RU2392875C1 - Non-suture haemorrhoidectomy by using plasma scalpel - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to colorectal surgery, and can find application in surgery of haemorrhoids stages 3-4. The method consists in mobilisation of an external haemorrhoid that is followed by en bloc resection of an internal haemorrhoid with the mobilised external haemorrhoid by a plasma apparatus "Scalpel SP-CPT" in a coagulation mode by technique No. 2, with gas flow 20%. Herewith, a "joint" suture 0.1-0.2 cm high is created.

EFFECT: said invention allows excising haemorrhoids with creating a reliable "joint suture" that does not require complementary ligation of a haemorrhoid vascular pedicle, and managing postoperative pain syndrome due to reduced injures of anal canal tissues, accelerating wound healing that leads to fewer patient days, and follow-up care and labour rehabilitation of the patients underwent the operation.

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Description

The invention relates to medicine, namely to colorectal surgery, and is intended to improve the treatment results of patients with hemorrhoids 3-4 tbsp.

One of the most common human diseases is hemorrhoids. Hemorrhoids affects more than 10% of the adult population of the planet, the leading number of the total number of coloproctological diseases is 40%. According to the literature, one in three of these patients who came to a specialized institution needs surgical treatment (Fedorov V.D., Dultsev Yu.V., Goligher J 1984; Rivkin V.L. et al., 1994; Vorobev G. I., 2001 MacRae HM, Temple LK, McLeod RS, 2002).

According to modern theory, the pathogenesis of hemorrhoids development is associated with increased arterial blood flow to hemorrhoids, impaired tone of precapillary sphincters, as well as degenerative processes that occur in the musculo-ligamentous apparatus of the internal hemorrhoids, leading to bleeding and prolapse of hemorrhoids from the anus. This led to the development and implementation in practice of numerous pathogenetically substantiated methods of treating hemorrhoids, which can be divided into conservative, minimally invasive and surgical methods. Each of them is used depending on the stage of hemorrhoidal disease. We use the well-known classification proposed by Thomson W (1982) and Cochiar L (1991).

The first stage is the allocation of blood from the anus without loss of hemorrhoids.

The second stage is characterized by prolapse of hemorrhoids with self-reduction into the anal canal, with or without bleeding,

The third stage - accompanied by periodic prolapse of the nodes with the need for their reduction into the anal canal with the help of a manual, with or without bleeding.

The fourth stage is characterized by the constant loss of hemorrhoidal nodes together with the mucous membrane of the rectum and the impossibility of their reduction into the anal canal, with or without bleeding.

Currently, the literature describes more than 250 methods of surgical treatment of hemorrhoids. Due to the introduction of the latest minimally invasive methods of treatment into widespread clinical practice, the performance of radical hemorrhoidectomy is shown in no more than 30% of all patients with hemorrhoids (Vorobyev GI et al., 2002; Rivkin V.L., Kapuller L.L., 2000; Abcarian H., 2001; Kosorok P., 2001).

The prototype of the operation can be the only research work according to our data on the method of using a plasma scalpel for the surgical treatment of hemorrhoids (Kulagin V.A. 2001).

Surgery was performed according to the following procedure.

When hemorrhoidectomy using a plasma scalpel, based on the method of Milligan-Morgan, the block of hemorrhoids was tightened with clamps of Luer and Alice. The perianal skin and rectal mucosa were incised with a steel scalpel, thereby marking the line of application of the plasma flow. To protect the surrounding tissues from the thermal effects of plasma energy, wet gauze wipes were used. The tissues were crossed with a plasma scalpel in cutting mode, up to the vascular pedicle of the hemorrhoid. As a result, the bed of the hemorrhoidal node was covered with a gentle coagulation scab; in the presence of a bleeding vessel, hemostasis was performed by a plasma flow in the “COGULATION” mode. The hemorrhoidal leg was stitched, tied with catgut, crossed at a distance of 0.3 cm from the ligature. The mucous membrane was restored with a continuous catgut suture with a stump immersion, from the node leg. In a histological examination of distant hemorrhoids, the depth of coagulation necrosis was no more than 50 μm.

The developed method for the treatment of hemorrhoids using a plasma scalpel made it possible to reduce the complication rate after surgery by 16.7% and the postoperative period, the length of hospital stay was reduced by 2.2 days (the average length of stay after surgery was 6 days). In this case, not a single case of such a formidable complication as postoperative bleeding was noted.

