RU2261057C1 - Clamp for isolating of auticula atrii from left auricle and apparatus for placing the same - Google Patents

Abstract

FIELD: medicine equipment, in particular, treatment and prophylaxis of cardiogenic tromboembolism with the use of endovideosurgical processes.

SUBSTANCE: clamp has elongated jaws which are connected so that their working surfaces may be brought together, and lock for bringing jaws to predetermined distance therebetween and fixing thereof in predetermined position. Lock is adapted for being moved onto jaws by means of pusher. Apparatus has elongated case, working member and handles. Control handles are arranged at case proximal end. Accommodated in case for longitudinal displacement therein are tube, tube pusher, coil spring for reciprocating of tube, and clamp lock pusher. Working member is made in the form of holder with clamp jaws receiving slot. Holder is immovably fixed in case. One control handle is connected to tube pusher and other control handle is immovably connected to case.

EFFECT: increased efficiency in preventing of complications which might occur after isolating of auticula atrii from left auricle.

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Description

The invention relates to medical equipment, in particular to means for isolating the left atrial abdominal cavity (MPI) from the left atrium in the treatment and prevention of cardiogenic thromboembolism using endovascular surgery technologies.

The thrombus formation zone was found to be the left atrial ear in 91% of cases in patients with non-rheumatoid atrial fibrillation and in 43% of cases in patients with rheumatic heart diseases.

In patients over 65 years of age with atrial fibrillation (AF), the frequency of thromboembolic strokes is from 12 to 28.7% per year, which is a significant economic problem for the healthcare system and society as a whole.

For the prevention of cardiogenic thromboembolism in patients with AF, LAPTONI-type surgeries are performed using endovideo surgical techniques, thoracoscopically by stitching or stitching using various staplers (type 35 endo GIA stepler) in the area of the mouth of the hospital (John A. Odell, FRCS (Ed) , Joseph L. Blackshear, MD, Edward Davies, MD, W. John Byrne, MB, ChB, Christine F. Kollmorgen, MD, William D. Edwards, MD, Thomas A. Orszulak, MD Thoracoscopic Obliteration of the Left Atrial Appendage: Potential for Stroke Reduction? Ann Thorac Surg 1996; 61: 565-569).

The use of loops and staplers to isolate the left atrial ear from the left atrium has several disadvantages. When a loop is applied, the ear wall is corrugated, the loop does not lie at the base, but distal to the mouth of the hospital, which creates the preconditions for thrombosis.

When using staplers, microbleeding occurs along the suture line, requiring evacuation of blood residues by suction. In the stitched part of the suture line, foci of micronecrosis and microthrombi are often determined. When stitching, the tissue of the hospital is crushed by the stapler, which sometimes leads to self-amputation of the hospital.

A known clamp on a blood vessel with an aneurysm and an apparatus for applying it, comprising an elongated body, a working element located at the distal end of the body, and control knobs located at the proximal end of the body (US 4706668 A, 11/17/1987, A 61 B 17/12 )

However, the design of the known clamp causes hemodynamic disturbances, injures the surrounding structures during the work of the heart.

The objective of the invention is to prevent complications after isolation of the left atrial ear from the left atrium.

The problem is solved in that the clamp for isolating the left atrial ear from the left atrium, containing elongated jaws connected with the possibility of rapprochement of their working surfaces, has a lock to bring the jaws to a certain distance and fix them in a given position, and the lock is made for installation on the jaws pusher.

It is advisable to use a clamp, in which longitudinal guides for installing the lock are made on the outer surface of the jaws, and the lock is made in the form of a U-shaped spring.

The problem is also solved by the fact that the apparatus for mounting the clamp to isolate the left atrial abdomen from the left atrium, comprising an elongated body, a working element located at the distal end of the body, and control knobs located at the proximal end of the body, contains a tube mounted in the body with the possibility of longitudinal movement, the tube pusher, a coil spring for the return movement of the tube and the clamp pusher, and the working element is made in the form of a collet with a recess for installing gu approx clamp fixedly secured in the housing, a control knob is connected to the pusher tube and the other is fixedly connected with the housing.

The elongated clamping lips allow you to isolate the eyelet at the most optimal level - along the line of the ear-atrium (in the area of the mouth), completely overlap the mouth of the hospital, and the lock installed on the lips ensures the necessary closure of the walls of the ear without corrugation with a safe endocardium, which reduces the possibility and risk of thrombosis. This leads to the formation of an even, smooth, free of defects, located at the base of the medical facilities of the suture line, the prevention of necrotic and inflammatory changes.

The execution on the outer surface of the jaws of the longitudinal guides for installing the lock and the execution of the lock in the form of a U-shaped spring provides a quick and safe clamping.

The design of the claimed clamp does not cause hemodynamic disturbances and does not injure the surrounding structures during the work of the heart.

