RU2338481C2 - Method of determination of places of optimum placement of handling trocars at laparoskopic operations on organs of retroperitoneal space - Google Patents

Abstract

FIELD: medicine; urology.

SUBSTANCE: carry out emunctory urography in a prone position. Place a label on the periomphalic area corresponding to the place of introduction of a laparoscope. Draw two perpendicular lines through the label centre. One of the lines passes through acanthas of vertebra. Also draw two perpendicular lines through the conditional centre of the greatest operational action. One of lines is parallel to the mentioned above line. Measure the pieces formed by crossing of the drawn lines. Carry out marking on an anterior abdominal wall, postponing the mentioned pieces and defining projection to a skin of the anterior abdominal wall of the conditional centre of the greatest operational action. A projection of the conditional centre is count as the centre of the conditional circle. Define circle radius as follows. In the preoperative period build conditionally a rectangular triangle in a body. The triangle hypotenuse is equal to depth of operational action of the instrument. One of the legs of a triangle is equal to distance from the anterior abdominal wall to the zone of the future operational influence measured before operation. The second leg of a triangle is equal to required radius Define three versions of size of radius at angle sizes between hypotenuse and 45, 60 and 75 degrees leg of triangle. Choose the size of required radius from the obtained value taking into account the sizes of the anterior abdominal wall. Count the periomphalic area accept as centre of the second conditional circle with the radius equal to half of length of the used laparoscopic instrument. Trocars for the laparoscopic toolkit are established on a periphery of the first circle at an angle of 45 degrees under the relation to each other out of the zone of the second circle.

EFFECT: increase of calculation accuracy of places of the optimum equipment of handling trocars at operations on organs of retroperitoneal space.

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Description

The invention relates to medicine, namely to laparoscopic surgery and urology.

It is known that access to retroperitoneal surgery is the most important component of surgical intervention. It largely determines the quality of the operation, the likelihood of intraoperative complications during its execution, the possibility of preventing or overcoming them, i.e. degree of risk and safety of intervention.

The use of endovideo surgical techniques in operations on organs of the retroperitoneal space is very promising. This is due to the fact that the operative technique itself (excision of the cyst, ureterolithotomy, pyelolithotomy, etc.) is minimal in terms of invasiveness, and the high invasiveness of operations on retroperitoneal organs is explained mainly by surgical access.

The correct rational introduction of trocars, handling tools, and auxiliary materials allows you to quickly and conveniently carry out any complex laparoscopic operation.

Indirect visualization of the operation object and rigid fixation of the endoscope and manipulators to the operating ports provide an examination of the internal organs and approach to them at a strictly defined angle. In this regard, the problem of determining the most appropriate placement of trocars, providing an adequate operational exposure and the necessary volume of operational actions, remains one of the most urgent in endosurgery.

Currently, a number of works have been completed on the development of criteria for evaluating surgical access in video endosurgery, and the creation of optimal endoscopic access. So A.A. Bondarenko et al. They proposed objective criteria for evaluating surgical approaches in endosurgery using the example of laparoscopic cholecystectomy, modernizing the criteria for surgical access of A.Yu.Sozon-Yaroshevich used in open surgery. V.L. Petrishin proposed new parameters for evaluating the surgical approach in video endosurgery, also transforming the criteria for an operative approach according to A.Yu.Sozon-Yaroshevich. O.G. Ustinov et al. In their work, they evaluated various options for the possible mutual arrangement of instruments for manipulating in an artificially created cavity (similar to a cavity created in the retroperitoneal space during endoscopic operations) and suggested optimal geometric parameters for the relative positioning of optics and instruments in the operation area. A.N. Tarasov developed a set of variables necessary for assessing the operating space, clarified the criteria for evaluating endosurgical accesses, proposed principles for the formation of optimal endosurgical access.

