RU2320281C2 - Method for endosurgical suturing and ligating - Google Patents

Abstract

FIELD: medicine, medicinal equipment, endoscopic surgery.

SUBSTANCE: the present innovation deals with intracorporal procedure of tissue suturing or ligating tubular anatomical structures of organs and tissues. One should fulfill Roedera's knot beforehand extracorporally upon an endosurgical instrument due to applying a free end of ligature. Through this knot after suturing or ligating anatomical structures one should intracorporally capture with the instrument and pull another end of the ligature which had passed through the tissues to shift along this end of the ligature the developed knot from the endosurgical instrument towards the structure under suturing or ligating along with tightening the knot that decreases tissue traumatism.

EFFECT: higher efficiency.

6 dwg

Description

The invention relates to medical equipment and can be used in endoscopic surgery for intracorporeal stitching of tissues or ligation of tubular anatomical structures of organs and tissues.

It is a well-known method of flashing tissue or ligating tubular anatomical formations with a conventional laparoscopic needle holder or clamp [I.V. Fedorov. Surgical Instruments Functions and purpose. - Kazan, AKP "Adelaide", 2001. - p. 155]. This method consists in the fact that the needle holder fixes the needle with the thread, then the tissue is stitched or the thread is carried out using a laparoscopic instrument for the tubular structure, for example, for a blood vessel or cystic duct with the formation of a loop of thread. This process chain ends with tying and tightening the assembly. As a result, stitching of different parts of the connected tissues or ligation of tubular structures occurs. Moreover, various types of marine nodes are often used in medicine [L.N. Skryagin, Marine nodes, Transport Publishing House, 1992, p.97].

The disadvantage of the method used is that after stitching the tissues or after ligating around the tubular structure, intracorporeal formation of a knot is required, which is technically difficult in case of cramped working cavity conditions during laparoscopic surgery, some knots, for example, the widely used Roeder knot (Roeder), cannot be performed intracorporeally.

The disadvantage of the device used to implement this method is the inability to fix the endosurgical unit in the endosurgical needle holder and at the same time fix the needle with the thread.

A known method and device of N.C. Clarke for extracorporeal formation and reduction of a node, which consists in using a tool with a ring-shaped neckline for reducing nodes [An Improved Ligator in Operative Laparoscopy: Obstet Gynecol, 83, 299-301 (1994)].

The disadvantage of this method and device is, as in the previous analogue, the impossibility of their use for complex nodes, for example for a sliding node Roeder.

There is another device for flashing and (or) ligation - EndoLoop, which allows you to use the Roeder node [V.N. Zaporojan, V.V. Grubnik, V.F. Saenko, M.E. Nichitailo. Video endoscopic surgery in surgery and gynecology. - Kyiv, Health, 2000, p. 37]. The device consists of a push rod and a thread, which can be with or without a needle. EndoLoop is inserted into a standard tubular conductor to introduce endoligature through a trocar into the abdominal or chest cavity. Stitched tissues are sutured with a needle or intracorporeally held behind the tubular structure of the ligature and both ends of the thread are brought out. In this case, the Roeder node is formed extracorporeally and only then reduced to a ligated structure.

The disadvantage of this method and device is the use of a long thread with a length of up to 70-90 cm. In this case, when tightened, the thread moves its entire length around the ligated structure and can cause a ligation of the ligated structure or stitched fabrics. In this regard, this technique is not used for flashing fabrics, and when ligating a vessel or duct, their protection is required with an additional tool, connected between the ligature and the ligated structure.

A known method of laparoscopic flashing of tissues with the EndoStitch apparatus, selected as a prototype [S.I. Emelyanov, I.V. Fedorov. Instruments and instruments for minimally invasive surgery. - St. Petersburg, publishing house "Man", 2004, p.37].

The above method is carried out as follows. A thread with a straight needle, specially made for this device, is placed in the working part of EndoStitch. The device branches are opened and installed in this form between the stitched fabrics. Then the branches are brought closer to each other, while the needle flashes the tissue in the selected injection site. Then, with the help of the device drive, the side of the needle fixation is changed to the opposite jaw. After the jaw is opened and the needle is pulled out from the stitched fabrics, the needle and thread are on the side of the puncture. Thus, tissue stitching or ligation occurs. Tying a simple knot is carried out by performing a loop and alternately changing the place of fixing the needle with thread on different branches of the device - either on one or the other side of the loop.

A serious drawback of the above method, selected as a prototype, is the impossibility of intracorporeal implementation of a complex node, for example, a Roeder node, the morbidity of flashing, difficulties in tightening the node.

