RU2294154C2 - Method and device for performing endourological operation - Google Patents

Abstract

FIELD: medicine; medical engineering.

SUBSTANCE: method involves utilizing endoscope and introducing luminous catheter into ureter for illuminating the ureter all along the whole introduction path. The introduced catheter shines with red pulsating light. Flexible optical glass fiber is available inside of light-impermeable catheter envelope. Working end surface of the glass fiber is connected to pulsating laser radiator having power supply source, pulsating current modulator, light source as semiconductor red light laser of wavelength λ=650-680 nm and optical lens for focusing light beam on the working surface of catheter light glass fiber end surface.

EFFECT: simplified and accelerated operation and postoperative period; reduced risk of traumatic complications.

2 cl, 1 dwg

Description

The invention relates to medicine and medical equipment, namely to endourology, but can also be used in other types of endosurgical operations on cavities and hollow organs, for example, removal of a stone from the gallbladder or the gallbladder itself.

Endosurgical, including endourological, operations using transillumination (illumination) created by a laparoscope to provide visual observation of the introduction of working trocars into the cavity are well known.

It is well known that transillumination is used in urology in the diagnosis and implementation of surgical operations. Powerful and safe sources of cold light injected directly into canals and urological cavities allow more accurate visualization of various pathological lesions and their location when illuminated, but unfortunately the transillumination used today in everyday endosurgical abdominal practice is created with a tough instrument with a light source on end, for example, a direct urinary catheter, a video laparoscope, a direct urological fiber, etc., the use of which is associated with many negatives GOVERNMENTAL sides, not excluding injury of internal surfaces, such as the ureter or other hollow organs.

Depending on the position of the light source used and the endoscope, transillumination is divided into:

- direct transillumination when the light source is located in a hollow organ,

- extra-cavity transillumination when the light source is located outside the investigated organ,

- reverse transillumination with the location of the endoscope in the lumen of the organ under study, with extraorgan highlighting.

It should be emphasized that the well-known methods of using transillumination involve the use of a luminous flux to illuminate sections of certain surfaces like a lantern with one or the other, or with one or the other side of a hollow organ at the same time.

Unfortunately, in endourological practice, transillumination techniques are limited, and the options for reverse transillumination using hard sources are in most cases not applicable for physiological (small diameters, large length and curvature of the channels) reasons. It should be noted that in endourological operating practice, endosurgical approaches are used to the organ to be operated, either through the abdominal cavity, or surgical operations are performed directly in the retroperitoneal space, creating an operating space by bloating retroperitoneal tissues for subsequent endosurgical access to the operated organ, but this space is very limited and great difficulties are created for the implementation of operational actions.

A known method of endourological operations; ureterolysis, ureterolithotomy, nephrectomy, etc., using transillumination created by a laparoscope in the cavity and a catheter inserted into the ureter to make it stiff and easier to find. Atlas of laparoscopic operations in urology. V.N. Stepanov. Publishing house "Miklosh", Moscow, 2001, pp. 60-63, 72-80.

The most time-consuming in carrying out these operations is the search for the ureter, its identification and isolation, which the surgeon performs visually, by touch with the lighting of the ureter search area created by the laparoscope.

A known method of endourological surgery (US 5902247 A, 05/11/99) and a device that are the prototypes of the proposed, where during a laparoscopic operation, a luminous catheter is inserted into the ureter, which displays the ureter along its entire length, as well as in the proposed device. However, when performing an operation in a closed cavity, external illumination of the ureter for the ureter is used, and under these conditions, the effectiveness of uniform illumination of the ureter from the inside to detect it is not very high, as mentioned above.

The essence of the proposed method of endourological surgery and the instrument for its implementation is that the ureter, or other hollow organ, from the inside along the entire length of the catheter inserted into it is illuminated by a pulsed (blinking) red light, which has better passability through tissues with a higher intensity of catheter end exposure when external illumination with a laparoscope, and the instrument that provides flashing of the ureter is a flexible translucent catheter inserted into it with a flexible fiberglass inside, interconnected It is connected via an adapter with a pulsed laser emitter consisting of a power source, a pulsed current modulator, a light source based on a semiconductor laser, which illuminates the fiberglass and catheter with a red (along the radiation wavelength λ = 650-680 nm) pulsed blinking light.

