RU2264192C1 - Method for laparoscopic appendectomy - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should cross a vermiform process for two thirds of its circumference, remove and sterilize mucous membrane of incomplete stump developed, apply high-intensive radiation of diode laser at wave length of 805 nm in quasi-uninterrupted mode at no contact at 2-4 W power, then finally cross processes in impact area. The method suggested enables to provide pronounced antibacterial effect, exclude complications associated with electrocoagulation while performing appendectomy.

EFFECT: higher efficiency.

2 ex

Description

The invention relates to medicine, namely to surgery, and in particular can be used when performing laparoscopic appendectomy.

A known method of laparoscopic appendectomy, including mobilization of the appendix, ligation of the base of the appendix with a catgut ligature, after which a typical appendectomy is completed, ending with sterilization of the mucous stump of the appendix with an endothermic coagulator at pulses of 5-10 sec and additional treatment with a dull solution after which the stump of the process is immersed in the lumen of the cecum with gray-serous sutures, for example, purse string and Z-shaped, which are applied under the direct ritual control with an atraumatic polysorb needle (see patent RU No. 2144325, IPC A 61 B 17/00, 18/08, publ. 01.20.2000).

According to the authors, this method is quite effective.

However, the use of endothermocoagulation for sterilization of the mucous stump of the process does not exclude the possibility of complications associated with its use, such as tissue burns, which adversely affect reparative processes in the stump of the appendix.

Moreover, this method is not effective enough, since during thermocoagulation the antibacterial effect is not sufficiently pronounced.

A known method of laparoscopic appendectomy, selected as the closest analogue, including mobilization of the appendix, intersecting it in two places at the base and 1.5 cm distally from the appendix, coagulating the appendix in the interval between these two ligatures with bipolar forceps for 20- 30 seconds using a high-frequency current and crossing it at the coagulation site with scissors, after which the process is removed from the abdominal cavity by placing it in an appendicoextractor, and the stump is treated with a stump with io donat and immersed in the lumen of the cecum (see K. Semm, 1983)

This method is not effective enough, because there remains a potential source of infection in the stump of the appendix between the proximal ligature and the coagulation zone.

At the same time, immersion of the stump of the vermiform appendix with purse-string and Z-shaped sutures is quite difficult, it requires certain skills from the surgeon and at the same time is associated with the risk of a through puncture of the rectal wall.

In addition, electrocoagulation has a fairly large number of contraindications, in particular electrocoagulation is contraindicated for patients in whose body there are metal objects, pacemakers, implantable electrodes.

During the operation of the electrocoagulator, surgical complications are possible, in particular, tissue burns both in the operation area and outside the operation area. Electric shock is also possible for both the patient being operated and the attendants.

Since electrocoagulation involves the contact of the instrument with the treated surface, this usually leads to the adhesion of coagulated tissue from the treated surface to the working surface of the instrument.

Moreover, since during electrocoagulation the antibacterial effect is not sufficiently pronounced, this method does not have sufficient efficiency.

And, in addition, the burn of stump tissues that has taken place adversely affects the course of reparative processes in the cult of the appendix.

Thus, the technical result to which this invention is directed is the elimination of the above disadvantages, that is, the creation of a safe and highly effective method of laparoscopic appendectomy.

The specified technical result is achieved by the fact that in the known method of laparoscopic appendectomy, including mobilization of the appendix, its ligation in two places: at the base and distally distant from the first and appendectomy performed between these ligatures, appendectomy according to the invention involves preliminary partial cutting off the appendix by about 2/3 of its circumference, after which the mucous membrane of the formed incomplete is removed and sterilized stump using high-intensity laser radiation from a diode laser with a wavelength of 805 nm in a quasi-continuous mode with a non-contact power of 2-4 W, after which the process is finally crossed in the affected area.

Appendectomy by preliminary partial excision of the appendix in approximately 2/3 of its circumference, further removal and sterilization of the mucous membrane of the incomplete stump using high-intensity laser radiation, and subsequent final intersection of the appendix in the affected area provide increased safety and efficiency of the method.

This is achieved due to the fact that it is the incomplete cutting off of the vermiform appendix that allows the stump to be held in a comfortable position during surgery, including turning to the position required for subsequent exposure to laser radiation, which ensures the best visualization of the surgical field and, as a result, the best efficiency operations.