However, the author proposes to stitch the vascular leg of the hemorrhoidal node and then cross it using a plasma stream, and it is known from previous studies that a plasma beam can reliably provide vascular hemostasis of more than 3 mm, and hemorrhoidal vessels have a diameter not exceeding 2 mm. Such tactics of the operation can be explained by the first experience of using a plasma scalpel to perform hemorrhoidectomy.

Analogs

The electrothermal system (apparatus-controlled bipolar coagulation) LigaSure (Valleylab), designed to coagulate and cross vessels up to 7 mm in diameter, provides a controlled supply of energy to tissues and reliable hemostasis. The mechanism of action on the tissue is based on the melting of collagen and elastin. The strength of the “brew zone”, consisting of partially denatured protein, is comparable to the strength of stitched fabric. In addition, there is no need for isolation and separate ligation of the vascular pedicle of the hemorrhoidal node, after which its stump remains. Therefore, in the literature, hemorrhoidectomy performed using the LigaSure apparatus is often called “closed seamless hemorrhoidectomy”. The technology is much like bipolar coagulation: high-frequency alternating current (470 kHz) with a maximum voltage of 120 V, a power of 4A and a maximum power of 150 W is used. Electric current is supplied in cycles (packets), at the end of the cycle, energy is not supplied, the tissues cool down, but at the same time the tool branches compress the tissues mechanically. Electric current supply cycles alternate with pauses until the moment of protein denaturation. The whole process takes about 5 seconds. Tissues placed between the tool branches (up to 5 cm) are “welded” together, then it remains only to cross them. Thermal exposure penetrates the tissue by 2 mm. The interest of the global medical community in the new hemorrhoidectomy technique is confirmed by a large number of publications on this topic. Researchers compared hemorrhoidectomy using the LigaSure apparatus and traditional interventions (closed and open hemorrhoidectomies). In this case, indicators such as the duration of the intervention, the intensity of the postoperative pain syndrome, the number of analgesics required, the length of the patient’s stay in the clinic after surgery, the length of the period of temporary disability, and the frequency of postoperative complications were usually taken into account. At the same time, attempts were made to study in more detail the results of various methods. So, S.N.Sobolev, I.M. Itkin, L.A. Blagodarny, Yu.A. Shelygin, V.Kh.Sottaeva, 2006, G.Milito, J.Sayfan and Y.Chung, among other parameters, were included in his study studying the timing of wound healing. The results of the published research are not entirely unambiguous and need to be understood, however, the advantage of hemorrhoidectomy with the LigaSure device compared to the traditional method was confirmed by various scientists for various indicators, while a comparative analysis did not reveal any shortcomings of the new method in any study.

However, like all electrosurgical devices, the LigaSure generator has its drawbacks:

- the need for using direct contact of the electrode with tissue,

- adhesion of tissue particles to the electrode (high cost of consumables, quick nozzle failure: an average of one electrode for 5-6 hemorrhoidectomies),

- inefficiency of coagulation of tissues with high resistance,

- the relative risk of electric shock, which can occur not only in direct contact with a power tool, but also as a result of the formation of an electric arc, possibly outside the field of view of the surgeon,

- the likelihood of indirect transfer of heat through carbonized tissue to nearby vital structures.

Hemorrhoidectomy with an ultrasonic harmonic scalpel

The principle of operation of an ultrasonic harmonic scalpel is based on the oscillation of the titanium blade of the working nozzle in the longitudinal direction with a frequency of 55,000 Hz and an amplitude of 50 to 100 microns. Oscillations of such a high frequency lead to the destruction of hydrogen compounds in the protein structures of collagen and their bonding, that is, their coagulation. The resulting coagulum reliably obstructs the lumen of blood vessels up to 3 mm in diameter. During the operation, there is no need for additional ligation of vessels of this diameter. At the same time, there is minimal damaging effect on the surrounding tissues, the temperature in the exposure zone does not exceed 80 ° C, the depth of the thermal effect does not exceed 1.5 mm. The second mechanism of action on the tissue is the effect of cavitation. In a liquid medium, for example, in an intracellular fluid, vacuum vacuoles arise under the influence of vibration, which upon boiling destroy the surrounding structures, due to which the anatomical layers of the tissue are separated.

