RU2397692C2 - Method of gasless laparoscopy and laparolift for its implementation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, particularly for surgery, especially endovideosurgery, is intended to lift the anterior abdominal wall, for creating a working space in the abdominal cavity of adjustable volume for surgical procedures using a videolaparoscopic technique. Under control of laparoscope Kirschner wire is passed extraperitonealy through the anterior abdominal wall in the transverse direction with capture of the front layers of direct abdominal muscles. The ends of the wire are fixed to the a half-ring of the Ilizarov apparatus, at that the traction-up is conducted with flexible threadlike draught with the ability to change its length, fixed with its one end to the half-ring, the other to the arc of the operating table, thrown through the horizontal knee of the operation lamp. Laparolift for realisation method of gasless laparoscopy comprises flexible threadlike element in the form of a draught to control the amount of working space in the abdominal cavity, the half-ring of the Ilizarov apparatus and the Kirschner wire, having the ability to fix with standard spoke-handlers to the half-ring of the Ilizarov apparatus, with a flexible threadlike element connected to the center of the half-ring of the Ilizarov apparatus and with the arc of the operating table thrown through the horizontal knee of the operation lamp.

EFFECT: invention provides exception of additional traumas of anterior abdominal wall, at simultaneous ensuring the necessary and sufficient working space in the abdominal cavity.

Description

The group of inventions relates to medicine, in particular to surgery, especially to endovide surgery, it is intended to lift the anterior abdominal wall, create a working space in the abdominal cavity - an adjustable volume for surgical operations using video laparoscopic technology.

Along with the indisputable advantages, endosurgical interventions have a number of disadvantages that limit the widespread use of the laparoscopy method, especially in patients with a high operational and anesthetic risk associated with the need to create a working space in the abdominal cavity by applying pneumoperitoneum (PP). The main negative factors of PP include: compression of the inferior vena cava with a decrease in central venous return of blood and a decrease in cardiac output, impaired blood flow in the arteries of the abdominal cavity, compression of the diaphragm with a change in the physiological axis of the heart and impaired respiratory function, adsorption of carbon dioxide by the peritoneum with the development of hypercapnia. Pathophysiological changes that occur during laparoscopy significantly increase the operational risk, being in some cases a contraindication for performing the operation under the condition of the patient (Fedorov V.D. Selected lectures on endovascular surgery. St. Petersburg: LLC KOSTA Firma, 2004, p. .205-209. Fedorov IV et al. Operational laparoscopy. - Moscow: Triada-X, 2004, pp. 83-88. S. Zakaryan et al. Features of laparoscopic cholecystectomy in individuals with concomitant cardiovascular pathology. Endoscopic surgery. M., 2003, p. 9).

In connection with these undesirable effects of PP, alternative methods are being developed to create the necessary working space in the abdominal cavity, which are based on mechanical lifting of the anterior abdominal wall (laparolifting) and devices for its implementation, the use of which avoids the negative consequences of PP (Bondarev A.A. and et al. Experimental substantiation of a laparolift model for laparoscopic cholecystectomy. Endoscopic Surgery, 2005, No. 1, pp. 20-21. Fedorov IV et al. Endoscopic surgery. - M.: GOETAR, 1998, pp. 62-65).

Known devices for lifting and fixing the anterior abdominal wall are conventionally divided into three groups.

The first group consists of devices based on metal lifts of various designs, inserted into the abdominal cavity through additional sections of the anterior abdominal wall, connected in various ways to a stand attached to the operating table (RU 2224472 C1, A61B 17/02, 02/27/2004, RU 2003105086 A, А61В 17/02, 09/10/2004, RU 2238045 С1, 05/13/2003, RU 2179829 С1, А61В 17/02, 12/13/2000, US 5353785, 10/11/1994, RU 2169528 С2, 03/18/1997).

When using these devices, the working space created in the abdominal cavity is not enough for adequate laparoscopic manipulations, their design is technically complicated. The rack, rigidly fixed to the operating table, is bulky, creating inconvenience to the operating surgeon.

The second group is a device (RU 2276584 C1, A61B 17/02, 06/29/2005), the principle of which is also associated with the introduction of L-shaped working elements connected to each other into V-shaped blades into the abdominal cavity through separate punctures of the anterior abdominal wall. The method does not imply rigid fixation of structural elements to the operating table, the working space in the abdominal cavity is created by traction of the device handle upward by an additional member of the operating team, and therefore, this option of laparolifting is possible only with a short surgical intervention.

A third group of the device for laparolifting is known, the principle of which excludes the introduction of hard working elements into the abdominal cavity, they use ligatures that lift the front abdominal wall by piercing it and fixed to the frame rigidly fixed to the operating table. The volume of the working space in the abdominal cavity is regulated by the tension of the ligatures with hoists of various designs (RU 2224472 C1, A16B 17/02, 07.23.2002, RU 2170058 C2, 08.27.1999).

The disadvantages of these devices include the disadvantages of the devices of the first group caused by the bulkiness and complexity of the designs.

