RU2309682C2 - Method for surgical access to cholecyst and common bile duct - Google Patents

Abstract

FIELD: medicine, abdominal surgery.

SUBSTANCE: the present innovation deals with surgical access in treating cholelithiasis due to fulfilling the following technique: it is necessary to dissect the skin being parallel to costal arch at the distance of about 2-3 cm against its edge; the incision of 4-5 cm length should be started about 2-3 cm laterally against the middle line, frontal folium of the sheath of rectus muscle of abdomen should be dissected according to the length and the direction of cutaneous incision; longitudinally one should exfoliate the fibers of rectus muscle of abdomen and peritoneum according to the direction of cutaneous skin. The innovation suggested enables to widen the volume of surgical manipulations, decrease traumatism of operation and risk for the development of post-surgical hernias.

EFFECT: higher efficiency.

2 dwg, 2 ex

Description

The invention relates to abdominal surgery and relates to surgical access in the treatment of gallstone disease.

Known mini-access according to Prudkov M.I. This access is performed in the following way: a vertical transrectal incision of the anterior abdominal wall up to 5 cm long is performed over the projection site of the hepatoduodenal ligament onto the anterior abdominal wall. The skin, subcutaneous tissue, and anterior leaf of the aponeurosis are dissected. The muscle fibers of the right rectus abdominis muscle bluntly stratify along the fibers and expose the posterior leaf of the aponeurosis of the rectus muscle. The latter, along with the peritoneum, is also captured and dissected in a vertical direction (Prudkov MI “Minilaparotomy and open laparoscopy in the treatment of patients with gallstone disease.” Abstract of a doctor of medical sciences. Moscow, 1993. S.13-16).

The disadvantage of this method is the limited availability of the neck of the bile and common bile duct, the inconsistency of the incision direction with the skin lines of Langer, which violates the principles of the formation of an optimal postoperative scar.

The objective of our proposed method is to expand the scope of surgical procedures on the gall bladder, elements of the hepatoduodenal ligament, reducing the invasiveness of the operation, the risk of developing postoperative hernias and other postoperative complications.

The task in the method of surgical access to the gallbladder and common bile duct, including layer-by-layer dissection of the tissues of the anterior abdominal wall, is achieved by forming mini-access by successive dissection of the skin parallel to the costal arch, at a distance of 2-3 cm below its edge, starting at 2-3 cm lateral to the midline, 4-5 cm long, longitudinal delamination of the fibers of the right rectus abdominis muscle and dissection in the oblique direction of the posterior wall of the vagina of the right rectus abdominis and peritoneum.

The proposed method and features that distinguish it from the well-known, in the medical and patent literature are not found, which allows us to conclude that its criterion of "novelty".

The essence of the proposed method is that mini-access is formed by sequentially dissecting the skin parallel to the costal arch, at a distance of 2-3 cm below its edge, starting 2-3 cm lateral to the midline, 4-5 cm long, longitudinal fiber separation rectus abdominis muscle and dissection in the oblique direction of the posterior vaginal wall of the right rectus abdominis and peritoneum.

The parameters of an oblique skin incision 4-5 cm long are due to the fact that with an incision less than 4 cm long it is difficult to manipulate in the abdominal cavity, more than 5 cm the incision becomes traumatic.

The parameters of the cut parallel to the right costal arch and below it by 2-3 cm are due to the fact that when the distance from the right costal arch is less than 2 cm, the costal arch interferes with manipulations on the abdominal cavity organs, more than 3 cm displacement relative to the gall bladder and elements of the hepatoduodenal ligaments.

The need to start a skin incision lateral to the midline by 2-3 cm is due to the fact that when entering the abdominal cavity, the round ligament of the liver is the upper limit of access.

It is the stratification of the muscle fibers of the rectus abdominis that can reduce the morbidity of access.

The oblique direction of access allows you to clearly visualize the gallbladder and elements of the hepatoduodenal ligament.

All these distinguishing features allow you to achieve the task.

The method is illustrated by drawings.

Figure 1. The first stage of the skew-variable mini-access.

The dashed line shows the skin incision, and the solid line shows the incision of the anterior sheet of the vagina of the rectus abdominis muscle.

Figure 2. The second stage of the skew-variable mini-access.

The dotted line shows the stratification of the fibers of the right rectus muscle, and the solid line is the dissection of the posterior sheet of the vagina of the rectus abdominis muscle.

The method is as follows: the patient lies on his back, along the operating table. A skin incision is made parallel to the costal arch at a distance of 2-3 cm below its edge, starting 2–3 cm lateral to the midline, 4–5 cm long. The subcutaneous tissue is stratified, the anterior sheet of the vagina of the right rectus abdominis is dissected in the oblique direction, respectively, and the direction of the skin incision. The muscle fibers of the right rectus abdominis muscle bluntly longitudinally exfoliate and expose the posterior sheet of the vagina of the rectus abdominis muscle. Dissect in the oblique direction the posterior wall of the vagina of the right rectus abdominis muscle together with the transverse fascia and peritoneum in the oblique direction, respectively, to the direction of the cut of the skin and the anterior leaf of the aponeurosis.

