RU2334476C1 - Method of spleen resection - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: haemostasis is performed by ligation of second-order arteries and circle ligation of spleen placing ligating means near and more proximally than planned line of resection. Affected section is ligated. Circle ligation of spleen is performed by applying compression clip as a ligating means. Clip is made from titanium nickelide with effect of form memory and superelasticity. Clip is made from two linear parallel closed branches connected to each other on ends. Clip is fixed to traction thread with its distal end. Loose end of thread is passed outside through opening of drainage tube. Drainage of left hypochondrium is performed. Wound is sutured. Clip is removed in 8-10 days after operation by thread traction.

EFFECT: reduction of labour intensiveness and operation duration time and ensuring permanency of compression.

6 dwg

Description

The invention relates to medicine.

An unpaired organ - the spleen - performs numerous vital functions in the immune, circulatory and lymphatic systems. The loss of this organ leads to a serious disorder of homeostasis and severe consequences for the life of the whole organism. Therefore, in case of traumatic injuries of the spleen requiring urgent surgical intervention, the priority of surgery tactics with the goal of organ conservation is the first and difficult decision to make. The forced restraint of surgeons when choosing gentle methods of operation is due to their relative technical imperfection, to date, and a high risk of postoperative complications. Therefore, organ-sparing surgery on the spleen is performed only in exceptional cases. According to emergency conditions, they prefer splenectomy - complete removal of the organ.

The relevance of the task is conducive to scientific research of the spleen, and on their basis, to the improvement of resection methods - partial removal of this, which in history was called the “mysterious organ”.

One of the most responsible operations of the operation, which determines the entire process and the modes of its individual components, is hemostasis - stopping bleeding. It is carried out at two levels: blood vessels are ligated, and various hemostatic measures are applied in the area of the intervention itself. Known pneumo - and electrocoagulation, infrared, laser, plasma and radio frequency coagulation. Such an abundance of technical equipment does not remove the task of improving them, since they have inherent disadvantages that complicate curability. The use of these funds increases the temperature of the spleen tissue, leading to additional trauma to the parenchyma. The equipment used is complicated and expensive.

Cheaper methods of hemostasis are known - with the help of adhesive compositions, the disadvantages of which are the need to create a dry surface for the adhesive to harden, which in itself is a task. Adhesive aggressiveness to tissues leads to inflammatory reactions and unreliability of hemostasis [M.V. Timerbulatov, A.G. Khasanov, PPFayazov, F.A. Kayumov "Organ-sparing and minimally invasive spleen surgery" M., MED - press-inform ", 2004 g., p. 74].

Avoiding these drawbacks, circular ligation of the spleen is used for hemostasis, i.e. clamping around the entire perimeter of the organ near the proposed resection to the degree of compression, ensuring the closure of the lumen of the blood vessels of the parenchyma.

A known method of resection of the spleen ["Organ-saving surgery of the spleen", ed. EGGrigoryeva, K.A. Apartsina, Novosibirsk, “Science”, 2001, p.288-290], adopted by the greatest similarity as the prototype of the invention. The method developed by the inventors [US Pat. RF №2113177] for a planar section that does not take into account the segmental structure of the organ. Such an operation is more invasive than segmental, and requires more care when stopping bleeding.

The method includes hemostasis, directly resection of the damaged area and the final steps of the operation - draining the surgical field and suturing the wound. Hemostasis is carried out at two levels: stopping arterial bleeding by ligation and intersection of second-order vessels supplying cut-off segments, and circular ligation of the spleen along a line 0.7-1 cm apart proximal to the projected line of the resection plane. The necessary compression that stops parenchymal bleeding is created by tightening the circular ligature. After resection, the resulting section is covered with a strand of a large omentum, which is fixed to the plane of the section, and the edges are brought to the surface of the stump and additionally fixed for a circular ligature. Thus, due to the subsequent adhesive peritonization, an additional safety hemostasis is performed.

