RU2299695C2 - Cholecystostomy method - Google Patents

Abstract

FIELD: endoscopic surgery.

SUBSTANCE: invention can be used for decompression of biliary tract in case of tumor-origin mechanical jaundice and is accomplished as follows. Abdominal wall is perforated in gallbladder projection and perforation is closed by purse-string suture. After last stitch, the end of thread is carried through loop formed on the opposite end of thread and puncture of gallbladder is then performed in the center of purse-string suture with needle provided with hollow metallic tube put on. Through the latter, catheter is inserted into gallbladder lumen, diameter of catheter being large enough to ensure decompression of biliary tract. Tube is removed and purse-string suture is tightened. Thread end in stretched state and catheter are attached to skin of anterior abdominal wall. Finally, gallbladder bottom is stretched to touch parietal peritoneum.

EFFECT: increased safety of reliability of contact laparoscopic cholecystostomy.

14 dwg, 1 tbl

Description

The invention relates to medicine, namely to the field of minimally invasive surgery, and can be used for decompression of the biliary tract as the first stage of a radical operation or as the final version of the operation for inoperable periampular tumors.

With the introduction of endoscopic diagnostic and treatment methods into clinical practice, laparoscopic options for drainage of the biliary tract have been widely used. Various options have been proposed for transhepatic gallbladder drainage and cholecystostomy by removing the bladder wall through a small incision in the anterior abdominal wall with a hemostatic forceps or a curved needle (Guidelines for Clinical Endoscopy. / Edited by BC Savelyev et al. M., Medicine. 1985 - C) .317-323). The most commonly used techniques are

- transhepatic variants of microcholecystostomy (stylet, trocar, according to the Seldinger method);

- cholecystostomy according to I.D. Prudkov;

- cholecystostomy no B.C. Saveliev et al.

Transhepatic microcholecystostomy in most cases is performed during the inflammatory process in the gallbladder in patients with high operational and anesthetic risk in order to decompress the gallbladder and biliary tract.

Cholecystostomy under the control of a laparoscope is also indicated for periampular tumors as the first stage of surgical treatment of this pathology.

However, when using transhepatic cholecystostomy techniques in these situations, when the gall bladder is not strained, the wall of the bladder is stretched and thinned, there may be complications in the form of perforation of the opposite (front) wall of the bladder. Bleeding into the cavity of the bladder may occur in patients with obstructive jaundice, followed by bladder tamponade. In addition, with transhepatic microcholecystostomy in cases of obstructive jaundice of tumor origin, adequate decompression of the biliary tract is not always ensured due to the presence of thick "putty" bile in the gallbladder and ducts, through the liver tissue into the lumen of the bladder without complications it is almost impossible to carry a catheter sufficient for the free passage of the indicated mass of diameter. Safer and providing adequate drainage of the biliary tract with obstructive jaundice of tumor origin are cholecystostomy through the bottom of the bladder under the control of a laparoscope.

Description of the prototype.

As a prototype, the method described in the monograph by V.S. Savelyev et al. (Endoscopy of the abdominal organs. M., Medicine 1977. - S.225-230). Laparoscopic cholecystostomy is as follows.

- Survey laparoscopy, in which a thorough revision of the abdominal organs is performed and indications for laparoscopic cholecystostomy are determined.

- Determining the possibilities of creating a laparoscopic cholecystostomy and solving a number of technical issues - the degree of stretching of the gallbladder, the nature of its location, the features of morphological changes in its wall, the presence of adhesions around the bladder, the choice of the puncture site of the gallbladder, determining the site for excretion of the bubble.

- Excretion of the gallbladder (the most critical stage in the entire operation) - puncture of the gallbladder using a special device or with a needle, laparocentesis, insertion of a clamp into the abdominal cavity, capture and excretion of the bladder area out.

- Formation of cholecystostomy - the gallbladder wall brought out through the wound canal is taken on the holders, the clamp is removed, dissected through all layers, the dissected wall is sutured to the skin, a rubber tube is inserted into the gallbladder and it is fixed to the skin.

Essential features of the prototype.

- The choice of the least safe option for decompression of the biliary tract during obstruction of the terminal part of the common bile duct.

- The ability to conduct in the lumen of the bladder of a catheter sufficient to discharge thick bile and "putty mass" diameter.

- The exclusion of the possibility of blood leakage into the cavity of the gallbladder and its subsequent "tamponade".

- Exclusions of the possibility of a catheter falling out of the lumen of the bladder

- Tight fit of the bottom of the gallbladder to the parietal peritoneum and thereby the exclusion of leakage of bile into the free abdominal cavity.

