RU2336844C1 - Method for surgical approach to abdominal cavity - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: circular periomphalic cut of skin and hypoderm is made. The hypoderm is separated from muscle fascia of the frontal abdominal wall. The hypoderm is separated by anchors. Obtained "surgical window" Is displaced to the interest side on the white line or to the pararectal zone or to the hypochondrium. The fascia is incised. The approach is broadened using retractors with lighting. Endoscopic instruments are inserted in the abdominal cavity under video assisted control. Necessary surgical operations are performed. The "surgical window" is returned to the omphalus zone. Skin integrity is recovered by a single circular suture. The method provides surgical adequate monoapproach to any anatomical zone of the abdominal cavity with minimal outer trauma of the frontal abdominal wall, allows reduction of the operation trauma, provides the opportunity to avoid gas laparotomy that is especially important in surgery of the debilitated patients with cancer, as well as the patients with cardiovascular pathologies and fatty patients.

EFFECT: reduction of operation trauma during approach to abdominal cavity.

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Description

The invention relates to medicine, namely to abdominal surgery. The invention can be used in operations on the abdominal cavity, in particular for the formation of visceral grafts in cancer patients.

A known method of preparing a patient for laparoscopic intervention, including creating an auxiliary space in the abdominal cavity between the internal organs and the abdominal wall, introducing a retractor into the auxiliary space of the abdominal cavity through a puncture, creating an operative space in the abdominal cavity of an appropriate volume and shape by stretching the abdominal wall, fixing the retractor in tool holder for maintaining operating space (RF patent No. 2283037). The known method involves the formation in the abdominal cavity of the operative space of the required volume and shape using a specially designed device due to mechanical stretching of the abdominal wall. Obviously, subsequent surgical actions should be carried out in accordance with the generally accepted laparoscopic intervention technique. Thus, the known method does not detract from the disadvantages inherent in the laparoscopic method of access to the organs of the abdominal cavity (multiple punctures of the abdominal wall, filling with gas of the abdominal cavity). Developed by the authors of the known invention, the method of mechanical stretching of the abdominal wall with high probability can lead to additional injury to the patient and increase the duration of the operation. In addition, the use of this method in clinical practice requires unique equipment and special staff training.

The closest to the claimed invention in terms of features is a laparoscopic method of access to the abdominal organs (Fedorov I.V., Zyatdinov K.Sh., Sigal E.I. Operational laparoscopy. M., 2004). The known method consists in the fact that in 3-4 places of the anterior abdominal wall produce punctures through which the ports are installed. Next, the abdominal cavity is filled with gas. Under video endoscopic control using laparoscopic instruments, intracorporeal surgical procedures are performed on the abdominal organs. To extract the removed tissue produce additional minilaparotomy. The method adopted for the prototype.

The main disadvantage of the prototype method is the need to fill the abdominal cavity with gas, which is accompanied by an increase in intraperitoneal pressure. The consequence of increased intraperitoneal pressure is the microvascular barotrauma. This circumstance is decisive during the operations of the formation of visceral grafts, since it leads to a violation of microcirculation in the blood vessels of the graft. In addition, the known method cannot be used in abdominal surgery of patients with concomitant cardiovascular pathology, and for obese patients.

The claimed invention is aimed at solving the problem of providing operational minimally invasive access to the abdominal organs for the implementation of minilaparotomy.

Using in clinical practice the proposed method allows to achieve several technical (medical) and economic results:

- adequate mono-access to any anatomical region of the abdominal cavity with minimal external trauma to the anterior abdominal wall;

- reduction of operational injury;

- the ability to avoid gas laparotomy, which is especially important during surgical operations in weakened cancer patients, as well as for patients with cardiovascular pathologies, for obese patients;

- sparing attitude to transplanted tissues during operations of forming visceral grafts with the possibility of manual palpation;

- relief of the postoperative period;

- reduction of treatment time.

The indicated technical (therapeutic) results during the implementation of the invention are achieved due to the fact that the minilaparotomic access is carried out by means of a circular umbilical incision of the skin and subcutaneous tissue, the cellulose is widely separated from the aponeurosis of the muscles of the anterior abdominal wall, the subcutaneous tissue is diluted with hooks and the formed “surgical window” is moved to the zone interest in the white line of the abdomen or in the pararectal region, or in the hypochondrium, minilaparotomy is performed by dissection of the aponeurosis, expand access with schyu retractor with illumination is introduced into the abdominal cavity under the control of video-endoscopic instruments, carry out operational activities to the extent necessary, return the "surgical window" on the navel and restore the integrity of the skin only a circular seam.

In a particular case, minilaparotomy is performed by dissecting the aponeurosis in the midline in the direction from the umbilical ring upward for 5-7 cm, followed by bordering the umbilical ring on the left and extending the laparotomic access downward by 5-7 cm.

The invention consists in the following.

The use of natural increased elasticity of the tissues of the anterior abdominal wall allows you to shift the inlet to any anatomical region in the region of the anterior abdominal wall with subsequent penetration into the abdominal cavity through a single "surgical window" and the necessary surgical operations in the abdominal cavity - resection of the stomach, resection of the small and large intestine , an extended biopsy, etc., with the subsequent return of the "surgical window" to the navel. The wound of the anterior abdominal wall is sutured in layers tightly with a cosmetic suture on the dissected skin of the umbilical region. Restoring skin integrity is carried out by a single circular suture. The use of the proposed method in clinical practice is especially important in the formation of visceral grafts in cancer patients.