This allows, without manipulation of search and identification, to quickly and confidently with maximum accuracy determine the location of the ureter along the entire length of the pulse glow, quickly and confidently carry out its selection, and also see the place of narrowing of the lumen or the location of the stone by the intense pulse glow of the end of the catheter, and this in turn fundamentally simplifies the entire operation, reduces the time of its operation and the postoperative period of bed days by reducing the morbidity, and also allows you to confidently perform urological operations ation with complicated testimony.

The drawing shows a General view of the instrument, consisting of a pulsed laser emitter with a removable-replaceable translucent flexible catheter with a flexible fiberglass inside it.

The proposed method of endourological surgery is as follows.

1. When carrying out laparoscopic (via peritoneal access) ureterolithotomy (removal of the stone), the patient is in a position on his back or in a lateral position, depending on the location of the stone. Under general anesthesia of the patient, pneumoperitoneum is created and a 10-mm trocar is introduced for the telescope of the laterally rectus abdominis muscle. Two additional trocars are introduced 3 cm laterally of the midclavicular line at a distance of 4-5 cm from each other.

2. A flexible catheter is inserted into the ureter to the stone located in it, and a flexible catheter connected with the switched on pulsed laser emitter is inserted, and the peritoneum is opened parallel to the toldi line, and the intestine is mobilized and retracted medially.

3. After entering the retroperitoneal space, the lower pole of the kidney appears, which is a guideline for further work.

4. The internal ovarian or testicular vein is identified in the paronephral tissue.

5. After adequate mobilization of the paronephral fiber by the pulsed red glow passing through the ureter tissue, the latter along the entire length of its glow is easily detected and confidently stands out under the supervision and lighting of the laparoscope from the surrounding fatty tissue, which eliminates the time spent on its search and identification.

6. An additional trocar with a hook is inserted to fix the ureter as a holder, and the displayed ureter is confidently fixed.

7. During the dissection of the ureter, the location of the stone of the ureteral abturizing lumen of the ureter is visually determined by intense pulsed emission from the end of the catheter 7, which can be checked by tactile palpation with a laparoscopic instrument.

8. After isolation, above and below the stone, the displayed ureter is easily fixed and dissected above the stone with an endosurgical cold knife.

9. The stone is freely removed from the ureter, placed in a special bag and removed through one of the 10-mm trocars.

10. The catheter 7 from the ureter is removed by suturing the wounds.

11. In the retroperitoneal space install drainage for 2-3 days.

12. The trocars are removed under visual control of the laparoscope, which is also removed and the wounds sutured.

1. During laparoscopic (via peritoneal access) nephrectomy under general anesthesia, the patient is transferred to the lateral position, as in conventional operations. A ureteral catheter is placed in the bladder.

2. A Veress needle is inserted horizontally at the lateral edge of the rectus abdominis muscle at the umbilicus level, and after creating the pneumoperitoneum, the needle is removed and a 10-11-mm trocar is inserted through the puncture to insert a laparoscope.

3. A careful examination of the organs of the abdominal cavity is carried out and 4-6 other trocars are introduced under visual control of the laparoscope.

4. A catheter 7 connected through an adapter 6 to a pulsed laser emitter is inserted into the ureter.

5. After determining the topographic anatomy, the peritoneum is opened 1-2 cm laterally in the lateral canal parallel to the section of the colon from the hepatic flexure to the upper edge of the entrance to the pelvis.

6. After exposing the retroperitoneal space and isolating the retroperitoneal fiber in the projection of the lower pole of the kidney, the ureter along the entire length of the pulsed red glow is easily detected and secreted, and by displacing the catheter 7, the ureter is clipped or ligated and intersected at the right place. A stump indicated by a glow can be coagulated under light and under the supervision of a laparoscope.

