RU2292850C2 - Method for applying venous "end-to-side" anastomosis - Google Patents

Abstract

FIELD: medicine, vascular surgery.

SUBSTANCE: it is necessary to make the incision of oblique vein and that of vein-transplant, on the vein one should make an arch-shaped incision its length being equal to the diameter of the vein-transplant under suturing in. Then one should apply interrupted sutures onto posterior lip of anastomosis; then anterior venous wall should be dissected along the arch to apply interrupted sutures onto anastomosis' anterior lip. The innovation enables to simplify the technique for applying anastomosis, increase its reliability and provide its carcass properties.

EFFECT: higher efficiency.

3 dwg, 1 ex

Description

The invention relates to medicine, in particular to vascular surgery, and may find application in the treatment of post-thrombotic disease, traumatic vascular injuries.

Currently, there is no such rapid development of vein surgery as in reconstructive artery surgery. A small amount of shunting surgery is used on the deep venous system. A restraining circumstance is the possibility of significant thrombosis at the site of anastomosis (I. Littmann, 1985). The features of both venous physiology and venous anatomy should be considered. In the technique of the formation of anastomosis of the type "end to side" during operations on the veins, unlike arteries, there are some features (A.N. Vvedensky, 1979). For example, in the inferior vena cava, the collagen content is 47%, and elastin - 7% dry matter; in the aorta, the corresponding indicators are 21 and 20% (B.C. Saveliev et al., 2001). Therefore, the lumen of the artery after dissection yawns, but the vein decreases. The wall of the vein is frameless. In the veins for the formation of anastomosis of the type "end to side" is necessary to form an "window" oval.

Numerous vascular connection methods have been proposed. At Carrel’s seam, three holder seams are preliminarily superimposed around the circumference of the vessel at an equal distance from each other. Between them a continuous twisting seam is applied. At the Morozova seam, only two holder seams are superimposed. N.A.Dobrovolskaya suggested, when stitching one vessel into the side of another, to apply the method of cutting a larger flap to increase the area of stitched vessels (P.I. Androsov, 1960). The same principle underlies the Holman and Hahn Z-joints. Hafner, Fogarty, Granley for the connection of vessels with a diameter of 4 mm or less suggested the use of glue methyl-2-cyanoacrylate (G.L. Ratner, 1965).

Closest to the proposed method is the method described by A.N. Vedensky (1979), when the dimensions of the oval hole formed in the side wall of the vein and prepared for anastomosis of the end of the vein must match. Forming veno-venous anastomoses of the “end to side” type, one should strive to create favorable conditions for subsequent blood flow. A.N. Vedensky also includes the preparation of the free end of the anastomosed vein to such conditions. It should correspond to the dimensions of the prepared oval hole formed in the side wall of the vein. For the formation of a venous anastomosis, the imposition of 4 suture-holders is recommended.

The disadvantages of the method of applying venous anastomoses "end to side" according to A. Vedensky is that it is difficult due to the difficulty of achieving the matching size of the lumen of the sutured vessel with the size of the oval hole in the vein wall, the lack of frame properties of the performed anastomosis due to excess tissue vascular wall, possible damage to the venous wall in the places of application of suture-holders as a result of squeezing and pulling the ends of stitched vessels, the complexity and duration in execution, possible de deformations of anastomosis followed by thrombosis.

The novelty of the proposal is to impart skeleton properties to the anastomosis at the time of surgery without additional surgical procedures, the absence of a prepared oval “window” in the vein wall, and the maximum adaptation of the edges of the anastomosed veins.

A significant difference of the proposed method is that they make an arched linear section of a vein with a length equal to the diameter of an oblique dissected vein, suture the posterior lip of the anastomosis, dissect the anterior wall of the vein in an arc with the formation of an oval hole, and suture the anterior lip of the anastomosis.

Our proposed method of applying a venous anastomosis of the "end to side" type is that it is performed by performing a linear section of a vein of a larger or the same diameter and suturing into an incision of an obliquely dissected vein of a smaller or the same diameter. A linear incision is performed along an arc with a length equal to the diameter of the oblique section of a vein of a smaller or the same diameter, and the anastomosis of the anterior lip is sutured after excision along the arc of the anterior wall of a vein of a larger or the same diameter.