Prototype criticism

- With close and far location of the puncture site of the anterior abdominal wall from the edge of the liver, it is not possible to bring the gall bladder out through the puncture channel. In such cases, cholecystostomy is imposed atypically or discarded.

- In patients with well-developed subcutaneous tissue and with a sufficiently thick anterior abdominal wall, the bottom of the gallbladder is not excreted due to the narrowness of the puncture channel.

- During the puncture of the gallbladder wall, leakage of bile into the free abdominal cavity may be noted.

- Excessive tension of the gallbladder, when they try to stretch the bottom of the bladder to the level of the skin, can lead to impaired blood circulation in the organ and to its necrosis with the subsequent development of peritonitis.

Thus, the identified disadvantages of the prototype include the following:

- low implementation of the method;

- the risk of bile leakage into the abdominal cavity and the high probability of infection;

- the possibility of circulatory disorders in the gallbladder wall with subsequent necrosis of the wall and the development of peritonitis.

In this regard, it seems relevant to search for a safer and more reliable minimally invasive method for external drainage of the gallbladder with obstructive jaundice of tumor origin.

The purpose of the invention

The aim of the invention is to increase the safety and reliability of laparoscopic cholecystostomy by developing a new version of the contact stoma, performed under the control of a video laparoscope.

SUMMARY OF THE INVENTION

According to the proposed method, the external removal of bile is carried out by contact cholecystostomy under video-laparoscopic control without removing the gallbladder to the skin level through the wound channel of the anterior abdominal wall (prototype).

To implement the method under video-laparoscopic control, the anterior abdominal wall is punctured at the projection point of the bottom of the gallbladder with a 5 mm diameter trocar, a needle holder from the laparoscopic surgical kit with atraumatic thread "POLVSORB-UL-203," CV-23, 17 needle is passed through the trocar into the abdominal cavity mm., 1/2 circle. Under video-laparoscopic control, a purse string suture is placed on the bottom of the gallbladder in such a way that after the last stitch, the end of the thread is passed through the loop created at the opposite end of the thread (Figs. 2, 3, 4). In the center of the purse string suture, the gallbladder is punctured with a special device (Figs. 5, 6, 7). The latter consists of a needle with a diameter of 3 mm and a length of 20 cm and a thin-walled metal tube worn on it. After receiving the contents of the bubble, the needle is removed and the working end of the hollow metal tube remains in the lumen of the bubble (Fig. 8). A drainage catheter is passed through it into the cavity of the bubble (Fig. 8). The tube is removed and the purse string suture is pulled (Figs. 9, 10, 11). The end of the thread to keep taut (11). And fixed to the skin (Fig). A drainage tube is also fixed to the skin (Fig. 12).

Thus, we propose a completely new endoscopic operation, which is carried out by sequentially performing the following main steps:

- transparietal puncture of the anterior abdominal wall with a trocar with a diameter of 5 mm at the projection point of the bottom of the gallbladder under video-laparoscopic control;

- the imposition of a purse string suture on the bottom of the bladder under video laparoscopic control;

- puncture of the gallbladder in the center of the purse string suture with a special device;

- the introduction of drainage through the lumen of a hollow metal tube in the lumen of the bubble;

- removal of a hollow metal tube;

- tightening the purse string suture;

- pulling the thread and fixing its end to the skin;

- Fixation of the drainage tube to the skin with silk thread.

Concrete example

Patient A., 63 years old, was admitted to the General Surgery Clinic of the Dagmedakademia on September 15, 2003, with a diagnosis of cancer of the Vater papilla (T ₂ , N _x-0 , M ₀ ), severe obstructive jaundice, liver failure, encephalopathy. She got sick two months ago, when itchy skin appeared, ikterichnost sclera, was in hospital for all this time in the district hospital with a diagnosis of acute hepatitis. The skin and visible mucous membranes are yellow in color, traces of scratching on the skin. In the lungs, vesicular breathing. Rhythmic scones, frequent PS - 92 beats per minute. HELL 30/80 mm RT. Art. The abdomen is slightly increased in volume, the liver protrudes from under the costal arches by 2 p / fingers, of a dense consistency. A tense and painless gall bladder is palpated. In the midline below the navel, a postoperative linear scar (after cesarean section). The chair is regular acholic. The urine is dark in color, urination is free, painless.

Blood test: hemoglobin 116 g / l, red blood cells 3.8 * 10 ¹² / _l , white blood cells 5.4 * 10 ⁹ / _l , ESR-47 mm / h, total bilirubin 588 μmol / l, direct 512 μmol / l, indirect 76 μmol / l, total plasma protein 58 g / l, ALT 0.72 mmol / tsp, ACT 0.93 mmol / tsp, thymol sample 6 units. Creatinine 122 μmol / L. Urea 10.5 mmol / L.