Known are the general principles for the introduction of manipulation trocars. The location of the trocars may differ from the "standard" schemes, but certain conditions must be met. You should not install trocars in the immediate vicinity of the costal arch and the xiphoid process of the sternum, pelvic bones - this limits their mobility. The proximity of the trocars to each other interferes with the movements of the instruments. The angle between the two main manipulators when converging them in the operating area should be as sharp as possible. The introduction of trocars must necessarily be controlled visually from the side of the abdominal cavity (the location of the internal organs, the presence of fusion of the parietal peritoneum, the course of the largest vessels determined by diaphanoscopy are taken into account). Strictly radial, in relation to the operated organ, the installation of trocars greatly facilitates and accelerates the course of the operation.

Also, when arranging ports, you must adhere to the following requirements. The distance between the insertion point and the surgical field should be approximately half the length of the tool used (about 15 cm). This avoids a large range of movements either with the handle (accidental violation of sterility) or with the working end (danger of uncontrolled movements in the abdominal cavity), and also balances the instrument. Tools should not be too close to each other and parallel, and also not close to the optics. There is a simple rule in endosurgery: the distance between two active trocars is equal to half the length of the instruments used. The video monitor should be located across the axis of the optical tube aimed at the area of operation. Tools should enter the surgical field towards the video monitor, and not away from it.

The shortest time of formation of an intracorporal assembly and the highest quality of performance are observed with a combination of the manipulation angle (angle between the instruments) of 60 ° and the elevation angle (between the instruments and the horizontal plane) of about 60 °. In this case, a variation in the angle of elevation with an equivalent azimuthal angle in the range of 45-75 ° is possible. If the handling angle increases, then the lifting angle should increase accordingly.

For the practical implementation of the intracorporeal suture, an isosceles triangle between the instruments is recommended as the optimal geometry. Moreover, the angle between the tools should be 45 °, and the angle of elevation - 55 °.

There is a method of selecting the optimal incision site on the anterior abdominal wall for placement of trocars and introducing needle holders for applying the endo suture (Patent RU No. 2131705, published 1999.06.20, IPC: A61B 17/00), which includes conducting a survey laparoscopy, during which the projection point is determined endoshva to the abdominal wall. Then, an imaginary axis is drawn through the endoscopic application site along the line of the proposed stitched surface, projecting it onto the anterior abdominal wall. In the horizontal plane drawn through the projection points of the endoscopic application site, the semicircle of the abdomen between the posterior axillary lines is measured and the distance M between the projection point of the endoscopic application site to the optimal location of the trocar and insertion of the needle holder is determined using a certain formula, and it is enough to carry out the trocar and insert the auxiliary needle holder the imaginary axis on the anterior abdominal wall through the projection point of the endosha to the left and at an angle of 30-60 ° to the axis of the stitched surfaces, project th on the abdominal wall, and put on the said axis distance M. The method is not precise enough, which makes qualitative overlay endoshov and prevent post-operative complications.

Closest to the claimed is a method of providing endoscopic access (Patent RU No. 2188587, published 2002.09.10, IPC: A61B 17/00, A61B 1/313). This method consists in introducing an endoscope, determining the area of operation under the control of an endoscope, and choosing the point of introduction of instrumental trocars. To do this, a square is projected onto the surface of the body, pulling a ring of flexible material between the points of introduction of the endoscope and the projection onto the cavity wall of the most critical intervention zone. Then it is stretched in the middle between these two points with the formation of a square, in the opposite corners of which on one diagonal there is an endoscope and a zone of the most critical manipulations, and on the other diagonal there are points of introduction of the main instrumental trocars. Puncture the walls of the cavity. The method allows for optimal endoscopic access to the operated organs.

The disadvantages of this method of providing endoscopic access include: increased operation time by determining the optimal points of introduction of instrumental trocars during endoscopy, that is, intraoperatively; the impossibility of using this method in operations on organs of the retroperitoneal space (nephropexy, nephrectomy, radical nephrectomy, resection of the kidney cyst, pyelolithotomy, ureterolithotomy, LMS plastic, adrenalectomy, ureterolysis, etc.), since it is impossible to see the operated organ located on the side of the laparoscopy ; the authors do not take into account such an important indicator of intraoperative geometry as the angle of elevation of the instruments (between the instruments and the horizontal plane), which may complicate the implementation of the main stages of the operation. These shortcomings cast doubt on the possibility of using this method of providing endoscopic access during laparoscopic operations on organs of the retroperitoneal space.