The device for implementing this method EndoStitch contains an elongated tubular body for the possibility of introducing it through a laparoscopic trocar, the working part in the form of two branches with a needle fixing mechanism. At the same time, a straight needle with a thread fixed in its center is placed in the EndoStitch branches. The needle is made with the possibility of sequentially securing to one of the jaws with the help of plate clamps, which are controlled by the drive of the device located in the area of the handles of the EndoStitch device. This device works by changing the fixation of the needle with thread from one branch to another. In the process of application on organs, tissue is stitched or ligated between the branches of the apparatus.

The disadvantages of the EndoStitch device for the above method are:

firstly, the need to use a disposable needle with thread specially made for this purpose;

secondly, the perpendicular fixation of the thread in such a needle causes additional tissue damage and impedes the passage of the needle in the tissues;

thirdly, the working length of the needle of the EndoStitch device cannot exceed the distance between the opened branches of this device, which in turn does not allow to sew stitched fabrics deep enough;

fourthly, with this device it is impossible to correctly and accurately deliver an extracorporeally made site through an endosurgical trocar, simultaneously fix a complex site, stitch and ligate anatomical structures;

fifthly, this device is difficult to use.

Given the foregoing, this invention is aimed at solving the problem of developing such a method and creating such a device for performing endosurgical stitching and ligation, which would simplify and improve the technological process of endosurgical stitching, ligation, tying and tightening the node, to make this process more accurate and less traumatic.

Therefore, the technical result of the invention consists in the possibility of performing complex knots in endoscopic surgery, in reducing the morbidity when stitching tissues, in increasing the depth of stitching, in the ability to deliver an extracorporeally made knot through an endosurgical trocar with the possibility of simultaneously fixing a complex knot with stitching and ligation of anatomical structures, in general, in facilitating the operation by the surgeon and in obtaining better results after the operation through the use of simplified and more adapted for this purpose a method and device structures for implementing the method.

The essence of the invention is to achieve the technical result according to the method of O.B. Ospanov for endosurgical stitching and ligation, namely that the surgical suture material is extracorporeally fixed in the endosurgical instrument, it is inserted through the trocar into the working endosurgical space, then the connected tissues are stitched under endoscopic observation or spend the thread for ligated tubular anatomical formation, then tie both ends of the thread and tighten the knot.

In contrast to the prototype in the present invention, an extracorporeal pre-extracorporeal instrument using a free end of the suture performs a complex knot through which, after stitching or ligation of anatomical structures, the other end of the suture, which has passed through the tissues, is grasped and stretched with an intracorporeal instrument. And then the formed knot is displaced along this end of the thread from the endosurgical instrument towards the stitched or ligated structure and at the same time the knot is tightened.

The essence also lies in the fact that the device for performing endosurgical flashing and ligation has an elongated tubular body with the ability to pass through the endosurgical trocar, branches of the device with a needle and thread fixation mechanism on the working end of the device with the ability to control this mechanism through the device’s drive on the other end of the tubular corps. Unlike the closest analogue in the device for the method of O.B. Ospanov, the branches are made in the form of branches of the needle holder with the possibility of longitudinal and transverse fixation of the needle with thread, and the mechanism of delivery and pushing of the thread assembly is made outside the needle holder.

The given set of features provides a technical result in all cases to which the requested amount of legal protection applies.

Signs characterizing the invention in particular cases and specific forms of execution are given below. Such signs are: the implementation of the mechanism of delivery and pushing of the thread unit in the form of at least two cylinders included in each other with the possibility of their longitudinal movement towards the working part; the implementation in the outer cylinder of at least two opposite slots for immersion and refueling the thread unit; the implementation of the working part in the form of three branches of the needle holder with the possibility of separate fixation of the two ends of the threads; the implementation of the jaw of the device in the form of two branches of the needle holder and the needle fixed to the tool with the possibility of its alternate translation from the open working position to the closed transport position, the execution on the branches of the needle holder sharp edges as scissors.

The causal relationship of most of the listed features with the aforementioned technical result is shown by their functional characteristics. We can only add that the surgeon’s original mechanism for fixing the needle with thread, made in the form of a jaw holder jaw, adapted not only for transverse, but also for longitudinal fixation of the working needle with thread, greatly facilitates the work of the surgeon. At the same time, the external placement of the delivery and pushing mechanism of the thread unit allows you to perform almost any complex unit before the instrument is inserted into the abdominal cavity. Thus, the device of O. Ospanov allows extracorporeal execution of the most difficult and accurate stage of the operation - reliable tying of the complex unit that is performed before the stage intracorporeal flashing or ligation of tissues. The process is completed by pulling an atraumatic needle through a pre-formed node and tightening the node by further simple tensioning the needle with thread.