Urinalysis: beats. weight - 1013, white blood cells - 5-7 in n / a. The reaction to bile pigments is sharply positive.

With ultrasound, the liver is enlarged, focal lesions in the liver parenchyma are not detected, the gallbladder is 14.7 * 5.8 cm in size, the contents are heterogeneous hyperechoic suspension, the common bile duct is expanded, its diameter is 25 mm, and the intrahepatic bile ducts are also enlarged. The head of the pancreas is enlarged 4.6 * 3.5 cm, in the projection there is a hyperechoic formation 2.5 * 2.0 cm in size. Free fluid is determined in the sloping places of the abdominal cavity.

On the second day after transfusion of 5% glucose with ascorbic acid, freshly frozen single-group plasma under local anesthesia (Sol. Novocaini 0.25% -40.0) pneumopertononeum 12 mm Hg was applied. Art. and introduced 11 mm trocar through paraumbilical access. With a review laparoscopy, the gallbladder is tense and enlarged, the liver is earthy in color, of a dense consistency, dilated bile capillaries are visualized under the capsule. In sloping places of the abdominal cavity up to 300 ml of a yellowish liquid. A puncture of the anterior abdominal wall was made in the projection of the bottom of the gallbladder with a trocar 5 mm in diameter. By trocar into the abdominal cavity of the needle holder held with atraumatic thread "POLYSORB-UL-203, the needle-CV-23, 17 mm, _^half circle (Figure 1)." A purse string suture was applied (Figs. 1-4). A puncture of the gallbladder is performed and a drainage tube is installed in its lumen (Figs. 5-10). The end of the purse string suture and the drainage tube are fixed to the skin at the drainage site (Figs. 13 and 14). The biliary tract was washed with saline.

The postoperative period is smooth, jaundice gradually decreased. By drainage from the biliary tract daily received bile in an amount of from 500 to 600 ml. Two weeks after the operation, fistulography was performed. At the same time, a satisfactory contrast of the biliary tract, a sharp expansion of the biliary tract, amputation of the common bile duct in its intramural part and complete absence of contrast in the duodenum were determined on the fistulogram.

After appropriate preoperative preparation

- transfusion of freshly frozen single-group plasma, hepatotropic therapy, antioxidant support of hepatocytes, correction of disorders of organs and systems, i.e. on the 20th day after the first stage of the operation, pancreatoduodenal resection was performed. The postoperative period is smooth. A histological examination of the drug revealed an adenocarcinoma of the Vater papilla. The patient was discharged with recovery for further follow-up observation on 10.24.03.

Comparative characteristics of the essential features of the prototype and invention. Prototype Invention Laparoscopy, laparocentesis Laparoscopy, puncture of the anterior abdominal wall with a trocar Puncture of the gallbladder with a needle, evacuation of the contents of the bladder under the control of a laparoscope Applying a purse string suture to the bottom of the gallbladder under the control of a laparoscope Capture of the gallbladder by clamping and removal of its bottom to the level of the skin through the wound channel Puncture of the gallbladder in the center of the purse string suture, evacuation of the contents of the bladder, insertion of a drainage tube into the cavity of the bladder Opening the bladder, introducing the drainage tube into the cavity of the bladder and fixing the wall of the bladder and drainage tube to the skin Tightening the purse string suture, fixing the end of the string of the purse string suture and drainage tube to the skin The bottom of the gallbladder is pulled to skin level The bottom of the gallbladder is pulled to touch the parietal peritoneum

As can be seen from the table, the same features of the prototype and invention (underlined) are

- laparoscopy;

- gallbladder puncture;

- evacuation of the contents of the bubble;

- the introduction of a drainage tube into the cavity of the bladder

Distinctive features of the invention and prototype are:

- during laparoscopy, laparocentesis is performed, violating the tightness of the abdominal cavity and worsening the overview of the abdominal organs, but this does not happen with the proposed method, all manipulations are performed through the sleeve of a 5 mm trocar;

- the bottom of the gallbladder is brought out to the level of the skin, pulling it through the wound channel, deforming the bladder and not disturbing the blood circulation in it, and with the proposed method, the bottom of the bladder is tightly pressed to the parietal peritoneum without deforming the bladder and disturbing intramural blood circulation, as well as keeping the organ at rest;

- cholecystostomy is formed in the form of a spinal fistula, and with the proposed method as a tubular fistula.

Positive effect

1. Laparoscopic cholecystostomy is formed with a more physiological gentle option.

2. When performing cholecystostomy according to the proposed method, the risk of infection of the abdominal cavity is minimal.

3. Performing cholecystostomy according to the proposed method does not technically complicate the second stage of the operation.