The method is as follows. Outbred dogs of various sexes and weights under thiopental anesthesia performed lower lateral laparotomy in a different direction. Access was made to the posterior vena cava and iliac veins. These veins are highlighted throughout, taken on rubber holders. On the neck through a longitudinal incision of the skin, fiber and fascia along the vein, the external jugular vein with a valve is isolated and pinched at the clamps. This valve-containing fragment 3-5 cm long is removed on the clamps. Its ends are cut off at an angle of 45 °. At a distance of 1-2 mm, both edges are cleared of peri-adventitial tissues. A reversed graft is placed in a prepared bed between the external iliac vein and the posterior vena cava. Under the optical magnification in 8-12x using microsurgical instruments in the prepared section of the external iliac vein, a linear arcuate incision is made equal to the diameter of the oblique incision of the sutured vein (Fig. 1). Prolene 10/0 imposed nodal sutures on the posterior lip of the anastomosis (figure 2). Then, along the arc, the anterior wall of a vein of larger diameter is excised with nodal suturing on the anastomosis anterior lip (Fig. 3). In a similar way, an anastomosis is applied to the posterior vena cava. The method was carried out in an experiment in 8 outbred dogs weighing 8-15 kg, which previously created a model of the occlusive form of post-thrombotic disease.

In the long term, up to 12 months, the animals are clinically healthy. During phlebography, ultrasound scanning of the anastomosis is passable, there are no signs of stenosis.

Examples of specific performance.

1. Protocol 12. Outbred dog weighing 6 kg. Under general anesthesia, a lower lateral laparotomy was performed. The back vena cava is allocated, ileal veins on the right, are taken on holders. A valve-containing autograft 2 cm long was prepared from the external jugular vein with a diameter of 0.5 mm. A linear arcuate incision equal to the diameter of an oblique dissected sutured vein, the lumen of the external iliac vein is opened. Nodal sutures were applied to the posterior lip of the anastomosis with prolen 10/0. Then, excision was made along the arc of the front wall from edge to edge of the section. Stitches were placed on the front lip of the anastomosis. The same actions were done when applying a proximal anastomosis with the posterior vena cava. After 6 months, the animal is clinically healthy. According to the results of phlebography, ultrasound scanning, the shunt is functioning.

2. Protocol 20. Outbred dog weighing 10 kg. Under general anesthesia, a lower lateral laparotomy was performed. The posterior vena cava, iliac veins on the right are highlighted. A valve-containing segment was prepared from the external jugular vein 1.5 cm long and 0.7 mm in diameter. A model for occlusion of the common iliac vein has been created. A linear arcuate incision revealed the lumen of the external iliac vein. Nodal sutures were applied to the posterior lip of the anastomosis. Excision was performed along the arc of the anterior wall of the external iliac vein. Nodal sutures were placed on the anastomosis anterior lip. Similarly, an anastomosis with posterior vena cava was applied. The observation period is 12 months. According to the results of phlebography, ultrasound, the shunt is functioning, there are no signs of deformation, stenosis.

There were no complications in the form of shunt thrombosis. It was found that when using this method of applying a venous anastomosis, the duration of the surgical intervention is reduced, the edges of the anastomosed veins are better compared, the elements of the skeleton are attached without additional surgical procedures, and the applied anastomosis does not deform.

This method will simplify and accelerate the process of applying a venous anastomosis, which ultimately can serve as a means of preventing the development of venous thrombosis and contribute to the success of the operation as a whole. The proposed technique will allow to achieve a coincidence of the linear dimensions of the hemmed vessel with the size of the vein, to add frame elements due to the fact that the section of the vein is excised, technically simple to perform, and the phased execution of the excision of the section of the vein allows you to adjust the possible dimensions of the hemmed vessel, which will not allow to narrow the lumen of the vessels on place of anastomoses.

The method was tested in an experiment on 8 dogs in which the plastic of the external iliac vein was performed by an autovenous valve-containing segment of the end-to-side type. Control studies consisted of phlebography and ultrasound scanning. In all cases, during the observation period of up to 12 months, the anastomosis functions.

Information sources

1. Androsov P.I. Mechanical suture in vascular surgery. - M .: Medgiz, 1960 .-- C.12-14.

2. Vedensky A.N. Plastic and reconstructive operations on the main veins. - M .: Medicine, 1979. - P.51-52 (prototype).

3. Littmann I. Operative surgery. - Budapest: Publishing House of the Hungarian Academy of Sciences, 1985. - P.813.

4. Ratner G.P. Reconstructive surgery of the aorta and major vessels. - M .: Medicine, 1965. - S.80, P.90.

5. Saveliev B.C. Phlebology. - M .: Medicine, 2001. - P.49.

Claims (1)

A method of applying an end-to-side anastomosis performed by performing a vein section and suturing into a vein section of a vein graft, characterized in that an oblique section of a vein graft is performed, an arched section is made on the vein with a length equal to the diameter of the stitched vein graft, then nodal sutures on the posterior lip of the anastomosis, then the anterior wall of the vein is excised along the arc and nodal sutures are applied to the anterior lip of the anastomosis.

Images