RU2273496C1 - Device for draining hepaticocholedochus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: device has draining guard-tube and internal tube of smaller diameter having projecting proximal end to be introduced into cystic duct or choledochotomic incision. Distal tube ends are fixed at the same level. The internal tube has a thrown-on loop attached to external tube edge. The loop is arranged at the level of proximal end of the external tube. The internal tube is removable. The loop enables one to enclose both threads of loop base into internal suture of the choledochus.

EFFECT: high reliability; accelerated draining process; simplified fixation procedure.

2 dwg

Description

The present invention relates to medicine, namely to surgery, and can be used for external bile duct in pathological conditions that cause hypertension in the common bile duct: choledocholithiasis, terminal block of common bile duct tumor origin, palliative interventions in the hepatobiliary zone, etc.

So, most foreign surgeons both before and now use the T-shaped Kera tube to drain the common bile duct. The advantages of this method include the strong fixation of the drainage tube in the duct, which excludes the possibility of its migration, as well as the free outflow of bile along the natural path into the duodenum. However, when using Kerov drainage, the duodenal contents can be thrown into the bile ducts, when using coarse tubes and large diameter tubes, difficulties arise in removing the drainage, its removal often leads to tears in the duct wall, and sometimes to tearing of the transverse elbow of the rubber tube. After its removal, a rather large wound remains in the duct wall, healing by secondary intention, which can lead to bile leakage into the abdominal cavity after removal of drainage and subsequently lead to the formation of stricture of hepatico-choledochus. Cases of death from shock during drainage extraction are described (Malyarchuk V.I., Pautkin Yu.F. - Diagnostics and surgical tactics for tumor obstruction of extrahepatic bile ducts. 2000)

D.L. Pikovsky (1964), taking into account the possibility of passing the daily amount of bile through a thin tube, suggests introducing drainage into the cystic duct and decompressing the bile ducts. Such drainage can be used when suturing the duct wall tightly. However, it is dangerous to use the drainage of D.L.Pikovsky in all patients, especially in emergency surgery, since mucus, sand, even thick bile can easily clog a narrow tube.

D.L. Pikovsky proposes to use split transpapillary drainage: the tube is cut longitudinally for some length, one branch is carried out towards the liver, the other is transpapillary so that its open surface faces the lower medial side. In this case, obstruction of the pancreatic duct does not occur.

Single-lumen drainage is more gentle and able to satisfy all the requirements for drainage. One of the weaknesses of single-lumen drainage is the difficulty of its reliable fixation in the duct wall, which can cause tube migration and bile leakage into the abdominal cavity (DL Pikovsky - Regarding operating cholangiography. I. Grekov Surgical Bulletin No. 6, 1990 .). The possibility of bile leakage into the abdominal cavity also occurs when the drainage tube is removed, especially in the early stages after surgery, when a channel around the tube has not yet formed.

A known method of external drainage for laparoscopic cholecystectomy (patent of the Russian Federation No. 2211890 from 10.10.2003, the authors - Volkov S.V., Eremeev A.G., Lebedev S.V.), sharpened in the following: a polyethylene tube of the corresponding diameter ( adequate to the width of the cystic duct) 20-25 cm long is cut off at the proximal end of the drainage at a right angle. The authors believe that only this type of proximal end of drainage (as opposed to oblique) allows for the detection of residual choledocholithiasis in the early postoperative period to conduct antegrade intraductal translocation of the residual calculus of the distal choledochus by the same drainage into the duodenum. 2-2.5 cm from its end, the drainage is repeatedly tied with a catgut ligature until a “ligature clutch” is created and the ends of the ligature assembly are left with a length of 1-1.5 cm for subsequent fixation of the drainage in the cystic duct. According to the authors, the known length from the proximal end of the drainage to the "ligature clutch" makes the depth of introduction of the drainage into the biliary system controlled. Drainage is completely introduced into the abdominal cavity through any of the available standard ports, its proximal end is passed through the incised cystic duct into the common bile duct, immersing the sealing "ligature sleeve" 1-2 mm into the lumen of the cystic duct. By dosed traction of the drainage downward with a clamp from the standard 4th port, a moderate tension of the cystic duct is reached above the injection site and in this position the ends of the ligature node of the “clutch” are clipped and together with them the wall of the cystic duct is as close to the drainage as possible. The outer (distal) end is increased with a thicker tube so that, in case of accidental traction, it does not extract all the drainage, but only the discrepancy of this connection. The drainage is usually removed on the 14-18th day of the operation after the control fistulocholangiography in a two-step way, in which, at the first stage, the drainage is withdrawn from the stump of the cystic duct into the subhepatic space with metered pulling and left as “trapping”, and in the absence of bile leakage after 4-6 hours, the drainage is completely delete. The disadvantages of this device for drainage are as follows.

- The long stay of the drainage is due to two points:

- the formation of the walls of the channel around the drainage to prevent bile leakage into the abdominal cavity.

- The fixation method is such that in the case of earlier removal times, when the tensile strength of the fixing catgut thread is still high, injury to the walls of the duct at the fixation site is possible.

leakage of bile past the drainage tube, until it falls out.

- Poor sealing - with this method of fixation, bile may leak past the drainage tube.

- It is possible to displace the drainage tube until it falls out.