The technical result of the invention is to improve the accuracy of calculating the places of optimal installation of manipulation trocars during laparoscopic operations on organs of the retroperitoneal space.

This result is achieved due to the fact that at the preoperative stage, based on the echographic and radiological diagnostic methods and anthropometric indices, the individual topography of the operated organ and the site of the greatest operative impact are determined, followed by the mathematical calculation of the places of optimal introduction of manipulation trocars and their projection onto the body surface ( skin) of the operated.

Adhering to the general principles of trocar placement, described above, and using the rules of geometry, we developed a method for preoperative determination of the places for optimal installation of manipulation trocars during laparoscopic operations on organs of the retroperitoneal space. The proposed method is as follows.

In the preoperative period, all patients were sonographically determined the distance from the anterior abdominal wall to the area of future surgical exposure (wound depth), intravenous excretory urography was performed with a label, and the external dimensions of the anterior abdominal wall were measured. The proposed method of intravenous excretory urography with a label is described below.

Consider the human body in the sagittal plane (in longitudinal section). Conventionally, we represent it in the form of an ellipse (Fig. 1 is a diagram of a trunk in a longitudinal section).

We build a right triangle ABC inside the ellipse, in which:

- AC hypotenuse (depth of the operational action of the instrument) is the distance between the insertion site of the trocar sleeve and the surgical field (ideally half the length of the instrument used);

- angle <C (elevation angle) - the value of which ideally tends to 60 ° and can fluctuate between 45-75 °;

- leg AB - depth of the wound, measured using ultrasound.

According to the rule of relations between the sides and the corners of a right-angled triangle BC = AB / tg <C, AC = AB / sin <C.

Data from the four-digit mathematical table of V.M. Bradis:

tg 45 ° = 1.0000; tg 60 ° = 1.732; tg 75 ° = 3.732;

sin 45 ° = 0.7071; sin 60 ° = 0.8660; sin 75 ° = 0.9659.

We calculate the BC leg and hypotenuse AC at different angles of C = 45 °, 60 °, 75 °. Moreover, each value of the angle of rise will correspond to a certain depth of the operational action of the tool: the larger the angle of rise, the smaller the depth of the operational action of the tool.

Consider the scheme of operational action in the horizontal plane (Figure 2 - scheme of operational action in the horizontal plane). The site of the greatest operative impact (using modified intravenous excretory urography with a label) is projected onto the skin of the patient's anterior abdominal wall, which is taken as the center of the conditional circle No. 1 with a radius equal to BC. Moreover, it is necessary to postpone three possible options for the circle of aircraft at different values of the angle C = 45 °, 60 °, 75 °. The paraumbilical region is taken as the center of the second circle No. 2 with a radius equal to half the length of the used laparoscopic instruments (laparoscope), taking into account the rule that the distance between two active trocars is equal to half the length of the instruments used.

Comparing the anthropometric parameters of the patient, namely the external dimensions of the anterior abdominal wall, with the possible options for the distance of the aircraft and the corresponding AC values, choose the most optimal port arrangement.

Trocars for laparoscopic instruments are set around the circumference of circle No. 1, at an angle of 45 ° with respect to each other, outside the zone of the second circle. The vector of introduction of the laparoscope and other instruments is directed towards the center of the circle No. 1.

Consider the principle of preoperative calculation of places of optimal installation of ports with ideal intraoperative geometry.

Consider the human body in the sagittal plane (in longitudinal section). Conditionally represent it in the form of an ellipse (figure 1 - diagram of the body in longitudinal section). A rectangular triangle ABC is built inside the ellipse, in which the AC hypotenuse is the distance between the place of insertion of the trocar sleeve and the surgical field (half the length of the instrument used), the angle <C (angle of elevation) is 60 °. According to the properties of right-angled triangles, the angle <A is equal to 30 °, and the side of the aircraft is equal to half the hypotenuse (AS).