7. Then select the lower segment of the kidney along the path indicated by the glow of the ureter in the proximal direction. During traction of the ureter displayed by pulsed red light, the front medial surface of the kidney is sequentially distinguished from surrounding tissues with the isolation, clipping and intersection of additional vessels, if necessary. Further, by traction of the kidney up and laterally, the region of the kidney gate is selected and the blunt path is used to mobilize the vascular pedicle with its careful selection for applying clips and crossing vessels, and then the remaining part of the kidney is selected, i.e. its upper segment.

8. After the kidney is secreted into the abdominal cavity, it is removed using an endoscopic bag or through an inserted 20 mm trocar.

9. A catheter 7 from the ureter and trocars are removed from the abdominal cavity, and the wounds at the sites of trocar placement are sutured.

When conducting similar endourological operations, but with retroperitoneal access, the reception of the designation of the ureter or stone located in it, with a pulsed red light in a limited operating space, acquires fundamental importance, allowing you to quickly determine the location of the ureter or stone, highlight it and confidently carry out all surgical operations when performing; ureterolysis, ureterolithotomy, nephrectomy and other endourological operations. The proposed method is applicable to various other endosurgical operations on the hollow organs, for example, in genicology, laparoscopy and thoracoscopy.

The instrument (see drawing) consists of a housing of the emitter 1, convenient for positioning in the hand of the surgeon when working with the instrument. Inside the housing 1 there are placed a serially connected power source 2 (IP) based on galvanic cells, a current modulator (MT) 3 made on the basis of a pulse generator with a power electronic key, a light source 4 made on the basis of a semiconductor laser (PPL) with a radiation wavelength λ = 650-680 nm, which forms red light, and is equipped with an optical lens 5, which provides focusing of the light beam on the working surface of the flexible light-piercing catheter 7 of the fiberglass 8 inside it attached to the adapter 6 to the body 1, sleep zhennomu a switch 9, wherein the inner diameter of the catheter is 0.8 mm, and 0.75 mm diameter steklosvotovolokna. The length of catheter No. 5 is 70 cm.

The work of the tool, ensuring the implementation of endourological operations proposed by the method, is as follows.

When you turn on the switch 9, the current from the power source 2 enters the current modulator 3, made on the basis of a pulsed generator, the operation of which in the pulsed mode allows you to get radiation, the amplitude of which is 10-20 times higher than the radiation of the PPL, working in constant mode, as well as the pulse radiation at the end of the catheter fundamentally increases the visibility of pulsed light in the background illumination of the endoscope, the pulsed generator is equipped with a power electronic key. The current from the current modulator 3 enters the light source 4, which is a semiconductor laser with a radiation wavelength λ = 650-680 nm, the red pulsed light of which is fed through the focusing lens 5 to the working surface 10 of the fiberglass 8, a flexible translucent catheter 7, fixed by an adapter 6 to the housing 1, while the catheter 7 along the entire length glows with a pulsed red light, intense at its end, which, when the catheter 7 is inserted into the ureter or other hollow organ, can reliably determine its location Erez endoscope glow across the length and perform all operational actions to ensure the implementation described as an example and other ongoing endosurgical operations on hollow organs.

Claims (2)

1. The method of endourological surgery, including the use of an endoscope and the introduction into the ureter of a luminous catheter, which highlights the ureter along the entire length of its introduction, characterized in that the catheter is inserted glowing in red pulsed light. 2. Instrument for endourological surgery, containing a catheter with fiberglass, characterized in that the fiberglass is flexible and located inside the translucent sheath of the catheter, the working end surface of the fiberglass through an adapter is connected to a pulsed laser emitter consisting of a power source, a pulsed current modulator, a light source, in the form of a semiconductor laser with a wavelength of λ = 650-680 nm red and an optical lens focusing a light beam on the working end surface of the glass tovolokna catheter.