- The possibility of shifting the calculus in the duodenum with the end of the tube declared in the method is doubtful; even increasing the stiffness of the tube with the mandrel, it is impossible to displace the tube on which there is a locking catgut sleeve.

For the prototype, we took a device for drainage using a drainage system developed at the Russian Center for Functional Surgical Gastroenterology (a manual for doctors: “Optimal methods for temporary external drainage of the biliary tract”, authors - Onopriev V.I., Rogal M.L., Markov P. V., Grigorov S.P., Krasnodar - 2002.).

The drainage system is a structure of two drainage tubes, one of which is placed in the lumen of the other.

For installation directly into the bile duct, an elastic thin-walled silicone or polyvinyl chloride tube with an outer diameter of 3-5 mm is selected, depending on the specific surgical situation.

Side holes are made on it for 2-3 cm. To reduce the intelligibility of drainage migration from the duct at a distance of 5-10 mm from the last lateral hole, a “sleeve” is formed on the tube, tying it with 4-5 turns of a thin monofilament thread (thread diameter 0.16-0.20 mm). In 2-4 opposite sides of the circle, the thread is tied with two to four knots. The created coupling after tying a nodal suture over it on a defect in the wall of the bile duct additionally fixes the intraductal drainage, not allowing it to migrate from the lumen of hepaticoholedochus.

The tube is a “watchman" 2-4 mm larger than the outer diameter of the in-duct drainage.

The disadvantages of this design are:

1) difficulties arise when removing the inner tube of the drainage system;

2) when removing the inner tube, the sleeve on it can displace the watchman tube and bile can flow into the free abdominal cavity.

Tasks:

Reducing injuries due to the original device of the "castle" and in this regard, reducing the treatment time, eliminating the difficulties encountered in removing the intraductal drainage.

The essence of the invention is that a device for draining hepatic choledochus, containing a drainage tube "guard" and an inner tube of smaller diameter with a protruding end inserted into the cystic duct or choledochotomy incision, unlike the known ones, has distal ends of the tubes fixed at the same level, and the inner the tube at the level of the proximal end of the outer tube is provided with a loop to be attached to the edge of the outer tube, while the inner tube is configured to capture both threads of the base etli endoshov in the common bile duct.

A device for drainage is shown schematically in figure 1, in which 1 is a tube of a larger diameter (5-7 mm), 2 is a tube of a smaller diameter (2-4 mm). Tube 1 has a length of 30-35 cm, and tube 2 is 35-40 cm, 3 is a loop, 4 are perforated holes of the tube 2, 5 is a thread that fixes the distal ends of the tubes at the same level.

The drainage system is used as follows:

the tube 2 is inserted into the tube 1 and arranged so that on one side the ends are at the same level where both tubes are fixed to each other 5. At the opposite end of the tube 1, a loop with a diameter of 5-6 mm from a monofilament, long absorbable thread is fixed, and on the protruding end of the tube 2, retreating 1 cm from the end of the tube 1, perforate several side holes 4. In this form, the drainage system is ready for use.

Figure 2 shows the device in the operating position. When using the drainage system, a loop is attached to the protruding part of the tube 2, which is fixed to the tube 1, and introduced into the cystic duct or choledochotomy incision.

The whole system is fixed by capturing both threads of the base of the loop attached to the tube 1 in the endos of the common bile duct, and additionally sealed with a lock of the stuffing box.

The loop 3 on the tube 1, the protruding part of the tube 2, passed through the loop 3 and endos, intercepting the loop at the base, represent the original "lock" of our drainage device. After removing the tube 2, the “lock” opens and the tube 1 is easily removed. When removing the tube 1, the loop at the end freely slides out of the end seam.

The advantages of such a drainage system are as follows:

1. Increased reliability of the device - in the case of leakage of bile near the tube 2, it flows through the tube 1.

2. A significant reduction in drainage time by 2-3 times. This is possible due to the fact that there is no need to expect the formation of a channel around the tube before it is removed, which prevents the flow of bile into the abdominal cavity. In the device, this function is performed by the tube 1, which remains in place after removing the tube 2 for 2-3 days, i.e. until the wound closes at the location of the tube 2 and the cessation of bile flow.

3. Convenient fixation - strong, reliable retention of the system at the installation site, the possibility of easy removal at any time.

4. When removing the inner, thin tube, a small defect remains on the choledochus, which is easily closed by the lock of the stuffing box, with which we seal the installation site of the drainage during endoscopic placement.

5. The use of the complex of described drainage technologies eliminates complications such as untimely and uncontrolled migration of the drainage tube from the duct, leaking bile after removal of the drainage.

6. The use of thin drainage tubes makes it possible to virtually eliminate the possibility of formation of a stricture in the standing position of the drainage in the long term after the operation.

Thus, the use of the proposed device for drainage of the bile ducts allows you to most effectively and safely carry out this procedure and prevent the development of complications.

Claims (1)

A device for draining hepatic choledoch, containing a drainage watchman tube and an inner tube of smaller diameter with a protruding proximal end inserted into the cystic duct or choledochotomy incision, characterized in that the distal ends of the tubes are fixed at the same level, and the inner tube at the level of the proximal end of the outer tube is provided a loop attached to the edge of the outer tube, while the inner tube is made with the possibility of extraction, and the loop is made with the possibility of capturing both threads about Considerations endoshov loops in the common bile duct.

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