RU2305501C1 - Mini-access method for carrying out cholecystectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves making 4-5 cm long skin incision 1 cm below costal arch. Anterior sheath of direct abdominal muscle and external abdominal muscle aponeurosis are cut in diagonal transverse direction. The direct abdominal muscle is medially brought aside. The transverse abdominal muscle is bluntly separated. Peritoneum is cut along the wound and sutured to the upper and lower wound edge, to medial and lateral wound angles. Gallbladder is separated from the liver beginning from its fundus. Patient is dorsally laid on roller in xiphoid process projection.

EFFECT: accelerated operation procedure; reduced traumatic consequences of the operation; improved cosmetic results.

2 cl

Description

The invention relates to medicine, namely to surgery of the biliary tract, and can be used in operations in patients with cholelithiasis.

The spatial relationship to the surgical wound is determined by well-known parameters, of which the so-called accessibility zone is the main one, i.e. the area accessible to the surgeon, while speed, radicalism, and most importantly, the non-invasiveness of manipulations with any abdominal intervention depend on successful operative access.

Currently, more than 60 different surgical approaches have been proposed for interventions on the gallbladder and extrahepatic bile ducts. The difficulties associated with operative access to these organs are evidenced by the fact that there is no other organ in the abdominal cavity in relation to which such a large number of access methods have been proposed. This is due to physique and chest shape, for example, the gallbladder can be completely covered by ribs, which makes it difficult to access these organs.

Recently, in abdominal surgery and in biliary tract surgery, in particular, there has been a reasonable tendency to small incisions (E.I. Galperin, D.M. Dederer, 1987). The sufficiency of the 8 cm incision is indicated by B.A. Korolev, D.L. Pikovsky, 1990 (2).

The “shortening" of the section is advisable, because a large incision is, first of all, a big injury. The intersection of sensory and motor nerve fibers of the right half of the abdominal wall is reflected in the postoperative period by the restriction of its mobility and significant pain.

A known method of performing mini-access for cholecestectomy, including a skin incision in the right hypochondrium with the formation of trans-rectal mini-access. In this case, all layers of the abdominal wall are cut vertically down from the costal arch, at the level of the middle third of the rectus muscle, the fibers of which are bred in a blunt way. (See Prudkov MI “Mini-parotomy” and “open” laparoscopy in the treatment of patients with cholelithiasis ”/ Surgery, 1997, 1, p.32-35.).

The disadvantages of this method are that with transrectal access, the breeding of fibers of the rectus abdominis muscle is accompanied by damage to nerves, usually going in the transverse direction to the fibers of the muscle. This leads to atrophy of the medial part of the rectus muscle. Transrectal mini-access significantly complicates operations on hepaticoholedoch due to the fact that the latter is away from the incision, and also causes difficulties in operations in patients with narrow breasts and an acute epigastric angle.

The closest in technical essence and the achieved effect and taken as a prototype is a method of performing mini-access for cholecystectomy (see patent RU No. 2188584, class A61B 17/00, filed January 25, 2005, published September 10, 2002 .), including a minimal skin incision parallel to the costal arch 3-5 cm long, which starts from the midline of the abdomen, then the anterior sheet of the vagina of the rectus abdominis muscle is dissected in the transverse direction, after which the white line is cut from the inside angle of the vagina of the rectus abdominis muscle and down 2 cm, then m dially edge of the rectus abdominis muscle is removed or incised outwards in the transverse direction, and a rear leaf sheath rectus peritoneum is dissected similarly with the front leaf, then dissect the peritoneum labial fold along the lateral edges liver round ligament up and down by the cut angle.

The disadvantages of this method are the fact that in cases of lateral location of the gallbladder, the presence of subhepatic infiltrate, as well as in patients with hypersthenic physique, due to the removal of the gallbladder, the rectus abdominis muscle is laterally dissected, i.e. as in the analogue, damage to nerves occurs, going, as a rule, in the transverse direction to the muscle fibers.

The objective of the invention is to increase the effectiveness of mini-cholecystectomy while reducing morbidity and reducing the time of surgery.

The technical result is the versatility of the incision for any physique and location of the gallbladder.

This problem is solved in that in the known method of performing mini-access for cholecystectomy, including a skin incision parallel to the costal arch with a length of 3-5 cm, according to the invention, a mini-incision is started, departing 1 cm from the angle of the costal arch, then the anterior cross section is cut. a sheet of the vagina of the rectus abdominis muscle, aponeurosis of the external oblique abdominal muscle, then the rectus abdominis muscle is removed medially, the transverse abdominal muscle is stupidly dissected, the peritoneum is dissected along the wound and sutured to the upper and lower edges of the wound, to the medial At the bottom and lateral corners of the wound, the separation of the gallbladder from the liver is carried out from its bottom.