Consider the operational action in the horizontal plane (figure 2 is a diagram of the operational action in the horizontal plane). According to the modified intravenous excretory urography, the site of the greatest operative impact is projected onto the skin of the anterior abdominal wall (description of the procedure below), which is taken as the center of the conditional circle No. 1 with a radius equal to BC (1/4 of the length of the used laparoscopic instruments).

The paraumbilical region is taken as the center of the second circle No. 2 with a radius equal to half the length of the used laparoscopic instruments, taking into account the rule that the distance between two active trocars is equal to half the length of the instruments used.

Trocars for laparoscopic instruments are set around the circumference of circle No. 1, at an angle of 45 ° with respect to each other, outside the zone of the second circle. The vector of introduction of the laparoscope and other instruments is directed towards the center of the circle No. 1.

Ideal intraoperative geometry is possible with a wound depth of 13 cm obtained empirically (AB = sin <C × AC).

But each patient has its own constitutional and topogrophoanatomical features, and the option of arranging ports with ideal intraoperative geometry is far from always possible.

In the preoperative period, all patients undergo a modified intravenous excretory urography with a label. When performing one of the pictures in a prone position on the paraumbilical region, a coin (label) is placed, which corresponds to the place of introduction of the laparoscope and allows you to more accurately project the place of surgical exposure onto the anterior abdominal wall.

Two perpendicular lines (M1 and M2) are drawn through the center of the mark, one of which (M1) passes through the spinous processes of the vertebrae and conditionally divides the body into two equal halves in the longitudinal direction (Fig. 3 - diagram of the layout of the x-ray with a mark with a cyst of the lower pole of the right kidneys).

Two perpendicular lines (O1 and O2), one of which - O2 - is parallel to the line M1, are drawn through the conditional center of the greatest operational impact (kidney gates, kidney cyst, kidney upper or lower pole, ureter stone). At the intersection of the line O2 with the lines O1 and M2, a segment L1 is obtained, and at the intersection of the line M2 with the lines O2 and M1, a segment L2 is obtained. Measure the lengths.

Line M1 is drawn through the navel and the xiphoid process of the sternum and the line M2 perpendicular to it. Then, on the M1 line from the navel, segment L1 is laid up, and on the M2 line from the navel, segment L2 is towards the organ on which the operation is planned. In parallel, the M2 line draws the O1 line at a distance L1 upward from the navel, and in parallel to the M1 line, the O2 line at a distance L2 from the navel to the side of the organ on which the operation is planned. The intersection of the lines O1 and O2 is the projection point on the skin of the anterior abdominal wall of the conditional center of the greatest operational impact (Fig. 4 is a marking diagram on the anterior abdominal wall of the site of the greatest operative impact).

For the period 2005-2006, in the Department of Urology of the Ryazan Regional Clinical Hospital, 43 laparoscopic operations were performed on organs of the retroperitoneal space with a preoperative calculation of the locations of the optimal installation of manipulation trocars. Of these, laparoscopic excision of the walls of the kidney cyst - in 19 patients, radical nephrectomy - 10, nephropexy - 10, ureterolithotomy - 4. During the operations, the manipulation, azimuthal and elevation angles are measured using an endoscopic protractor, as well as the height of the anterior abdominal wall ( wound depth) using an endoscopic manipulator with a diameter of 5 mm with applied divisions (1 cm step).

Previously, in 2003-2004, 50 laparoscopic interventions were performed on organs of the retroperitoneal space without using the proposed method for the optimal installation of trocars. Of these, there were 18 radical laparoscopic nephrectomy, 18 nephropexia laparoscopic access, 9 excision of the walls of the kidney cyst, 5 ureterolithotomy.

The duration of laparoscopic operations on the organs of the retroperitoneal space is compared. The results are shown in the table (Figure 5 - comparison of the duration of laparoscopic surgery on the organs of the retroperitoneal space without and using the proposed method).

