RU2318457C1 - Device for performing hemostasis at endoscopic operations on kidneys - Google Patents

Abstract

FIELD: medicine; surgical instruments.

SUBSTANCE: device has tube made of hyper-conducting material. Cut of rod with cryogenic-isolated handle is placed inside tube for axial movement. Cut is made of penetrable-porous titanium nikelide to be cryogenic depot in case it is impregnated with nitrogen.

EFFECT: improved efficiency of hemostasis.

4 cl, 4 dwg

Description

The invention relates to medicine, to surgical methods and instruments.

Endoscopic technology of surgical operations, without changing the principles and foundations of traditional direct access operations, allows you to solve many problems with significantly less invasiveness. In urological discipline, using endoscopic percutaneous access, operations are successfully performed: percutaneous (percutaneous) nephrolitholapaxia and nephrolithoextraction, percutaneous nephrostomy with hydronephrosis and acute pyelonephritis, percutaneous endotomy, digestion and dilatation of the pelvis and ureter-ureteric ureteric segment. Advances in modern materials science and high technology help expand the list of such operations.

Intra- and postoperative bleeding of the percutaneous trans-lumbar wound canal, passing through the thickness of the vessel-rich parenchyma of the kidney, complicates the surgical procedures of the surgeon and threatens the patient's life. Stopping bleeding (hemostasis) is relatively simple with open access (electrocoagulation, ligation and flashing of blood vessels), but it is a problem with endoscopic access, when the surgeon’s hands are removed from the operating area and the instruments are not yet perfect.

Known plugging of the wound channel and fornix dilatator, nephrostomy drainage [Martov A.G. X-ray endoscopic methods for the diagnosis and treatment of kidney and upper urinary tract diseases. Abstract. Doct. diss. M. 1993. S. 18-19], when the bleeding walls undergo mechanical occlusion. These technical means are ineffective. The resulting failure of hemostasis leads to the need for open surgery to stop bleeding by selective embolization of the corresponding branch of the intrarenal artery or even nephrectomy. Thus, the success of the operation itself is reduced to severe iatrogenic consequences.

A more functional device is known for hemostasis of the wound canal in the form of a catheter with an inflatable balloon (occluder) at the end [Martov A.G. X-ray endoscopic methods for the diagnosis and treatment of kidney and upper urinary tract diseases. Abstract. Doct. diss. M. 1993. S. 50]. To stop bleeding, the device is introduced into the desired section of the channel and a liquid solution is supplied under pressure. Increasing in radial size, the balloon obstructs the mouth of the damaged vessels. The disadvantage of this device is the low efficiency of hemostasis. After working exposure and removal from the wound canal, bleeding may resume.

By the greatest similarity of the technical nature of this analogue is selected as a prototype.

The technical result of the invention is to increase the effectiveness of hemostasis.

The specified technical result is achieved by the fact that in the device for hemostasis during endoscopic operations containing a cylindrical occluder of the wound channel, the cylindrical occluder is made in the form of a tube of cryoconductive material and a segment of the rod of permeable-porous titanium nickelide as cryodepo. A segment of the rod is located coaxially in the cavity of the tube with a touch of its walls and the possibility of free axial movement. The external diameter of the tube is proportional to the diameter of the wound channel.

It is preferable to supplement the length of the shaft with a cryo-insulated handle.

Preferably, the ends of the rod are oval-shaped to facilitate axial movement in the tube.

A preferred choice is permeable-porous titanium nickelide with a predominant pore size of 60-100 microns.

The attainability of the technical result is due to the action of the properties of the distinguishing features.

The proposed device performs hemostasis due to the rapid freezing of the near-surface volume of tissue of the wound channel, and therefore, bleeding mouths of damaged vessels. The physiological mechanism of cryocoagulation is not sufficiently explained, however, it is known that after freezing of the opening vessels, bleeding is blocked even in the richly vascularized organs themselves. In the device, indirect cryotherapy is carried out from a cryo source — a segment of the rod 1 (Fig. 1) made of permeable-porous titanium nickelide cooled and impregnated with liquid nitrogen through an intermediate element — a tube 2 made of cryoconductive material. In this case, the capillary and heat-conducting properties of permeable-porous titanium nickelide (effective cryodepo) are used, as well as the transformation of the cryostream to tissues through the volume of the tube wall. The latter softens the mode of tissue freezing, localizing it to the near-surface area of channel 3. This reduces the volume of cryonecrosis of healthy tissue and, at the same time, is sufficient for obstruction of the mouths of damaged vessels. The tube, in addition, serves as a shaper of the lumen of the wound channel (ampullar tube, in the accepted terminology of surgeons) to access the surgical field and carry out the necessary instruments on it.

