RU2334470C2 - Method of radial hepatotomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves performing radial hepatotomy - 14 with access to source of bleeding in liver parenchema - 1 without liver resection after section by sharp method (scalpel) of liver capsula from wound - 2 towards liver gate - 9 taking into account segmented structure of liver. After that, liver parenchema is bluntly separated from liver edge towards wound - 2 and liver gate - 9 parallel to large tubular structures (blood vessels - 3, bile ducts - 4), with presence in wound - 2 of large unaffected tubular structures the latter are not crossed and ligated. With inefficiency of haemostasis electrocoagulation is used, Tachocomb plate or sewing - 10 parts of liver parenchema - 1. Then visual revision of wound canal - 2 is carried out, with further detection of source of bleeding or bilorrhea or both, after which final surgical haemostasis is performed by means of suturing - 11 of wounds of large arteries, veins - 3 or by means of ligating - 15 affected subsegmental blood vessels - 3, subsegmental bile ducts - 4, after which suturing of liver wound is performed.

EFFECT: increased reliability of operation in case of deep liver injuries.

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Description

The invention relates to medicine and can be used in emergency abdominal surgery.

Currently, three types of operations are used for deep wounds of the liver: the first is suturing of the liver wound using sutures that are applied through the glisson capsule (liver capsule) with or without the omentum, round ligament of the liver, the second method is a tight tamponade of the liver wound with an omentum with subsequent fixation, the third method is liver resection. However, taking into account the anatomical features of the structure of the liver (peculiarities of blood supply, architectonics of the liver parenchyma, the presence of nearby non-decaying blood vessels, bile ducts), topographic features, the problem of final hemostasis in deep wounds of the liver has not been solved.

There is a method of hemostasis of liver wounds using various types of sutures; to prevent eruption of the liver parenchyma, a round ligament of the liver or a lock of omentum is used as a gasket [1], but these methods have several disadvantages: frequent eruption of the liver parenchyma in the suture zone leads to additional trauma to the liver tissue , a small depth of liver stitching leads to the formation of a closed cavity in the liver parenchyma, when stitching large vascular structures, there is a high risk of ischemicisation of the liver parenchyma, the inability to visualize the source of bleeding and, as a consequence, the inability to perform the methods of final surgical hemostasis (vascular suture of the main arteries, ligation of blood vessels). With this method, the percentage of repeated operations and complications remains rather large, the cause of which is more often the formation inside the hepatic hematoma, ongoing bleeding. There is a method of tight tamponade of a liver wound with an omentum, which is corrugated with a ligature, is carried out through the bottom of the wound through the entire thickness of the liver, the ligature is removed to the lower surface of the liver, a tight wound tamponade is reached with an omentum, and the ligature is fixed to tissues of the posterior wall of the abdominal cavity [2], but this method has disadvantages: limited use (determined by the location of the wound, the length of the blood supply strand of the omentum), the inability to visualize the source of bleeding and, as a consequence, the inability to perform eye procedures definitively surgical hemostasis, so when this method is large enough percentage of reoperations and complications, which often is the cause of the formation of intrahepatic hematoma, bleeding continued. The method of liver hemostasis is used after performing atypical liver resection by means of catgut threads along the wound diagonal followed by capture of the upper corner of the wound, the lower corner of the wound [3], the disadvantages of this type of operation are the great trauma (the viable part of the organ is resected), the complexity of the operations ( which requires high qualification of the operating surgeon). This leads to an increase in the time of surgery, the amount of blood loss, which makes the prognosis of the patient's life more difficult.

The prototype of the claimed invention is a liver resection method according to the Ton-That-Tung method: without taking into account the segmental structure of the liver, after dissection of the glisson capsule and superficial layers of the parenchyma, the latter in its deeper sections is not cut, but separated by a finger (digitoclasia) [4]. Surgeons determine the location of large vessels by the resistance of the parenchyma to separation. Having felt a large vessel or bile duct, a ligature is brought under it, bandaged and crossed. The positive of this method is a clear visualization of the tubular structures located in the wound, the source of bleeding, which allows you to perform reliable final surgical hemostasis (figure 3, figure 4). The disadvantages of this method of operation are unreasonably high trauma, the complexity of the operations (which requires highly qualified operating surgeon). This leads to an increase in the time of surgery, the amount of blood loss, which makes the prognosis of the patient's life more difficult.

The objective of the present invention is to increase the reliability of surgery for deep wounds of the liver.