Radical laparoscopic nephrectomy was performed in 28 patients with renal cell carcinoma. The average duration of operations was:

- with radical laparoscopic nephrectomy without the use of the algorithm for optimal trocar placement - 130 ± 15 min;

- a similar operation, but using the algorithm - 105 ± 11 min.

Operated by laparoscopic access of 28 women aged 17 to 40 years, suffering from right-sided nephroptosis 2-3 degrees.

The average operation time was:

- nephropexy without the use of the algorithm for optimal trocar placement - 65 ± 7 min;

- using the algorithm - 50 ± 7 min.

Example 1. Patient S., 39 years old, diagnosis - bilateral nephroptosis on the right - 2 tbsp., On the left - 1 tbsp. Pain syndrome. Secondary chronic pyelonephritis. The indication for surgery was the presence of objectively proven symptomatic nephroptosis in the patient with pain, with frequent attacks of renal colic and complicated chronic pyelonephritis. In the preoperative period, a modified intravenous excretory urography was performed with a label, in which bilateral nephroptosis was revealed: on the right - lowering of the right kidney in a standing position by 3.5 vertebrae, change in the calyx-pelvis image of the right kidney in the form of a "withering flower", there is a bend of the ureter in the form loops; on the left - 2 vertebrae (Fig.6 - intravenous excretory modified urography with a label, 15 minutes, lying down, Fig.7 - intravenous excretory modified urography for 10 minutes, standing).

The radiographs were marked with a label (Fig. 8 — intravenous excretory modified urography for 15 min, lying with a label, marking was made):

- L1 = 8.0 cm;

- L2 = 6.0 cm.

The site of greatest operative impact was projected onto the anterior abdominal wall according to iv intra-excretory urography with a label (Fig. 9 is a photo of the projection onto the anterior abdominal wall of the site of greatest operative impact).

A preoperative calculation of the locations of the optimal installation of manipulation trocars was performed. Given that the depth of the wound, measured using ultrasound, in this patient is 13 cm, the calculation of the places of optimal installation of manipulation trocars was carried out from the position of ideal intraoperative geometry:

- the depth of the operational action of the tool is equal to half the length of the tool used;

- the angle of rise corresponds to 60 °;

- the radius of the circle centered at the site of the greatest operational impact is 1/4 of the length of the used laparoscopic instruments.

Marked places optimal installation of manipulation trocars (figure 10 - photo markings on the skin of the anterior abdominal wall of the places of setting laparoscopic ports).

Performed laparoscopic nephropexy on the right with a mesh implant, viscerolysis. The duration of the operation was 55 minutes. Data of intraoperative geometry: manipulation angle = 48 ± 4 °; elevation angle = 60 ± 6 °. The postoperative course is smooth, without complications (Fig.11 - photo 1 day after surgery).

Laparoscopic access was performed on 28 patients with kidney cysts. Cysts of the left kidney were found in 17 cases, on the right - in 11 cases. Cysts of the lower pole were found in 19 cases, of the upper pole in 9. The sizes of cysts ranged from 5 to 15 cm in diameter. The volume of cysts is from 50 to 600 ml. In 3 people, a kidney cyst was combined with cholelithiasis, in connection with which these patients underwent simultaneous operations: excision of the cyst and laparoscopic cholecystectomy.

The average duration of operations was:

- with laparoscopic excision of the walls of the kidney cyst without preoperative calculation of the optimal installation of trocars - 64 ± 12 min,

- a similar operation, but using the algorithm - 48 ± 9 min.

Example 2. Patient S., 48 years old, diagnosed with a cyst of the lower pole of the left kidney. Pain syndrome. Performed laparoscopic excision of the walls of the kidney cyst.

The indication for the operation was the presence in the patient of an objectively proven cyst of the left kidney with pain, an increase in size.

An ultrasound of the kidneys was performed, in which a fluid formation (cyst) of 95 mm × 71 mm × 78 mm in size was detected that deforms the CLS slightly in the lower pole of the left kidney. The distance from the anterior abdominal wall to the zone of future surgical exposure was determined sonographically (the depth of the wound was 17 cm).