Moreover, it is the use of high-intensity laser radiation that enhances the effectiveness of the results of the operation, since laser radiation contributes to thermal damage to tissues to the least extent, eliminates the risk of electrosurgical complications, and has a pronounced antibacterial effect.

The authors experimentally established that the use of high-intensity laser radiation of a diode laser with a wavelength of 805 nm in quasi-continuous mode with a non-contact power of 2-4 W contributes to the achievement of the technical result set for the invention.

The method is as follows.

The patient is placed in a supine position. After anesthesia, the patient is transferred to the Trendelenburg position with a small angle of inclination of the table. Then apply pneumoperitoneum. Trocars are inserted into the abdominal cavity - in the navel (for the video laparoscope), along the midline and in the right iliac region in the projection of the appendix. Perform an examination of the abdominal cavity. Confirm the diagnosis. Then proceed to perform appendectomy. The appendix is pulled by the apex upward or towards the pelvis so that the mesentery of the appendix is more visible.

The mesentery of the appendix is intersected by any known method, either using bipolar electrocoagulation, or after braces, or using a laparoscopic linear stapler.

The selected appendix is bandaged at the base with three endoligatures: two are applied proximal and one distally from the proposed site of intersection of the appendix. The distance between the ligation sites is approximately 1 cm. In the interval between the last two places of ligation of the appendix, endoscopic scissors carry out a preliminary partial intersection of approximately 2/3 of its circumference. After that, the mucous membrane is removed and sterilized, resulting from this partial intersection of the incomplete stump of the appendix using high-intensity laser radiation from a diode laser with a wavelength of 805 nm in quasi-continuous mode with a non-contact radiation power of 2-4 W. To do this, through a trocar located in the right iliac region, a fiber with a diameter of 0.6 mm is brought to the site of exposure. After bringing the fiber to the place of exposure at a distance of about 5 mm from the surface of the incomplete stump formed, the fiber moves in a spiral to directly effect the laser on the surface to be treated. The speed of the fiber in a spiral is approximately 1-2 mm / s. After completing this transition, the light guide is diverted from the site of exposure and removed from the trocar. Endoscopic scissors are brought to the site of exposure to the incomplete stump of the appendix, and the final intersection of the appendix in the area of the remaining 1/3 of its circumference is made. The crossed appendix is placed in a sterile bag and removed from the abdominal cavity. After this, a standard washing and drying of the right iliac region is performed. If necessary, in the abdominal cavity install drainage through a trocar located in the right iliac region. After thorough hemostasis, pneumoperitoneum and the remaining trocars are removed. Wounds are sutured in the usual way.

The method is confirmed by examples of specific performance.

Example No. 1. Patient O., 17 years old. Diagnosis: Acute phlegmonous appendicitis.

The patient underwent laparoscopic appendectomy as described above. The power of high-intensity laser radiation from a diode laser with a wavelength of 805 nm, used to remove and sterilize the mucosa resulting from the partial intersection of the appendix, was 2 watts. Exposure to laser radiation is carried out non-contact in a quasi-continuous mode.

Bowel function restored on the 1st day. The patient began to eat the next day after surgery.

Postoperative sutures were removed on the 5th day in the clinic.

The patient was discharged on the 2nd day in a satisfactory condition.

Normal activity in the patient was restored on day 10.

Example No. 2. Patient Sh., 16 years old. Diagnosis: Acute phlegmonous appendicitis in infiltrate.

The sequence of operations according to the method described above. Modes of high-intensity laser radiation of a diode laser with a wavelength of 805 nm, used to remove and sterilize the mucosa formed as a result of incomplete intersection of the appendix: power 4 W, quasi-continuous mode, non-contact. The patient began to eat at the end of 1 day after surgery.

Postoperative sutures were removed on the 5th day in the clinic.

The patient was discharged on the 2nd day in a satisfactory condition.

The patient returned to normal physical activity at the end of the 2nd week after surgery.

Claims (1)

A method of laparoscopic appendectomy, including mobilization of the appendix, its ligation and appendectomy performed in the interval between two ligatures, characterized in that when the appendectomy is performed, the appendix is first crossed at 2/3 of its circumference, after which the mucous membrane of the resulting incomplete stump is removed and sterilized of high-intensity laser radiation of a diode laser with a wavelength of 805 nm in quasi-continuous mode with a non-contact power of 2-4 W, after which the process is finally crossed in the affected area.