The key point of circular ligation is the creation of such a compression, in which the circulation of blood in the trabecular and segmental vessels falling into the plane of the section would cease, and the spleen capsule would not be damaged. Since ligation is carried out before resection, there is no visual control of the necessary compression and the intuition and skill of the surgeon remain a subjective test. Such testing is unreliable and constitutes a significant disadvantage of the method.

Ligature does not provide a constant compression, like a fibrous material, it gets wet and stretches.

The danger of slipping the squeezing ligature from the spleen tissue and the resumption of bleeding is great. To create a more reliable proaptic ligature bed, the resection plane is removed from it by a distance of 1 cm, leaving a large volume of necrotic tissue. The desire to minimize the risk of renewed bleeding increases the surgeon’s labor, time of operation and nervous tension.

These and other, smaller, disadvantages reduce the viability of the operation and detract from the merits of the prototype method.

The technical result of the invention is to reduce the complexity and time of the operation, increase its viability.

The specified technical result is achieved by the fact that in the method of resection of the spleen, including hemostasis by ligation of arteries of the second order and circular ligation of the spleen with the location of the ligation agent near and proximal to the intended line of resection of the damaged area, drainage of the left hypochondrium and suturing of the wound, circular ligation of the spleen is carried out by applying as a ligation means of a compression clip made of titanium nickelide with a shape memory effect and superelasticity made in the form of two lines s parallel, of closed, interconnected at the ends of jaws attached to the distal end of the traction thread the free end of which is carried out through the lumen of the drainage tube. 8-10 days after surgery, the clip is removed by traction per thread.

The attainability of the technical result is due to the whole set of interrelated essential features, the determining one of which is the use of a compression clip made of titanium nickelide as a ligation agent for hemostasis. The clip (figure 1) contains two branches 1, usually wire, linear, parallel, closed (in the cold state) along the entire length and connected to each other at the ends 2. The principle of operation of the clip, with respect to circular ligation of the spleen, is next.

Cooled, for example, with chloroethyl or cold ice, the clip is activated by pushing branches 1 to the lumen containing the spleen (Figs. 2, 3). Installed in place of ligation 4 (Fig. 4), the clip is heated by organ heat and, under the influence of thermomechanical restoration of its original, closed, shape (shape memory effect), slowly - for tens of seconds - and steadily compresses tissues (Fig. 5). The specified movement of the clip continues until the alignment of the forces of action of the clip and the reaction of the tissue. In a correctly calculated clip, by this time, the temperature of the material, tending to the patient’s body temperature, passes the temperature region of the phase transition, thermal deformation is completed and parenchymal hemostasis should be optimally completed with it.

Thus, the care and care for optimal organ clamping is removed from the surgeon and entrusted to the objective mechanism of the ligation agent itself. At the same time, the duration of ligation and, as a consequence, the time of the entire operation are reduced by several times.

In the future, after the operation is completed (Fig.6), the action of the clip continues with pressure on the prolated tissue with an effort of superelastic strain. Gentle but steady pressure on the tissue leads to atrophy and necrotization of the area under the clip, scarring of tissue near and proximal to this zone. The clip along with the stump section 6 is separated from the organ. Tied to the traction thread 7, it has the ability to freely and atraumatically be removed outside through the standard drainage tube 8. In this operation, the necrotic section of the stump 6 is resorbed by the body. Since a certain energy resource is spent on this recycling process, it is desirable to minimize the amount of necrotic tissue. The superelastic material of the clip allows this to be done, since the unremitting pressure of the clip reliably forms a prolapsed bed, eliminates the possibility of slipping even when the length and, consequently, the volume of the necrotic area are reduced.

Removing clips from the body as a foreign body also constitutes an advantage over the prototype method, where the ligation material remains in the wound, and the body must take measures to encapsulate it in the long term.

After the clip is rejected, the surface of the parenchyma exposed by the resection is completely covered by its own spleen membranes - fibrous and serous. Compared with the prototype method, where the said surface is covered with a composite of the peritoneum and connective tissue, as a backup option for the restitution of the membrane, such a shelter for the body is more energetically beneficial, reliable, and therefore increases the viability of the operation and shortens the rehabilitation period of the patient.