At the State Scientific Center for Coloproctology of Roszdrav, a study was conducted by LM Khmylova, 2006, based on an analysis of the results of treatment of 175 patients for combined hemorrhoids of stage 3-4. With hemorrhoidectomy with an ultrasonic scalpel: the external and internal hemorrhoidal nodes are removed from the outside to the inside in a single unit. To minimize thermal damage to tissues, the skin is dissected in the base area of the removed external hemorrhoidal node with the sharp edge of the titanium blade in cutting mode. Removal of external and internal hemorrhoidal nodes as a single unit is carried out by a blunt surface of a titanium blade in coagulation and cutting modes, which provides reliable hemostasis with minimal thermal effect on the underlying tissue. In this case, care must be taken not to damage the fibers of the external and internal sphincters. The processing of the vascular pedicle in the upper corner of the wound is performed exclusively in the coagulation mode with a wide surface of the titanium blade until it completely intersects, which ensures a sufficient length of the coagulation layer in the stump of the vascular pedicle and virtually eliminates the risk of postoperative bleeding.

disadvantages

- The hemostatic effect of the ultrasound scalpel is lower than that of the RF generators.

- The need for direct contact with the tissue when using an ultrasound scalpel.

- The high cost of consumables.

The objective is to improve treatment outcomes: By reducing the time of surgery. Technically, the creation of a “weld” seam that does not require stitching of the vascular pedicle of the hemorrhoid, which leads to a decrease in postoperative pain due to less trauma to the tissues of the anal canal and, consequently, to a reduction in the bed-day, the healing time of the wound and the medical and labor rehabilitation of the operated sick.

The novelty of the proposed method consists in cutting off the hemorrhoidal node and forming a “weld” seam with the help of a plasma scalpel that does not require additional ligation of the vascular pedicle of the hemorrhoidal node.

Plasma scalpel hemorrhoidectomy technique

The principle of operation of the plasma generator (Plasma-arc scalpel Plasma SP-CPT plasma-arc installation for soft tissue dissection and coagulation) is based on passing argon inert gas (pure, very pure) through an electric discharge from 600 to 1800 W that arises between the two electrodes. In this case, ionization of the gas and the formation of a plasma torch flowing out of the exit nozzle of the manipulator occur. The temperature of the flows varies from 3000 to 12000 ° C depending on the selected mode, the type of gas used and the modification of the installation. In physics, plasma is called ionized gas, in which the concentration of positive and negative charges is equal. Plasma exposure to organs and tissues differs from all other high-energy methods by the multifactorial effect, namely, the simultaneous action of the plasma heat flow, gas-dynamic pressure, and hard ultraviolet flux emerging from the plasma scalpel nozzle. Moreover, argon plasma is a carrier of ozone, which has a wide range of bioregulatory effects.

1. Stage: Preparation for the operation and audit

The patient is laid on the table, as for perineal lithotomy: on the back with legs laid on special supports, bent at the knee and hip joints. After anesthesia, the anal canal is processed, and then the surgical field is tripled with 70% ethanol in the same way as when performing a typical hemorrhoidectomy. With the help of a rectal mirror, a sparing divulsion of the anal sphincter is produced. Next, the anal canal is revised.

2. Stage: Mobilization of the external hemorrhoid

The edges of the anus are stretched using the terminals Alice. The top of the external hemorrhoid at 3 hours is captured by Alice's terminal. The skin is economically excised in the projection of the external hemorrhoid. To minimize the thermal effect on the tissue, dissection of the perianal skin in the base area of the external hemorrhoidal node at 3 hours is performed using an electric knife (high-frequency electrosurgical unit EHVCh-200-01 “EFA-0201”). In this case, the external hemorrhoid is separated from the fibers of the subcutaneous portion of the external sphincter. The node is mobilized to the area of the mucocutaneous transition, while the Alice clip is not removed from the mobilized node even after the end of the mobilization.