The common significant disadvantages of the above groups of devices, in addition to the above, are the following:

1. The need to use specific tools and devices for laparolifting, which have a fairly high cost.

2. The design of most laparolifts is quite complex in design and method of use, which limits their widespread use.

3. In some devices, the necessary condition for the introduction of intra-abdominal lifts is the installation of additional trocars or dissection of the anterior abdominal wall, which increases the invasiveness of the operation and helps to increase the number of postoperative ventral hernias;

4. With traction of the anterior abdominal wall, the parietal peritoneum is traumatized, contributing to its inflammation and increased risk of adhesions.

The objective of the invention is to simplify the design of the device, the development of an affordable, technically uncomplicated method of gas-free laparoscopy while providing an adequate working space in the abdominal cavity for laparoscopic surgery.

The technical result is achieved by the original method using a laparolift, which is a half-ring with a diameter of 25 cm with the spoke holders fixed at the ends used in the famous Ilizarov apparatus and a Kirchner titanium spoke 40 cm long.

A distinctive feature of the proposed method lies in the fact that the Kirchner needle is passed through the anterior abdominal wall in the transverse direction extraperitoneally, under the control of a laparoscope with the obligatory capture of the anterior sheets of the vagina of the rectus abdominis muscle. Laparolifting is carried out by traction of the device by means of thread traction thrown through the horizontal knee of the operating lamp and fixed to the arc of the operating table. Suturing of the puncture points of the anterior abdominal wall at the points of insertion of the needle after surgery is not required.

A distinctive feature of the proposed technical solution should also include the fact that the absence of bulky structures fixed directly to the operating table frees up the surgical field and allows you to change the position of the working trocars depending on conditions directly during the operation.

The inventive method of laparolifting is as follows.

According to the accepted methodology, laparocentesis is performed in the umbilical region. A laparoscope is inserted into the abdominal cavity. Primary laparoscopy is performed by raising the anterior abdominal wall with a hoe fixed to the umbilical ring. Under the control of a laparoscope in the transverse direction, parallel to the horizontal plane, in the epigastric region 3-4 cm above the navel through the front abdominal wall is carried Kirschner needle [2] (Figure 1). A prerequisite is the capture of the front sheets of the vagina of the rectus abdominis muscle [4]. The ends of the needles are fixed in the spoke holders [3] of the half-ring from the Ilizarov apparatus [1] by the accepted method. The proximal end of the lavsan or kapron thread rod [7] (Figure 2) is attached to the upper part of the half-ring, which is then thrown through the horizontal knee of the operating lamp [6] or the pulley previously fixed to it and mounted with the distal end on the arc of the operating table [8]. The degree of tension of the distal end of the thread pull down the operating surgeon creates an adjustable volume of the working space in the abdominal cavity. Minor changes in the working space can occur when the operating table is tilted relative to the horizontal plane, which are easily compensated by the tension of the thread traction.

The possibility of using the proposed method and laparolift is confirmed by a clinical example.

Patient K., 62 years old, medical history No. 6270, was admitted to the emergency surgery department of the BMCG TOF on August 4, 2004 with a diagnosis of Acute calculous cholecystitis. Concomitant pathology: coronary heart disease, postinfarction (1999), small focal cardiosclerosis, circulatory insufficiency, II tbsp. The examination revealed a destructive calculous cholecystitis. Given the presence of destructive cholecystitis in a patient, indications for urgent surgery are exhibited. The risk of surgery is recognized as high due to the presence of a cardiovascular pathology in the patient. A decision was made to perform laparoscopic gas-free cholecystectomy, debridement, and drainage of the abdominal cavity. Performed video laparoscopy (operation No. 803). In the abdominal cavity friable paravesical infiltrate, phlegmonous calculous cholecystitis. A typical laparoscopic cholecystectomy was performed. There were no intraoperative complications and technical difficulties. The postoperative period was uneventful, on the 5th day the sutures were removed from the wound, and was discharged for outpatient treatment in satisfactory condition.

To date, using the proposed method and laparolift performed three laparoscopic surgery for acute calculous cholecystitis, two diagnostic laparoscopy in patients with high operational and anesthetic risk.

Thus, the claimed method and laparolift for its implementation is technically simple, does not require specific equipment and tools, avoids the complications associated with the application of PP and perform laparoscopy in patients with high operational and anesthetic risk.

Claims (2)

1. A method of gas-free laparoscopy, including traction of the anterior abdominal wall up, characterized in that, under the control of a laparoscope, the Kirschner needle is transperitoneally drawn through the anterior abdominal wall transversely with the anterior abdominal rectus muscles, its ends are fixed to the half-ring of the Ilizarov apparatus, while the traction upwards, they carry out flexible thread traction with the possibility of changing its length, fixed at one end to the half ring, the other to the arc of the operating table, thrown through the horizontal knee of the operas radiation lamp. 2. Laparolift for implementing a gas-free laparoscopy method, comprising a flexible filament element in the form of a traction for regulating the volume of the working space in the abdominal cavity, a half-ring of the Ilizarov apparatus and Kirchner needle, transversely passed through the front abdominal wall in the transverse direction with capture of the front leaves of the vagina of the rectus abdominis muscles, which can be fastened with standard spoke holders to the half-ring of the Ilizarov apparatus, the flexible thread element being connected to the center of the half-ring of the Ilizarov apparatus and the arc of the operating table is thrown across the horizontal knee of the operating lamp.

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