RU2312620C1 - Method for videothoracoscopic esophageal access - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with providing endoscopic esophageal access. It is important to put a patient onto left side in case of microsomatic type at the angle of 70°, in case of mesosomatic type - at the angle of 60°, at macrosomatic type - 50° being open against anterior body surface. One should introduce a trocar for access towards the upper esophageal third through III intercostal area along anterior auxiliary line, for the access towards the middle third into IV intercostal area along anterior auxiliary line and into V intercostal area along the middle auxiliary line, and for the access to epiphrenal department - into V intercostals area along anterior auxiliary line and into IV intercostals area along posterior auxiliary line. The innovation enables to decrease the quantity of introduced trocars and decrease the traumatism of the access.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to surgery, and can be used to provide videothoracoscopic access to the esophagus.

A study of patent and medical literature has allowed to identify the following methods of videothoracoscopic access to the esophagus.

A known method of positioning a patient on an operating table for extirpation of the esophagus described by A. Cushieri et al. (1994). The patient is laid on his stomach, trocars are introduced at the following points: I - in the II intercostal space in the rear axillary line, II - in the III intercostal space in the middle axillary line, III - in the IV intercostal space in the rear axillary line, IV - in the V intercostal space in the front axillary line , V - in the VI intercostal space along the posterior axillary line.

The disadvantages of the method when the patient is located on the abdomen are the limitation of excursions and compression of the chest, which complicates the mechanical ventilation of the lungs, the high probability of displacement of the endotracheal tube, the possibility of atelectasis in the lungs, a sharp decrease in lung elongation, residual capacity and total volume of respiratory movements, the inconvenience of manipulating neck and the inability to perform abdominal access in this position for the reconstructive stage of the operation.

The prototype of the invention as the closest in combination of features to the claimed method, the following method of extirpation of the esophagus when the patient is located on the operating table on the left side (T. Akishi et al., 1996). The patient is placed on the left side at an angle of 90 degrees, 6 thoracoports are introduced into the right pleural cavity: I - in the II intercostal space along the anterior axillary line, II - in the III intercostal space along the posterior axillary line. III - in the fourth intercostal space along the midclavicular line, IV - in the fourth intercostal space in the middle axillary line, V - in the fifth intercostal space in the posterior axillary line, VI - in the sixth intercostal space in the middle axillary line.

The disadvantage of the method of performing extirpations and resections of the esophagus in the modification claimed by the authors is a greater number of trocars (5-6 according to the prototype), which complicates manipulations in the limited space of the posterior mediastinum and pleural cavity, increases the invasiveness of access, in contrast to the proposed method, in which the number of introduced trocars decreases until 3.

The task of the invention is to provide optimal video thoracoscopic access to the esophagus, depending on the somatic type of the patient, with a minimum number of manipulator tools.

The task is achieved in that when the microsomatic type of the patient is placed at an angle of 70 °, with a mesosomatic 60 °, with a macro somatic 50 ° open to the front surface of the body, to access the upper third of the trocar enter through the III intercostal space along the front axillary line, to access the middle thirds - in the IV intercostal space along the anterior axillary line and in the V intercostal space along the middle axillary line, and for access to the epiphrenal department - in the V intercostal space along the anterior axillary line and in the IV intercostal space along the posterior axillary line.

The method is as follows. Before the operation according to the method of Dorokhov R.N. and Petrukhina V.G. determine the somatic type of patient [Dorokhov R.N., Guba V.P., Petrukhin V.G. Methods of early selection and orientation in sports, Smolensk, 1994]. Then, according to the table at the intersection of the column corresponding to the somatic type and the row corresponding to the esophagus to which access is made, the location of the trocars is determined.

Depending on the somatic type of the patient, they are placed on the left side with the microsomatic type at an angle of 70 °, open to the front surface of the patient’s body, with the mesosomatic type - 60 °, with the macrosomatic type - 50 °. In certain places according to the table, manipulator tools are introduced and surgery is performed.

The method was tested in 7 patients at the Rostov State Medical University.

Examples of specific performance of the method

Example 1. Patient R-ko, 56 years old, was admitted to the Department of Thoracic Surgery of Rostov State Medical University on June 15, 2004. Based on the data of objective and instrumental research methods, a diverticulum of the upper third of the esophagus was established. The microsomatic body type was determined.

After preoperative preparation on June 28, 2004, the operation was performed.

1 trocar - 10 mm in the III intercostal space in the anterior axillary line for a thoracoscope 30 °, 2 trocar - 10 mm in the V intercostal space in the mid-axillary line, 3 trocar - 5 mm in the III intercostal space in the rear axillary line. Without technical difficulties, the operation was performed and completed according to the generally accepted technique. There are no intraoperative and postoperative complications.

At the follow-up examination after 6 months, the patient's condition is satisfactory, no complaints. Continues to work in the specialty.

Example 2. Patient Iva, 47 years old, was admitted to the surgical thoracic department on 07/13/2005. Based on the data of objective and instrumental research methods, a leiomyoma of the middle third of the esophagus was established. Defined macrosomatic body type.

After preoperative preparation on July 26, 2005, an operation was performed. 1 trocar - 5 mm was installed in the IV intercostal space in the anterior axillary line, 2 trocar - 10 mm in the IV intercostal space in the mid-axillary line, 3 trocar - 10 mm in the III intercostal space in the posterior axillary line for a 30 ° thoracoscope. Without technical difficulties, the operation was performed and completed according to the generally accepted technique. There are no intraoperative and postoperative complications.

During the follow-up examination after 2 months, the patient's condition is satisfactory, no complaints, passage of food through the esophagus is satisfactory.

Example 3. Patient Sh-v, 52 years old, was admitted to the Department of Thoracic Surgery of Rostov State Medical University on February 17, 2005. Based on the data of objective and instrumental research methods, a diverticulum of the epiphrenic esophagus was established. The mesosomatic body type is determined.

After preoperative preparation 21.02.2005, the operation was performed.

1 trocar - 10 mm in the IV intercostal space along the anterior axillary line for a thoracoscope 30 °, 2 trocar - 10 mm in the VI intercostal space on the mid-axillary line, 3 trocar - 5 mm in the IV intercostal space on the rear axillary line. Without technical difficulties, the operation was performed and completed according to the generally accepted technique. There are no intraoperative and postoperative complications.

At the follow-up examination after 6 months, the patient's condition is satisfactory, no complaints, passage of food through the esophagus is satisfactory.

Thus, in comparison with the prototype, the method provides optimal videothoracoscopic access to the esophagus, depending on the somatic type of the patient, with a minimum number of manipulator tools, which improves the quality of surgical care for patients with esophageal diseases.

Claims (1)

A method of providing endoscopic access to the esophagus, in which the patient is placed on the left side, characterized in that with the microsomatic type of the patient placed at an angle of 70 °, with a mesosomatic 60 °, with a macro somatic 50 °, open to the front surface of the body, to access the upper third the trocar is introduced through the III intercostal space along the anterior axillary line, for access to the middle third in the IV intercostal space along the anterior axillary line and in the V intercostal space along the middle axillary line, and for access to the epiphrenal department in the V intercostal space according to Independent user axillary line IV intercostal space in the posterior axillary line.