In addition, the patient in the supine position can be laid on his back in the projection of the xiphoid process on the roller, in the supine position in the projection of the xiphoid process on the roller, which is equipped with the operating table.

Studies on patent and medical information have shown that the proposed method is not known and should not be explicitly from the material studied, i.e. meets the criteria of "novelty" and "inventive step".

The proposed method relates to surgery of the biliary tract and can be used in operations on the bile duct and gall bladder in patients with cholelithiasis, performed on domestic equipment using domestic or foreign instruments, therefore, "industrially applicable".

It was experimentally established that the implementation in the method of mini-incision of skin with a length of 3-5 cm of skin parallel to the costal arch, departing 1 cm from the angle of the costal arch, then dissecting in the oblique direction of the anterior sheet of the vagina of the rectus abdominis muscle and aponeurosis of the external oblique muscle of the abdomen with medial abduction - direct abdominal muscles and blunt dilution of the transverse abdominal muscle with dissection of the peritoneum along the wound with separation of the gallbladder from the liver from its bottom, provides a versatile incision for any physique of the patient, any the location of the gallbladder (lateral or medial), the location of the gallbladder behind the costal arch, with a high standing of the liver, and with subhepatic infiltrate there is no need to make a conversion (transition to laparotomy).

At the same time, hemming of the peritoneum to the upper and lower edges of the wound to the medial and lateral corners of the wound, as well as laying the patient on the back in the projection of the xiphoid process on the roller, which is equipped with the operating table, reduces the depth of the wound with the approach of the gallbladder to the anterior abdominal wall.

Thus, the combination of essential features ensures the achievement of a technical result, namely, the versatility of the incision for any physique and location of the gallbladder.

The method of performing mini-access for cholecystectomy is as follows.

The position of the patient on the operating table. Lying on your back with a raised chest in relation to the operating table by 35-40 degrees (using a mechanical roller located on the operating table under the patient’s back, in the projection of the xiphoid process).

The progress of the operation. The incision is carried out parallel to the right costal arch 1 cm below the angle of the costal arch (in the projection of the cystic point) 4-5 cm long.

Tissue dissection: skin; subcutaneous fat; rectus sheath; aponeurosis of the external abdominal muscle. The rectus abdominis muscle is removed by the hook of Farabef in the medial direction. The transverse abdominal muscle is bluntly bred with Kocher scissors, the peritoneum is taken on Mikulich’s clip and perforated with an electric knife in the direction of both corners of the wound. Next, the peritoneum is sutured to the skin with four interrupted sutures of capron No. 4 to the upper and lower edges of the wound and to the corners of the wound. The upper edge of the wound is removed with a Farabef hook, after which the gall bladder is visualized (hereinafter w.p.). The bottom of the railroad is seized with a Luer clamp and taken to the wound. Assistant crocheted Farabef deflects the edge of the liver. An electric knife (bipolar forceps) produce subserous detachment from the liver. Having separated the z.p. to the level of the neck, focusing on the Kahlo triangle, the cystic artery is taken to the clamp, they are crossed and ligated with nylon No. 3. The cystic duct is crossed at a level of 5-7 mm from the common bile duct, the stump is ligated with capron No. 3. After controlling the hemostasis, a drainage is installed to the Vinslov hole and it is removed through a separate hole in the right hypochondrium. The surgical wound is sutured in layers tightly.

The duration of the operation in chronic cholecystitis is 28 ± 3 minutes, with acute phlegmonous cholecystitis 35 ± 3 minutes.

1. Clinical example 1

The patient Stepanov A.V., 59 years old, was admitted to the surgical department on 04/20/2000 with a clinic of acute cholecystitis. Ultrasound revealed acute calculous cholecystitis, the size of the gallbladder (hereinafter referred to as w.p.) 6 by 3 cm, in the neck a calculus up to 2 cm, the wall w.p. up to 5 mm. Within 48 hours, infusion therapy was carried out, against which the attack did not stop. April 22, 2000 according to urgent indications, the patient was taken for surgery. Operation mini-laparotomy, resection of the gallbladder, plugging of the subhepatic space.