The method is as follows.

Patient Balgsheim E.I. 68 years old, and / b No. 3633, was admitted according to emergency indications on July 23, 2005. From the anamnesis it is known that in 1994, 1997, 2003. suffered a myocardial infarction. In 2004, angioplasty was performed twice with stenting of the coronary arteries. In April 2005, for acute calculous obstructive cholecystitis, puncture of the gallbladder was performed under ultrasound guidance. Within a day before the present receipt, an attack of pain in the right hypochondrium.

Upon admission, the patient's condition is moderate. The skin is of normal color. In the lungs, vesicular breathing. A / D 150/90 mm RT. Art. Heart sounds are muffled, rhythmic. The abdomen is not swollen, soft, painful on palpation in the right hypochondrium, where the enlarged gall bladder is palpated.

With ultrasound, the gallbladder is enlarged 8 × 3 cm, the walls are thickened to 6 mm, and two large calculi are found in the lumen. Pathology of the liver, pancreas was not detected. The diameter of the common bile duct is 4 mm. For the purpose of preoperative preparation, the patient was examined by a cardiologist, additional appointments were given.

07/27/2005 operated. A skin incision was made parallel to the costal arch at a distance of 2 cm below its edge, starting 3 cm lateral to the midline, 4 cm long. Subcutaneous tissue was stratified, the anterior sheet of the vagina of the right rectus muscle was dissected in the oblique direction according to the length and direction of the skin incision. The muscle fibers of the right rectus muscle are bluntly stratified along and the posterior leaf of the vagina of the rectus abdominis muscle is exposed, the latter was captured along with the peritoneum and transverse fascia and also dissected in the oblique direction, respectively, to the incision of the skin and the anterior leaf of the aponeurosis. Performed cholecystectomy. Smooth postoperative course. Under the control ultrasound from 01.08.2005, there is no free fluid in the subhepatic space and in the projection of the gallbladder bed. Smooth postoperative course. Sutures were removed on the 7th day. Primary healing. Histological examination No. 12757-760: acute phlegmonous cholecystitis.

Patient Bukanova R.I., 81 years old, medical history No. 3808, was admitted according to emergency indications 02.08.2005. From the anamnesis it is known that in 2000 she suffered an acute violation of cerebral circulation, suffers from hypertension. 3 weeks before admission, she suffered an attack of intense pain in the right hypochondrium. Since then, moderate pain has persisted.

Upon receipt, a moderate condition. Patient hypersthenic type of addition. The skin is of normal color. In the lungs, vesicular breathing is carried out in all departments, heart sounds are muffled. A / D 130/80. The abdomen is not swollen, soft, painful on palpation in the right hypochondrium, where the bottom of the gallbladder is palpated.

With ultrasound, the gallbladder is 9 × 4.5 cm, the anterior wall of the bladder is locally thickened to 1.5 cm with the formation of an intramural abscess 2.5 × 1 cm. Liver and pancreas - no pathology was detected. Choledoch 4 mm. In the preoperative period, the patient was examined by a cardiologist, neuropathologist, additional appointments were given.

08/06/2005 operated. A skin incision was made parallel to the costal arch, 3 cm below its edge, starting 3 cm lateral to the midline, 5 cm long. The subcutaneous tissue was stratified, the anterior sheath of the right rectus abdominis muscle was dissected in the oblique direction according to the length and direction of the skin incision. The muscle fibers of the right rectus muscle are bluntly stratified along and the posterior leaf of the vagina of the rectus abdominis muscle is exposed, the latter was captured along with the peritoneum and transverse fascia and also dissected in the oblique direction, respectively, to the incision of the skin and the anterior leaf of the aponeurosis. Performed cholecystectomy. With the control ultrasound of 08/13/2005, there is no fluid in the subhepatic space and the gallbladder bed. Smooth p / o flow. Sutures were removed on the 8th day, primary healing.

Histological examination No. 13822-831: acute phlegmonous cholecystitis. Pericholecystitis. In the adjacent lymph node, a picture of acute serous-purulent lymphadenitis.

The proposed method allows to achieve the task of expanding the volume of surgical procedures on the gallbladder, elements of the hepatoduodenal ligament, reducing the invasiveness of the operation, the risk of developing postoperative hernias and other postoperative complications.

The method was tested (clinical trials were conducted in the Department of Surgery for Emergencies of the Russian Scientific Center of Medical Sciences for 50 patients) and gave a positive result in all cases.

The obtained positive results allow us to expect that the proposed method will find wide application in the surgery of gallstone disease.

Claims (1)

A method of surgical access to the gallbladder and common bile duct, including layer-by-layer dissection of the tissues of the anterior abdominal wall, characterized in that the access is formed by sequentially dissecting the skin parallel to the costal arch at a distance of 2-3 cm below its edge, starting 2-3 cm lateral to the average lines, 4-5 cm long, of the anterior sheet of the vagina of the right rectus abdominis muscle, respectively, the length and direction of the skin incision, the longitudinal separation of the fibers of the right rectus muscle of the abdomen and dissection of the posterior sheet of the vagina howl of the rectus abdominis and peritoneum, respectively, the direction of the skin incision.

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