The invention is illustrated by drawings, where Fig. 1 shows the working part of a tool of O.B. Ospanov for laparoscopic stitching and ligation with an atraumatic needle and thread with an extracorporeal modified Roeder assembly (side view), in Fig. 2. Shows when the Roeder assembly is submerged inside the tool. Figure 3 shows the transport position of the working part of the instrument for its introduction into the abdominal cavity through a trocar (side view). Figure 4 shows the position of the needle and the Roeder assembly in the instrument of O.B. Ospanov before endosurgical stitching and ligation. Figure 5 shows the longitudinal grip of the needle with thread after flashing them with fabrics and the completion of the stage of pushing the node. Figure 6 shows the tightening of the Roeder node while further pulling on the needle with thread.

The proposed method of O.B. Ospanov endosurgical flashing and ligation is implemented as follows.

The atraumatic needle with a thread is extracorporeally fixed on the working part of the endosurgical instrument and the Roeder knot modified by us is performed on this instrument so that the needle-free end of the thread creates all the loops of the knot around the tubular body of the instrument, which, by analogy with the usual method, would temporarily replace the ends another leading fixed thread around which the driven lead thread is rotated with the usual method of tying the Roeder knot [p. 100, Fedorov I.V., Zyatdinov K.Sh., Sigal E.I. Surgical laparoscopy, Triad-X, 2004, 464 p.].

After the site has been completed, the endosurgical instrument is inserted through the laparoscopic trocar into the abdominal cavity, where, under video surveillance, the connected tissues are intracorporeally stitched with a needle and the needle and thread are intercepted along the length of the needle at the puncture point. Pulling the needle, stretch the end of the thread that has passed through the stitched fabrics. In this process, at this end of the thread in the form of a conductor, the formed Roeder assembly is displaced from the tool to the stitched fabric and at the same time the assembly is tightened.

The device of O.B. Ospanova for endosurgical flashing and ligation in the working part (Fig. 1) contains an outer tube 1 with two lateral longitudinal slots 2, a needle holder 3. Between the outer tube 1 and the needle holder 3 there is a knotter 4. Between the branches 5 of the needle holder 3 the needle 6 is located with an atraumatic type of thread attachment 7. The drive of the device of O.B. Ospanov for endosurgical stitching and ligation is not shown in the figures.

Work device O. B. Ospanova for endosurgical flashing and ligation as follows (Fig.1).

On the site of the needle holder 3 between its branches 5 and the edge of the outer tube 1, using the free end of the thread 7, we perform the Roeder 8 assembly modified by us. Place (in FIG. 2) both ends of the thread 7 in the side slots 2 and immerse the assembly 8 inside the tool to the end knot pusher 4. Then (in FIG. 3) the ends of the thread 7 are placed inside the instrument and the outer tube 1 is moved towards the working part until the needle 6 with the thread 7 in the outer tube 1 is fully inserted. In this transport position, the instrument is inserted through the laparoscopic trocar into the abdominal cavity (in Fig. not p seemed) wherein (in Figure 4) is returned to the starting position the outer tube 1, the exposed needle 6 attached thereto is sewn part 7. yarn (of Figure 5) connects the fabric 9 and the capture needle 6 along its length. Then, the assembly 8 is displaced outward with the help of the pusher assembly 4 towards the branch 5 of the needle holder 3 and the needle 6 is pulled together with the thread 7 through the Roeder 8. In this case (in FIG. 6), the assembly 8 slides off the needle holder 3, then from the needle 6 and further, as in a conductor, it drops along this end of the thread 7, which has passed through the stitched fabrics, to the stitching point, while simultaneously tightening the Roeder 8 assembly.

Claims (1)

A method of endosurgical stitching and ligation, including the use of a device for endosurgical stitching of tissues, containing a tubular body with the ability to pass through a trocar, a branch of the device with a mechanism for fixing the needle with thread on the working end, the drive of the control mechanism at the end of the device, fixing extracorporeal suture material in the device, introduction devices through a trocar into the workspace, flashing fabrics with the formation of a Roeder node, characterized in that after the puncture, the needles fix the needles in the needle holder along its length, the assembly is shifted to the side of the needle holder jaw, the needle and thread are pulled through the Roeder assembly and tightened.

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