The progress of the operation. Access by the proposed method. When examining the subhepatic space, the infiltrate formed by the gall bladder, the mesentery of the colon and the greater omentum is determined. Z.p. bluntly isolated from the infiltrate, it is purple-red in color, tense, the wall is infiltrated with cartilaginous density. When puncture received up to 15 ml of pus. Palpation is determined by an injected calculus in the neck of the gallbladder. Separation of the liver from the liver with bipolar forceps from the bottom to the level of the neck. After digging with an electric knife (gland, the calculus was removed, 2 × 2 cm in size. The cystic artery with a part of the wall was crossed at the clamp, ligated with nylon No. 3. The cystic duct does not differentiate: the bladder neck passes into hepatic choledochus. A cholecystohepatic choledochial fistula was detected up to 0.7 see. The choledoch 8 mm does not contain calculi. A resection of the breast was performed at the neck level. The neck of the bladder was sutured with interrupted kapron sutures. A swab and drainage were brought to the bed of the breast. They were removed through a separate incision in the right hypochondrium. The surgical wound was sutured in layers agluho.

Diagnosis: acute calculous phlegmonous cholecystitis. Empyema of the gallbladder. Subhepatic infiltrate. Mirizzy's syndrome, the second form.

The postoperative period without complications. Within 5 days, antibiotic therapy: cefazolin 2 g 2 times a day / m. The tampon is removed on the 6th day. Sutures were removed on the 7th day. Discharged 10 days after surgery in satisfactory condition.

Clinical example 2

Patient Mukhametdinova Z.V., 78 years old, was admitted to the surgical department on 05.10.2000 with a clinic of acute calculous cholecystitis complicated by obstructive jaundice. From the anamnesis it is known that the patient turned yellow about 3 days ago. In blood biochemistry: bilirubin 200-160-40, ACT-3,5, ALT-4, alkaline phosphatase - 840 ml mol / l. On ultrasound: calculi in the gallbladder up to 0.8 cm. Choledoch up to 1.5 cm, a stone up to 1 cm is determined in it. Infusion therapy was carried out. The attack of acute cholecystitis was stopped. 05/11/2000 bilirubin 240-190-50. Given the elderly age of the patient and the growth of jaundice, she underwent laparoscopy with the application of cholecystostomy during the course using drainage company "Unicon". Received up to 70 ml of thick bile. On the 10th day after laparoscopy with the normalization of biochemical analyzes, the patient was taken for surgery. 05.21.2000 - surgery mini-laparotomy, cholecystectomy, choledocholithotomy, drainage of the common bile duct according to Keru.

The progress of the operation. Access by the proposed method. After removal of drainage from the gallbladder, the bottom of the bladder is withdrawn into the wound. Produced cholecystectomy from the bottom using bipolar forceps. Choledoch up to 1.5 cm palpation contains calculi. In the supraduodenal part of the common bile duct, choledochotomy was performed up to 1 cm, 4 calculi were removed from the bile duct: one up to 0.8 cm, three 0.5 cm each. Dololiotti probe No. 3 freely passes through the duodenum through the BDS. Kerr choledoch drainage. The drain is connected to the Vinslov hole. The surgical wound is sutured in layers tightly.

Diagnosis: acute calculous cholecystitis. Choledocholithiasis. Obstructive jaundice.

The postoperative period without complications, the drainage was removed on the 12th day after the operation. Discharged on the 13th day after surgery in satisfactory condition.

The proposed method of mini-access for cholecestectomy in comparison with the prototype provides an increase in the effectiveness of mini-cholecestectomy while reducing the morbidity and reducing the duration of the operation.

In addition, the method uses standard surgical instruments, which avoids additional material costs during the operation, a small postoperative scar (4-5 cm) and an oblique incision give the best cosmetic effect.

In this way, 480 patients with chronic calculous cholecystitis were operated on, 235 patients with acute calculous cholecystitis.

Claims (2)

1. A method for performing mini-access in case of cholecystectomy, comprising a skin incision parallel to the costal arch 3-5 cm long, characterized in that the mini-skin incision is started 1 cm from the angle of the costal arch, then the anterior sheet of the rectus sheath is dissected in an oblique direction. the abdomen, aponeurosis of the external oblique muscle of the abdomen, then the rectus abdominis is removed medially, the transverse abdominal muscle is stupidly dissected, the peritoneum is dissected along the wound and sutured to the upper and lower edges of the wound, to the medial and lateral corners of the wound, separation gallbladder from the liver produce from its bottom. 2. The method of performing mini-access for cholecystectomy according to claim 1, characterized in that the patient is laid on his back in the projection of the xiphoid process on the roller, which is equipped with an operating table.