Clinic Application

Our method of laparoscopic cholecystostomy was used in the treatment of 28 patients with obstructive jaundice of tumor origin. The tumor process in the head of the pancreas was localized in 19 patients, in the terminal part of the common bile duct - in 5 and in the region of the Vater papilla - in 4 patients.

As the first stage of surgical treatment, cholecystostomy was performed by 22 patients; the remaining 6 patients served as the final therapeutic measure due to the prevalence of the tumor process.

Complications in the form of bile leakage into the free abdominal cavity or an increase in jaundice and liver-renal failure were not noted.

All patients in the postoperative period performed fistulography. Moreover, in all cases there was a complete block in the terminal department of the common bile duct. Bile did not enter the duodenum. In this regard, from the moment of admission, patients received nutritional dietary and drug support, as well as antioxidant protection of hepatocytes by intravenous drip of reamberin. In three cases, there were conditions for a radical operation. He performed pancreatoduodenal resection with a favorable outcome. The remaining 19 patients underwent palliative surgery: cholecystejunostomy 15, cholecystoduodenostomy 3, cholecystogastrostomy 1, immediate results of treatment of patients are satisfactory. Long-term results of treatment of patients have not been studied.

The characteristic of medical and economic efficiency.

- It is expected to reduce the number of complications that occurred when using the prototype.

- It is supposed to accelerate preoperative preparation, primarily among patients who are to undergo a radical operation.

- The possibility of using the gallbladder in the second stage of surgical treatment of periampular tumors.

Information sources

1. B.C. Saveliev, V.M. Buyanov, A.S. Balalykin. Endoscopy of abdominal organs. M., "Medicine", 1977.

2. B.C. Saveliev, V.M. Buyanov, G.I. Lukomsky. Guidelines for clinical endoscopy M., "Medicine", 1985.

3. M.A. Khamidov. Laparoscopic treatment of acute cholecystitis in patients with high operational risk. Diss ... can. sciences. 1996.

Signatures to figures 1-14, illustrating the invention. Figure 1, 2 1 - liver; 2 - gall bladder; 3 choledoch; 4 - duodenum; 5 - thread "POLVS-ORB - UL -203", 6 - needle holder; 7 - sleeve of a trocar; 8 - abdominal wall; 9 - laparoscope; 10 - sleeve of a trocar; 11 - abdominal wall; 12 - loop at the end of the atraumatic thread. Figure 3 - 12 - section of the gallbladder inside the purse string suture Figure 4 - 11 - section of the gallbladder inside the purse string suture 5, 6, 7, 8 - 1 liver; 2 - gall bladder; 3 - choledoch; 4 - duodenum; 5 - thread "POLVSORB-L / L-203"; 6 - a puncture needle; 7 - a hollow metal tube; 8 - a sleeve of a trocar; 9 - abdominal wall; 10 - the end of the thread, which is fixed to the skin; 11 - laparoscope; 12 - sleeve of a trocar; 13 - abdominal wall; 14 - a section of the gallbladder inside the purse string suture. Fig. 9, 10 - 1 - liver; 2 - gall bladder; 3 - choledoch; 4 - duodenum; 5 - thread "POLVSORB-UL-203", 6 - drainage tube; 7 - sleeve of a trocar; 8 - abdominal wall; 9 - the end of the thread, which is fixed to the skin; 10 - laparoscope; 11 - sleeve of a trocar; 12 - abdominal wall; 13 - hole in the wall of the gallbladder. FIG. 11.12 - 1- liver; 2 - gall bladder; 3 - choledoch; 4 - duodenum; 5- thread "POLVSORB - UL-203"; 6- drainage tube; 7 abdominal wall; 8 - laparoscope; 9 - a sleeve of a trocar; 10 - abdominal wall; 11 - tightened purse string suture. 13 and 14 - 1 - liver; 2 - gall bladder; 3 - choledoch; 4 - duodenum; 5 - drainage tube; 6 - a vessel with bile; 7 - puncture of the abdominal wall; 8 - a node on the skin of the abdominal wall; 9 - abdominal wall.

Claims (1)

Method of laparoscopic cholecystostomy, including decompression of the biliary tract, characterized in that the operation is performed by puncture of the anterior abdominal wall in the projection of the gallbladder, a purse string suture is applied, and after the last stitch, the end of the thread is passed through the loop created on the opposite end of the thread, gall bladder puncture is performed in the center of the purse string suture with a needle with a hollow metal tube on it, along the latter a catheter with a diameter sufficient to decompress the biliary tract is inserted into the lumen of the bladder a, the tube is removed, the purse string suture is tightened, the end of the thread is stretched and the catheter is fixed to the skin of the anterior abdominal wall, while the bottom of the gallbladder is pulled to touch the parietal peritoneum.

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