The object of the invention is carried out by radial hepatotomy due to access to a source of bleeding in the liver parenchyma without liver resection - after cutting the capsule of the liver from the wound towards the portal of the liver with an acute route, the liver parenchyma is bluntly divided towards the wound and portal of the liver parallel to large tubular structures, the presence of large intact tubular structures in the wound, the latter do not cross and do not bandage; if hemostasis is unsuccessful, electrocoagulation, a tachocomb plate, or stitching of the liver parenchyma, then make a visual audit of the wound canal with subsequent identification of the source of bleeding and / or bile leakage, make final surgical hemostasis by suturing the wounds of large arteries and veins or by ligation of damaged subsegmental blood vessels and bile ducts, after which the wound is sutured the liver.

The invention is illustrated by drawings, in which Fig. 1 shows a liver in a frontal projection, divided into segments, a hatched area shows a zone, in wounds in the projection of which a dissection of the liver parenchyma in the radial direction is shown; figure 2 shows the stage of the operation - a temporary stop of bleeding from a wound of the liver using finger clamping of the hepatoduodenal ligament; figure 3 shows the area of hepatotomy; figure 4 shows the zone of hepatotomy after flashing the liver parenchyma with ligated subsegmental blood vessels, bile ducts; figure 5 shows the liver in the frontal projection, divided into segments, the shaded area is shown, with wounds in the projection of which shows a section of the liver parenchyma in the direction of the portal of the liver; figure 6 shows the liver in the frontal projection, the shaded area of the radial hepatotomy in the direction of the gate of the liver; figure 7 shows the liver, a bottom view, the shaded area of the radial hepatotomy in the direction of the gate of the liver; on Fig shows the zone of radial hepatotomy in the direction of the gate of the liver, taking into account the segmental structure; figure 9 shows the ligation of subsegmental blood vessels in the area of hepatotomy; figure 10 shows the flashing of the liver parenchyma; figure 11 shows the closure of a large artery; 12 shows suturing of a liver wound using a round liver ligament.

The method is as follows: preoperative preparation of the patient for surgical intervention is carried out in an emergency operating room - against the background of anti-shock measures carried out by a team of anesthetists-resuscitators. After the patient is introduced into anesthesia by the anesthesiologist, the surgeon performs the processing of the surgical field, then the primary surgical treatment of the wound is performed, the nature of the wound penetrating into the abdominal cavity is determined. Perform laparotomy, revision of the abdominal cavity, determine the nature of the damage. If there is blood in the abdominal cavity, the latter is reinfused if there is no combined damage to the hollow organs and in the absence of hemolysis. Next, determine the source of bleeding. In the presence of a liver wound - 1 visually (with injuries of the posterior surface of the liver - by palpation) determine the localization, the nature of the wound - 2, the size of the wound on the surface of the liver - 1. By introducing into the wound of the liver - 2 instruments (metal probes, direct clamps) find out the direction , the depth of the wound channel, the probability of damage to large anatomical structures (vessels - 3, bile ducts - 4, gall bladder - 5). If there are shallow wounds or wounds close to the edge of the liver without marked bleeding, the wound is sutured with interrupted sutures or tampon with a lock of omentum (more often with through wounds). In case of deep wounds of the liver - 2 in the IV, V, VII, VIII segments of the liver (Fig. 5) with intensive (frequent-jet) bleeding in the absence of necrosis of the liver parenchyma, temporary hemostasis is performed - the hepatic-duodenal ligament is squeezed by the thumb and index finger of the left hand inserted into the Vinsloid opening - 6 (Fig. 2). The effectiveness of clamping is evaluated by reducing the intensity of bleeding. Determine the possibility and direction of hepatotomy - 14. Acute way dissect the capsule of the liver towards the wound - 2 and the portal of the liver - 9 (Fig.6, Fig.7). The resulting bleeding is insignificant and stops either on its own or using electrocoagulation. Next, the liver parenchyma - 1 is bluntly divided (dissection zone - 14) towards the wound - 2 and the portal of the liver, taking into account the segmental type of blood supply - parallel to large tubular structures (blood vessels - 3, bile ducts - 4) (Fig. 8). Use finger crushing with sequential ligation of 13 subsegmental arteries and veins - 3 (Fig. 9). In the presence of large intact tubular structures in the wound, the latter do not cross and do not bandage. If hemostasis is inconsistent, electrocoagulation is used, a tachocomb plate or flashing of liver parenchyma sections with 1 nodal or continuous sutures - 10 (Fig. 10). With the massiveness of the crossed liver parenchyma - 1 crushing of the latter is carried out fractionally, in separate portions. At each stage, the viability of hemostasis is assessed, if possible, the clamping of the hepatoduodenal ligament - 6 is weakened, thereby increasing blood flow in the area of the operation, identifying sources of bleeding are ligated - 13. Next, a visual audit of the wound canal - 2 is performed to identify the source of bleeding, bile duct. At a partial intersection of a large arterial trunk - 3, an artery suture is performed using atraumatic suture material - 11. At a complete intersection of blood vessels - 3, vessels are ligated - 13. Damaged bile ducts are ligated - 15 (Fig. 11). After this, the viability of hemostasis is assessed, the hepatoduodenal ligament - 6 is no longer pinched until the end of the operation. Next, the liver wound is sutured - 2. Apply Z-shaped or continuous stitching sutures - 10, use atraumatic suture material - 10. To prevent eruption of sutures - 10 use a mobilized round ligament of the liver - 8 or a lock of stuffing box through which stitches are made - 10 ( Fig. 12). Repeated revision of the abdominal cavity. If damage to other organs is detected, they are sutured. Then the abdominal cavity is sanitized with antiseptic solutions, the abdominal cavity is drained through an incision in the right hypochondrium - to the wound suturing area with glove-gauze, tubular drains for optimal outflow of wound exudate, control of hemostasis in the postoperative period. The abdominal cavity is sutured in layers.