The proposed apparatus for mounting the clamp, comprising an elongated body, located at the distal end of the body, a working element made in the form of a collet with a recess for installing the clamp jaws, fixedly mounted in the body, a tube mounted in the body with the possibility of longitudinal movement, and a tube pusher connected to the control knob allows you to easily bring the clamp jaws to the mouth of the medical facility and by moving the tube using the pusher to compress the collet for a given rapprochement of the jaws. The clamp lock pusher provides a connection between the lock and clamp jaws. The cylindrical spring allows you to return the tube to its original state. The device allows you to quickly and simply install the clamp in the right place.

The claimed clip for isolating the left atrial abalone from the left atrium and apparatus for its installation can also be used in operations with embologic (floating) phlebothrombosis in the system of the inferior vena cava: for cava-clipping in the infrarenal section; for clipping the external iliac vein.

Figure 1 shows the details of the clamp to isolate the left atrial ear from the left atrium; figure 2 is a section aa in figure 1; figure 3 - clip, General view; on Fig, 4 - apparatus for installing the clamp, General view.

The clip for isolating the left atrium from the left atrium contains elongated jaws 1, connected with the possibility of rapprochement of their working surfaces, and a lock 2 made in the form of a U-shaped spring, mounted on the jaws 1. On the outer surface of the jaws 1 there are longitudinal guides 3 for installing the lock 2

The apparatus for installing a clamp for isolating the left atrial eyelet from the left atrium contains an elongated body 4, a working element in the form of a collet 5 with a recess for installing the jaws 1 of the clip located on the distal end of the body 4, the tube 6 mounted in the body 4 with the possibility of longitudinal movement, the pusher 7 of the tube 6, the coil spring 8, providing a return movement of the tube 6, and the pusher 9 of the lock 2 of the clamp. A sleeve 10 is installed in the tube 6, fixedly connected to the housing 4 and the collet 5. A cylindrical spring 8 is fixed at one end in the tube 6 and rests against the sleeve 10 with the other. The apparatus is equipped with a fixed handle 11 connected to the housing 4 and a handle 12 connected with a pusher 7 of the tube 6 and pivotally connected to the fixed handle 11. To control the pusher 9 of the lock 2 of the clip, a lever 13 is provided, connected to the pusher 9 and installed in the slot 14 made in the housing 4.

Under general anesthesia, against the background of a pharmacological slowdown of the heart rhythm, using a double-lumen endotracheal tube to clap the left lung, a special patient is laid down with the lowering of the leg end by 40-50 degrees and the rotation of the operating table to the right by 30-40 degrees.

To perform the operation using a standard endovirus surgical stand. Install the 1st trocar (5 mm) in the 5 intercostal space on the left parasternal line, the 2nd trocar (12 mm) in the 5 intercostal space on the midclavicular line on the left, the 3rd trocar (12 mm) in the anterior axillary line in 4 or 5 intercostal space depending on the constitutional features of the patient.

A thoracoscope is inserted through the second thoracoport, and the pleural cavity is revised. The pericardium with n.frenicus is visualized with its accompanying vessels located in the fatty tissue on the left surface of the pericardium. The most visible is the translucent through the pericardium MPI, which is located mostly on the right and at the top of n.frenicus. Using a soft clamp, the fatty tissue is separated, if necessary, coagulated, from the first thoracoport and the pericardium is opened anteriorly and parallel to n.frenicus from the middle of the distance of the pericardium upward. If necessary (due to the individual characteristics of the location of the heart with MPI), the pericardium is opened more widely. Using a soft instrument, moderate traction of the heart is performed anteriorly, to the right, and upward until a comfortable position of the medical institution appears, which is necessary for applying a clamp to the mouth of the medical institution. During diastole from the third thoracoport using the claimed apparatus under the control of vision, a clamp is applied.

The disconnected clamp parts are sequentially installed in the apparatus; the lock 2 is in the distal part of the tube 6, and the jaw 1 is in the recess of the collet 5, after which the apparatus is ready for operation.

The mouth of the healthcare facility is located between the jaws 1 installed in the collet 5. Bringing the handles 11 and 12 together, the pusher 7 is moved, while the tube 6 moves along the body and clamps the collet 5 with its distal end, bringing the jaws 1 closer and ensuring the mouth walls are closed Health care facilities. When the tube 6 is moved, the spring 8 is compressed. The pressure of the thumb on the lever 13 moves it along the slot 14 in the housing 1, while the pusher 9 moves the lock 2 along the longitudinal guides 3 made on the jaws 1 until the lock and jaws are fully aligned. The handle 12 is released, while the spring 8 expands and returns the tube 6 to its original position, and the collet 5 expands and releases the clamp mounted on the mouth of the medical facility. The tool is removed from the thoracoport.

Assess the condition of the health facilities and the procedure done. If necessary, the pericardium is sanitized and drained by suction, sutured with one of the methods used.

In an experiment on 35 outbred dogs, the results of thoracoscopic obliteration of MPI by various means were studied.

35 blocks (parts of the left atrial myocardium with obliterated MPI) were examined on the 7th and 30th days after the operation. Changes in the structure of the part of the myocardium of the left atrium with the ear were compared with isolation of the MPI:

1 - when applying a loop;

2 - when applying a stitch seam with a stapler (35 endo GIA stepler);

3 - when applying the claimed clamp using the claimed apparatus.