In the preoperative period, a modified intravenous excretory urography with a mark was performed, in which a compression of the pyelocaliceal system on the right was detected by volumetric formation of the lower pole of the right kidney (Fig. 12 - iv excretory modified urography with a mark for 7 min, lying down).

An x-ray was marked with a label: L1 = 10.0 cm; L2 = 11.0 cm (Fig.13 - iv excretory modified urography with a label for 7 minutes, lying down, marking made).

The site of greatest operative impact was projected onto the anterior abdominal wall according to iv intra-excretory urography with a label (Fig. 14 is a photo of projection onto the anterior abdominal wall of the site of greatest operative impact).

A preoperative calculation of the places of optimal installation of manipulation trocars was carried out. The depth of the wound (leg AB) measured by ultrasound in this patient is 17 cm. The hypotenuse AC (depth of the operative action of the instrument) and leg catheter (radius of a circle centered at the site of greatest operative influence) were calculated for different angles C - 45 °, 60 °, 75 °.

BC = AB / tg <C,

AC = AB / sin <C.

Data from the four-digit mathematical table of V.M. Bradis:

tg 45 ° = 1.0000; tg 60 ° = 1.732; tg 75 ° = 3.732;

sin 45 ° = 0.7071; sin 60 ° = 0.8660; sin 75 ° = 0.9659;

BC = 17 cm; AC = 24 cm (45 °);

BC = 15 cm; AC = 13.3 cm (60 °);

BC = 5 cm, AC = 17 cm (75 °).

Marking of the places of optimal installation of manipulation trocars was performed (Fig. 15 is a photograph of the markings on the skin of the anterior abdominal wall of the places of placement of laparoscopic ports, Fig. 16 is a photograph - the 1st day after the operation).

Performed laparoscopic excision of the walls of the cyst of the left kidney. The duration of the operation was 50 minutes. Data of intraoperative geometry: manipulation angle = 44 ± 5 °; elevation angle = 62 ± 3 °.

The postoperative course is smooth, without complications.

Performed 9 laparoscopic ureterolithotomy (5 women and 4 men). Stones were localized in the lower third in 1 person, in the middle third in 4, in the upper third in 4 people. The operation time was 70 ± 8 min without using the algorithm, 62 ± 7 min using the algorithm.

Thus, the proposed method for the optimal installation of manipulation trocars during laparoscopic operations on the organs of the retroperitoneal space allows us to systematize the spatial orientation of the urologist for the correct introduction of basic endosurgical materials and instruments, reduces the duration of the operation.

Preoperative modeling of endoscopic access reduces the number of conversions and intraoperative complications.

Claims (1)

The method of determining the location of the optimal installation of manipulation trocars during laparoscopic operations on the organs of the retroperitoneal space, characterized in that they perform excretory urography in the supine position, placing the “mark” on the paraumbilical region corresponding to the place of introduction of the laparoscope, two perpendicular lines are drawn through the center of the mark, one of which passes through the spinous processes of the vertebrae; two perpendicular lines are also drawn through the conditional center of the greatest operational action, one of which is parallel to the line indicated above; the segments formed by the intersection of the drawn lines are measured, and then the markings are made on the anterior abdominal wall, postponing the said segments and determining the projection on the skin of the anterior abdominal wall of the conditional center of greatest operational action, take it as the center of the conditional circle, the radius of which is determined as follows: in the preoperative period Conditionally, a rectangular triangle is built inside the body, the hypotenuse of which is equal to the depth of the operational action of the instrument, one of the legs is equal to the distance from the anterior abdominal wall to the area of future surgical intervention, measured before the operation, and the second leg is equal to the desired radius, and three variants of the radius are determined for the angle formed by this leg with hypotenuse equal to 45 °, 60 °, 75 °, respectively, and the size of the desired radius is selected from the obtained values, taking into account the size of the anterior abdominal wall; then the paraumbilical region is taken as the center of the second conditional circle with a radius equal to half the length of the used laparoscopic instruments, trocars for laparoscopic instruments are set around the circumference of the first circle at an angle of 45 ° relative to each other outside the zone of the second circle.

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