3. Stage: Resection of the internal hemorrhoid in a single unit with a mobilized external hemorrhoid

The top of the internal hemorrhoid is captured by the Luer clamp and pulled outward. On the base of the node in the radial direction with respect to the anus, as close to the rectum wall as possible, a Billroth vascular clamp is applied from the outside to the inside so that the ends of the clamp jaws protrude 0.5 cm more distant from the captured tissue and the Bill bridge clamps between the jaws and Luer must be at least 0.3 cm. To protect the surrounding tissues from the thermal effects of plasma energy, wet gauze wipes are used, which are wrapped around the billroth clamp jaws, isolating the surrounding tissue, directly under the branches and distal to them. Removing the internal hemorrhoidal node with a mobilized external hemorrhoidal node is performed as follows: pulling the internal hemorrhoidal node with a Luer clamp and the mobilized external hemorrhoidal node with Alice's clip with your left hand, bring the nozzle of the device to the cut-off node with your right hand. Instrument setup: in coagulation mode (method 2, gas flow rate 20%), which ensures reliable hemostasis with minimal thermal effect on the underlying tissues. The plasma scalpel nozzle is parallel to the billroth clamp jaws 0.3 cm from their edge, slowly stroking the plasma beam in the direction from the billroth clamp jaws to the Luer clamp jaws, we begin to cut off the internal hemorrhoid. At the same time, the thickness of the tissue is coagulated and cut off, so that a weld seam of 0.1-0.2 cm high is formed on the side of the incision at the Billroth clip. Stitching and dressing of the vascular pedicle are not performed. The protective wet towel is carefully removed and the billroth clamp jaws open. In the same way, the remaining hemorrhoidal nodes are cut off. Care should be taken not to damage the fibers of the external and internal sphincters.

4. Stage: End of operation

The operation ends with the introduction into the anal canal of a narrow strip of gauze cloth, abundantly soaked with ointment on a water-soluble basis. With care, we place the napkin with the help of Billroth’s clamp into the anal canal, trying not to touch the “weld” seam, a gas outlet tube is installed along the same path, the free part of the ointment wrap is wrapped around the tube. From above, with the help of elastic bandages No. 6 or No. 8, a meter gauze napkin, with a pre-perforated hole for a gas outlet pipe, is fixed by the type of panties.

In the postoperative period, patients are prescribed strict bed rest during the day. Anesthesia on the first day after surgery produce 1 ml of a 2% solution of promedol, which is administered intramuscularly every 6 hours. In the future, according to indications, non-narcotic analgesics are used. On the first day after surgery, patients are prescribed table number 2, in the next number 15. Dressings are made 1 time per day. The perineal wound is treated with antiseptics. Posterisan ointment is injected into the anus. A gauze napkin with water-soluble ointment (Levosin, Levomekol, Dioxikol) is introduced into the perineal wound. The patient is discharged on the 2nd day after the first stool.

Case Study

Patient A., 62 g., Medical history No. 2818-08, was routinely admitted to the 1st clinical department for examination and treatment, with complaints of prolapse of internal hemorrhoidal nodes during defecation, relieved with manual aid, itching burning in the anus. Periodic discharge of red blood from the rectum after bowel movement. From the anamnesis it is known that he has presented the above complaints for 6 years, in the last 3 years he began to notice prolapse of hemorrhoidal nodes during physical exertion. For a long time it was treated conservatively. He went to the polyclinic of the SSCC of the Ministry of Health of the Russian Federation for examination and the 1st surgical department for surgical treatment was hospitalized. Upon receipt, the condition is satisfactory.

STATUS LOCALIS: When examining the perianal region of maceration, there are no scratches. At 3, 7 and 11 hours there are enlarged external hemorrhoidal nodes with no signs of inflammation.

With a digital study of the rectum - the sphincter tone and volitional efforts are not reduced, at 3, 7 and 11 hours there are enlarged internal hemorrhoids that prolapse outward when strained, and are adjusted with the help of a manual. The walls of the lower ampullar region are elastic.

Colonoscopy: a colonoscope was placed in the dome of the cecum. There are no pathological changes in the examined sections of the colon. Physiological examination of ZPKA - corresponds to the physiological norm.

Diagnosis: External and internal hemorrhoids 3 tbsp.

09/05/08 the patient underwent hemorrhoidectomy using a plasma scalpel. The postoperative period was uneventful. In satisfactory condition, the patient was discharged home on the 6th day after the operation under the supervision of a surgeon at the place of residence. Subsequent observation of the complete healing of the wound 29 days after surgery. When examining the function of the obturator apparatus of the rectum after 1 month, there were no significant deviations from the norm. There is no relapse of the disease after 6 months.

Claims (1)

A method for the surgical treatment of stage 3-4 hemorrhoids, including mobilization of the external hemorrhoid, subsequent resection of the internal hemorrhoids as a single unit with the mobilized external hemorrhoids using the plasma scalpel SP-CPT plasma system in coagulation mode according to method 2, with a gas flow rate of 20 %, while creating a "welded" seam with a height of 0.1-0.2 cm