0 mm. Systolic-diastolic turbulent blood flow above the pulmonary valve is noted. Blood flow through the valve of the pulmonary artery can be traced only to systole. There is prolapse of the right cusp of the mitral valve without regurgitation, insufficiency of the tricuspid valve with regurgitation (1+), additional trabecula in the left ventricle. The design pressure in the right ventricle is 25 mm Hg.

Clinical diagnosis: condition after surgery for plastic surgery of benign prostatic hyperplasia, OAP, mitral valve prolapse.

A video-assisted thoracoscopic extravasal occlusion was performed using three-trocar access: 11.0 mm, 6.0 mm and 6.0 mm. When revising the organs of the chest, injuries and adhesions were not detected. The diameter of the descending aorta is 17.0 mm. Produced retraction of the apex of the lung down and medially. The front, upper and lower walls of the OAP are marked with a dull and sharp path. The outer diameter of the narrowest part of the duct is 5.0 mm. The required clip size is determined by the table "Ratios of the sizes of clips with the outer diameter of the vessel." The duct is clipped with two medium-sized small titanium clips “Atrauclip” near the aorta. With transesophageal echocardiography: there is no blood flow through the OAA. The pleural cavity is drained. Hemostasis control is dry. A control drainage through the trocar wound is installed in the pleural cavity. Easy straightened. Postoperative wounds sutured in layers tightly. Iodine. Aseptic sticker. The duration of the operation is 2 hours. On an outpatient examination after 5 years, on the basis of clinical and instrumental data, there is no blood flow through the arterial duct, the patient is in good health and condition.

The use of video thoracoscopic extravasal occlusion of the open arterial duct with metal clips eliminates damage to the vascular wall and ensures complete interruption of pathological blood flow, which reduces the number of deaths, complications, reoperations, reduces the time of surgery and the duration of postoperative rehabilitation of patients.

The developed method of videothoracoscopic extravasal occlusion of the open ductus arteriosus was successfully used in clinical practice. Videothoracoscopic correction of the defect using titanium clips was performed in 51 patients aged 24 days to 15 years, weighing from 1 kg 650 g to 53 kg 500 g. In this case, complete cessation of pathological blood flow was achieved in all cases. No complications were noted. Long-term results of the operation were traced in 45 patients in the period from 8 months to 5 years. There were no complications associated with the operation.

Claims (2)

1. The method of video thoracoscopic extravasal occlusion of the open arterial duct, including the introduction of three trocars into the chest, video endosurgical extraction of the anterior, upper and lower walls of the duct, clamping of the duct with clips, characterized in that after the extraction of the anterior, upper and lower duct walls, the outer diameter of the duct itself is measured narrow part and select the clip in accordance with the ratio of the size of the clips with the outer diameter of the vessel, at which the outer diameter of the vessel 3.0 mm correspond to s with a length of 5.0 mm and 6.0 mm in a closed state, and the outer diameters of vessels 3.5 mm, 4.0 mm, 4.5 mm and 5.0 mm correspond to clips with a length of 8.7 mm and 9, 0 mm, and the outer diameters of the vessels 5.5 mm and 6.0 mm correspond to clips 12.0 mm long, while for clipping, the instrumental trocar is replaced by a trocar for the clip applicator at the selected point. 2. The method according to claim 1, characterized in that the lung retractor is replaced with a clamp-dissector with bent tips of the jaws, which fix the leaf of the prepared pleura for exposure of the open ductus arteriosus and the laryngeal nerve, while the clips are superimposed, retreating 2.0- 3.0 mm from the aortic wall.