An example of a specific implementation:

1. Patient O., age 40, medical history No. 15089, was received on 08/14/04 due to a thoracoabdominal wound, intraperitoneal bleeding. The operation revealed a wound along the diaphragmatic surface of the liver at the border of 4 and 8 segments with intense bleeding. The depth of the wound channel in the liver is 7 cm. The wound of the liver was sutured with plugging the wound with an omentum. Hemostasis achieved. In the postoperative period, an intrahepatic hematoma formed. On the 10th day there was a breakthrough of the hematoma into the free abdominal cavity. The patient was reoperated on an emergency basis - a thoracophrenolaparotomy, hepatotomy according to the proposed method, hematoma revision, suturing of the wound of the left hepatic artery, drainage of the hematoma cavity, abdominal cavity were performed. The postoperative period without complications. Recovery.

2. Patient C, 31 years old, medical history No. 1037. Received January 14, 2006 with a thoraco-abdominal stab wound to the right, a wound to the right lobe of the liver, and a clinic of hemorrhagic shock. The operation has a wound along the diaphragmatic surface of 4 segments of the liver with intense arterial bleeding. A hepatotomy was performed according to the technique, bleeding from the arterial trunk up to 3 mm in diameter in the depth of the wound was detected. Ligation of the vessel, the wound of the liver is sutured with an upholstery stitch with plugging with a round ligament of the liver. The postoperative period without complications. Recovery.

Information sources

1. Dederer Yu.M., N.P. Krylova. Atlas of liver operations. Moscow, Medicine. 1975, p. 26.

2. RF patent for the invention No. 2155002 MKI A61B 17/12. "A method for suturing extensive liver damage in patients with combined trauma."

3. RF patent for the invention No. 2007133 MKI A61B 17/04 "Method for suturing of crushed and scalped liver wounds."

4. V.A. Vishnevsky, V.A. Kubyshkin, A.V. Zhao, R.Z. Ikramov Liver operations. Moscow: “Miklosh”, 2003, p. 114.

Claims (1)

The method of hemostasis for deep wounds of the liver, including dissection of the liver parenchyma along the large tubular structures for the implementation of the final hemostasis, characterized in that the source of bleeding in the liver parenchyma is accessed without resection of the liver - after cutting the capsule of the liver from the wound in the direction of the liver gate, Further, the liver parenchyma is bluntly separated from the edge of the liver towards the wound and portal of the liver parallel to the large tubular structures, in the presence of large intact tubular structures in the wound the ice ones do not cross and do not bandage, if hemostasis is inconsistent, use electrocoagulation, a tachocomb plate or stitching of the liver parenchyma sections, then make a visual inspection of the wound channel with subsequent identification of the source of bleeding and / or bile leakage, make final surgical hemostasis by suturing the wounds of large arteries and veins or due to ligation of damaged subsegmental blood vessels and bile ducts, after which liver wounds are sutured.

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