Hemostasis by cryotherapy virtually eliminates the possibility of secondary bleeding. A concomitant effect of cryotherapy is cold anesthesia, due to the early “shutdown” of sensitive receptors during tissue freezing. The cryotherapy zone heals faster compared to other types of local tissue destruction.

The operability of the device is ensured by the conjugation of the transverse dimensions of the segment of the rod and the tube: a tangent with the possibility of free movement - for the internal size of the tube, and commensurate with the wound channel for weak bougienage and cryocontact - for the external size.

For the convenience of manipulating the rod and the safety of working with a refrigerant, it is preferable to supply it with a cryo-insulated handle 4.

Oval rounding of the ends of the rod segment is desirable to reduce interference with axial movement.

The process of isolating cold from a porous cryodepo, which is optimal in terms of efficiency and speed, has been experimentally established for the distribution of pore sizes in the structure of a material with an advantage in the range of 60-100 microns.

The set of essential features in their logical connection with the technical result is not found in the prior art, which indicates the compliance of the proposal with the criterion of "inventive step".

The illustrations show:

Figure 1. Device for hemostasis during endoscopic operations (offer). 1 - a segment of a rod made of permeable-porous titanium nickelide (cryodepo), 2 - a tube, 3 - a wound channel, 4 - a cryo-insulated handle, 5 - a rounded end of the rod.

Figure 2. Scheme of hemostasis during endoscopic kidney surgery. 6 - kidney, 7 - abdominal system of the kidney.

Figure 3. Cooling the rod with liquid nitrogen. 8 - Dewar vessel with liquid nitrogen.

Figure 4. X-ray of the hemostasis zone.

An experimental verification of the device’s operability served as the basis for clinical use in the implementation of endoscopic operations in the urological clinic of the Novosibirsk GOKB.

Example.

Patient Ch., 63 years old, was admitted to the hospital with a complaint of bouts of pain - from acute to dull - in the left lumbar region. The examination established the diagnosis: a stone in the pelvis-ureteric segment of the left kidney, hydronephrosis on the left 2 tbsp., Secondary chronic pyelonephritis in the stage of latent inflammation. The patient performed endoscopic nephrolitholapaxia. With percutaneous access, after removal of the amplic tube, intense bleeding from the wound channel developed. For its relief, the proposed device for hemostasis was used (Fig. 1).

The device comprises a stainless steel tube 2 with cross-sectional diameters of 10/8 mm and a length of 120 mm; a rod segment 1 made of permeable-porous titanium nickelide TH - 20 with a diameter of 8 mm with a negative tolerance of 0.1 mm and a length of 80 mm. The pore sizes of titanium nickelide are statistically distributed with a maximum of about 80 microns. The rod segment is equipped with a handle 4 with a plastic tip for safe immersion in liquid nitrogen.

In the course of use in operation, the device operates as follows. For hemostasis, tube 2 is inserted into the wound channel, the lumen of which is paired with its outer radius. The cavity system of the kidney 7 and the lumen of the tube are drained from the blood with gauze turundas and balls. A segment of the rod 1 is immersed in liquid nitrogen in a Dewar vessel 8, cooled until the boiling stops and placed in the lumen of the tube, turning it into a cryoapplicator. Exposure to cryotherapy is carried out for 2-3 minutes with the possibility of two or three repetitions until the bleeding stops. After cryoapplication, the tube is removed and the nephrostomy catheter Foley catheter No. 20-22 according to Sharyer is now installed in the dry wound canal according to the usual method.

The indicated operation is completed by removal of the stone and the routine actions of wound healing.

By this method, intraoperative hemostasis was performed in 28 patients with various types of endoscopic intervention on the kidneys. In this case, not a single case of the development of bleeding was noted. The terms of patients' activation in the early postoperative period decreased from 24 to 8 hours with a corresponding decrease in the consumption of medicines and a decrease in the number of hospital beds.

The device is suitable for hemostasis during endoscopic operations on other organs with similar anatomy conditions with dimensional variation of its parts. The degree of validity, technological readiness of the device itself and the medical component indicate that the proposal meets the criterion of "industrial applicability".

Claims (4)

1. A device for hemostasis during endoscopic kidney surgery, comprising a cylindrical occluder of the wound canal, characterized in that the cylindrical occluder of the wound canal is made in the form of a tube of cryoconductive material and a piece of rod made of permeable-porous titanium nickelide as a cryodepo coaxially located in the tube with touching the walls and the possibility of free axial movement, and the outer diameter of the tube is proportional to the diameter of the wound channel. 2. The device according to claim 1, characterized in that the segment of the rod is equipped with a cryo-insulated handle. 3. The device according to claim 1 or 2, characterized in that the ends of the rod segment are ovally rounded to facilitate axial movement in the tube. 4. The device according to claim 1, characterized in that a permeable-porous titanium nickelide with a predominant pore size of 60-100 microns is selected.

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