For the specialization of the surgeon, the specified operation of the proposed method requires minimal measures. From this point of view, and in relation to the technological readiness of the clip, the proposed method meets the criterion of "industrial applicability".

The combination of essential features unknown to the specialist indicates that the proposal meets the criterion of "inventive step".

The illustrations show:

Figure 1. Compression clip for circular ligation of the spleen, 1 - jaws, 2 - junction junction.

Figure 2. Activated clip.

Figure 3. The working moment of activating the clip.

Figure 4. The working moment of the operation, 4 - the intended line of resection, 5 - ligation vessel.

Figure 5. The working moment of the operation.

6. The working moment of the operation, 6 - stump, 7 - traction thread, 8 - drainage tube.

The efficiency of the method and the achievement of the technical result are proved experimentally by a series of operations - on 15 sexually mature males of a laboratory rat, each weighing up to 250 g. An experiment using the method was carried out as follows.

Under ether anesthesia, the surgical field is treated with iodine and alcohol. Performed median laparotomy. The spleen is visualized, which has an elongated shape with dimensions of 30 × 11 × 5 mm and a loose type of gate structure. With the help of pointed scissors, a cut wound was inflicted with damage to the segmental vessels and parenchyma. At the same time, profuse arterial and moderate parenchymal bleeding was observed from the incision site. Arterial bleeding from segmental vessels is stopped by clamping followed by ligation. To stop parenchymal bleeding, a compression clip (Fig. 1) made of nickel-titanium wire with a diameter of 1.0 mm was used. The length of the clip in the cold state is 25 mm. One end 2 of the clip is formed by bending the wire, the second 2 - by twisting it (figure 1). A traction thread 7 (FIG. 6) is attached to the second end by holding it between the branches and double addition. The thread is made of nickel-titanium wire with a thickness of 100 μm. After cooling the clip to a temperature of 0 ° C, its branches are diluted to the formation of a lumen containing the spleen (figure 2, 3). In the activated state, the clip is immediately applied to the spleen 0.5 cm proximal to the proposed section line 4 (Fig. 4), with the orientation of one branch along its diaphragmatic, the second along the visceral surface (Fig. 5). After 60 s, when the return of the clip to its original form is completed and, therefore, hemostasis is performed, a resection of the damaged part of the organ is performed (Fig.6). Moreover, in all 15 episodes of the experiment, bleeding along the resection plane was not observed.

The free end of the traction thread 7 is threaded through the drainage pipe 8, brought to the surface of the aponeurosis and fixed to the mesh implant made of nickel-titanium wire. The latter is used to shelter the traction thread and protect the device from premature removal by the rat itself, which in its behavior is prone to such actions.

After visual inspection for hemostasis and foreign bodies, the wound with the drainage tube placed in it is sutured in layers.

The rejection of devices in animals occurred on the 8-10th day, and then they were removed by traction for the thread under the control of ultrasound.

The results of the experiment are purely positive. No animals died due to complications associated with the operation. In the early and late periods after surgery, their condition is satisfactory, their activity is high, and their appetite is good. X-ray and ultrasound examination, repeated laparotomy showed no signs of intra-abdominal bleeding. The resection edge of the spleen is even, hermetically closed. The results obtained indicate the efficiency of the method, and the timing of the operation and the subjective experience of the surgeon indicate high efficiency, interest and desire for clinical use.

Claims (1)

A method for resection of the spleen, including hemostasis by ligation of second-order arteries and circular ligation of the spleen with a ligation agent located close to and proximal to the intended resection line, resection of the damaged area, drainage of the left hypochondrium, wound closure, characterized in that the circular ligation of the spleen is performed by applying compression as a ligation agent clips made of titanium nickelide with the effect of shape memory and superelasticity, made in the form of two linear, parallel, closed x, connected to each other at the ends of jaws attached to the distal end of the traction thread the free end of which is carried out through the lumen of the drainage tube, removing clips produce 8-10 days after the operation for the traction of the thread.

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