The inventive method is developed in MNII them. P.A. Herzen was used in the clinic for the treatment and rehabilitation of 23 cancer patients. Of these, 14 tumors had craniofacial localization and 9 tumors had an oropharyngeal zone. In all patients, the formation of flaps was made in accordance with the claimed method through minimally invasive minilaparotomic access in the anterior abdominal wall. It was formed and prepared for autotransplantation of 15 omental flaps, 3 gastro-omental flaps and 5 colonic-omental flaps. All patients underwent microsurgical plastic surgery of extensive defects of the head and neck with visceral autografts. In the postoperative period, complications from the abdominal organs were not noted. All patients expressed a good cosmetic result of surgical intervention in the abdominal cavity. Reduced hospital stay for laparotomy. The consumption of dressings and pain medication has been reduced.

The invention is as follows.

Make a circular umbilical incision of the skin and subcutaneous tissue (1) (Figure 1). Subcutaneous tissue is widely separated from aponeurosis of the muscles of the anterior abdominal wall and is bred with hooks. This creates a mobile window, which is shifted to the zone of interest in the white line of the abdomen, pararectal region or in the hypochondrium. For example, minilaparotomy is performed by dissecting the aponeurosis in the midline in the direction from the umbilical ring upward for 5-7 cm, followed by bordering the umbilical ring on the left and extending the laparotomy access downward by 5-7 cm.

Examples of options for entering the abdominal cavity through a surgical window are presented in Figure 2:

- surgical window (1);

- section according to Kocher (2);

- upper median laparatomy (3);

- pararectal incision on the right (4);

- pararectal incision on the left (5);

- transverse ventilation (6).

The edges of the laparotomy wound are bred using retractors with illuminators. A video camera and endoscopic instruments are inserted into the abdominal cavity through the formed surgical window, which provides access to the organs of the upper, middle and lower floors of the abdominal cavity (Figure 3). Under video endoscopic control, an abdominal cavity is revised. Then, if necessary, adhesions in the abdominal cavity are dissected.

In the case of the formation of visceral grafts in cancer patients, donor organs (omentum, greater curvature of the stomach, transverse colon) are removed through the minilaparotomic opening to the anterior abdominal wall. After the formation and clipping of the transplant, organ anastomoses are extracorporeally formed. The abdominal cavity is drained. The anterior abdominal wall is sutured in layers tightly with an atraumatic suture applied to the skin. Next, the visceral transplant is revascularized and the reconstructive stage of the operation is performed.

Clinical example.

Patient X., 29 years old, case history OA-3600 with a diagnosis of stage II T2NoMo cancer of the tongue, condition after preoperative radiation therapy in 2004

From the anamnesis: during examination at the Moscow P.A. Herzen in 08/22/04 was diagnosed with cancer of the right half of the tongue. At the first stage of the combined treatment, chemoradiotherapy with 5-FU and platinum SOD-22 Gy was performed. The second stage of the combined treatment on September 29, 2004, performed the operation: hemiglosectomy on the right with submandibular lymphadenectomy on the right, microsurgical plastic surgery of the colonic-omental flap.

By transoral access, a resection of the right half of the tongue with a resection of the mucosa of the bottom of the oral cavity on the right was performed. A skin incision was made in the right submandibular region. The submandibular salivary gland with the adjacent submandibular and chin fiber was isolated and removed. The facial artery and vein on the right were isolated and prepared for anastomosis. Next, a circular paraumbilical skin incision was made. Subcutaneous tissue is separated from aponeurosis of the muscles of the anterior abdominal wall. A surgical window has been formed, which is moved to the white line of the abdomen. Minilaparotomy was performed by dissecting the aponeurosis in the midline in the direction from the umbilical ring upward for 6 cm, followed by bordering the umbilical ring on the left and extending the laparotomy access down by 6 cm. The edges of the laparotomy wound were diluted with retractors with illuminators. A chamber and endoscopic instruments were introduced into the abdominal cavity through a minilaparotomic access. Under video endoscopic control, the abdominal cavity was revised - no pathology was detected. The transverse colon and omentum are brought to the anterior abdominal wall through the minilaparotomy opening. Dissected visceral peritoneum over the middle colon vessels. The feeding leg of the flap was mobilized - the middle colon artery and vein. With the help of SFA devices, a colonic-omental flap was formed from a transverse colon of 10 cm long and an adjacent strand of a large omentum. The supply vessels of the transplant are crossed, the flap is transferred to the face defect. An extracorporeally formed anastomosis between the fragments of the colon by the type of "end-to-end" double-row sutures. The transverse colon is submerged in the abdominal cavity. The abdominal cavity is drained and sutured in layers tightly with suturing the skin of the paraumbilical region with an atraumatic suture. The postoperative period is smooth. The bandage on the abdominal wall was not applied from 3 days. Pain in the area of operation was not critical. The wounds healed by primary intention.

Thus, the claimed method has significant advantages and meets the criteria of patentability.

Claims (1)

A method of performing an operation on the abdominal organs, characterized in that the minilaparotomic access is carried out by circular paraumbilical incision of the skin and subcutaneous tissue, the cellulose is separated from the aponeurosis of the muscles of the anterior abdominal wall, the subcutaneous tissue is diluted with hooks and the formed "surgical window" is moved to the zone of interest on a white line the abdomen, or in the pararectal region, or in the hypochondrium, dissect the aponeurosis, expand access with the help of retractors with lighting, enter the abdominal cavity under the video sistirovannym control of endoscopic instruments, carry out operational activities to the extent necessary, return the "surgical window" on the navel and restore the integrity of the skin only a circular seam.

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