Drugs were evaluated macroscopically and microscopically. Paraffin 5-7 micron sections were made, which were stained with hematoxylineosine and according to the Van Gieson technique. The analysis of the preparations was carried out under small (× 70, × 140) and large (× 280) magnifications, followed by microphotography.

The results of histological studies showed the following.

1) The state of the health care facility after its isolation using a loop.

In macroscopic examination, the MPI has an uneven bag-like shape, reduced in size. The loop overlay area is corrugated, the clamping line is uneven, located not at the base of the hospital, but 2-3 mm more distally (towards the apex). From the side of the left atrial cavity, trabeculae are visible and there are diverticular-shaped depressions.

Microscopic examination of the myocardial zone to the line of clamping the loop: Myocardium is edematous, in a state of discompletion (sparse), forms cavities - spaces of a bay-shaped form, with the part open to the left atrium.

In the clamping zone, the remains of suture material, granulation tissue, loose soft-fibrous connective tissue are revealed by the loop. There are intertrabular spaces filled with hemolized red blood cells with organization phenomena, groups of fat cells next to the maturing connective tissue.

The HCI area is above the clamp loop, closer to the apex. The intertrabular spaces are filled with hemolized blood, the process of organizing a blood clot is going on around the periphery. MPI is partially and unevenly sclerotic, with fields of granulation tissue and maturing connective tissue.

2) The state of the medical facility after its isolation with a stapler.

In a macroscopic examination, the medical facilities are uniformly obliterated, reduced in size more than when using the loop method. The seam line is located at the base of the hospital, partially folded, thinned, up to 2 mm thick. In 2 cases (20%) with an ear thickness of about 5 mm, a third of the ear is not completely stitched. On day 7, foci of micronecrosis are determined along the suture line without pronounced signs of inflammation from the surrounding tissue.

With a microscopic examination. In the area below the suture, closer to the atrium, with a small increase, a preserved, somewhat edematous myocardium of the left atrium, cardiomyocytes without features are determined. A slight swelling of the spaces between the cardiomyocytes is noted.

The transition zone (suture zone) with the phenomena of organization, the development of connective tissue, there are a large number of capillaries, empty and filled with red blood cells, outside the vessels - free-lying red blood cells in a state of partial or complete hemolysis. The microvessels of the arteriolar type are empty, the venous lumens are full-blooded.

In the area above the suture line, the cavity (closer to the apex) of the MPI is obliterated, partially empty intertrabular spaces are revealed, abalone cardiomyocytes in a state of block decay and fatty degeneration. Focal accumulations of hemosiderophages, next to which are groups of segmental leukocytes and macrophages. Vessels in the obliteration zone are in a state of pericalibration with focal proliferation of intima or thickened entire wall, in some - formed old blood clots with recanalization phenomena.

3) The state of the healthcare facility after its isolation by the declared clamp.

Macroscopically: the medical facility is obliterated uniformly, reduced in size, the seam line is even, smooth, without defects, located at the base of the medical care facility.

Microscopically: below the overlay of the clamp, the myocardium is intact, cardiomyocytes without pronounced dystrophic changes. Moderate myocardial edema and the phenomena of partial discompletion are determined.

In the clamping zone and distal to the apex of the abalone (obliteration zone) - the mass of hemolyzed blood in the state of organization, fields of maturing granulation tissue, connective tissue, accumulations of hemosiderin and macrophage cells loaded with pigment.

The area of abalone obliteration without inflammation, the existing and newly formed vessels in a state of pericalibration with a thickened wall, a thickened intima, some of them with a gaping lumen, others are obliterated.

The results of a morphological study of the state of the part of the left atrial myocardium with the eye when using various means of obliteration indicate that the obliteration of the MPI cavity with the claimed clamp for isolating the left atrial ear from the left atrium and apparatus for its installation is the most optimal.

Using the claimed invention allows to prevent complications after isolation of the left atrial abalone from the left atrium.

Claims (3)

1. A clip for isolating the left atrial ear from the left atrium, containing elongated jaws connected with the possibility of rapprochement of their working surfaces, characterized in that it has a lock for bringing the jaws to a certain distance and fixing them in a predetermined position, and the lock is made for installation on the jaws with a pusher . 2. The clamp according to claim 1, characterized in that on the outer surface of the jaws are made longitudinal guides for installing the lock, and the lock is made in the form of a U-shaped spring. 3. An apparatus for mounting a clip to isolate the left atrial abdomen from the left atrium, comprising an elongated body, a working element located at the distal end of the body, and control knobs located at the proximal end of the body, characterized in that it contains a tube mounted in the body with the possibility of longitudinal movement, the tube pusher, a coil spring for the return movement of the tube and the clamp lock pusher according to claim 1, wherein the working element is made in the form of a collet with a recess for installing the clamp jaws, n adjustably fixed in the housing, a control knob is connected to the pusher tube and the other is fixedly connected with the housing.

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