RU2402982C1 - Method of nonparasitic liver cyst laparoscopy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to surgery and can be used in true liver cyst treatment. The cyst puncture, aspiration of its contents, de-epithelisation of its walls and excision of prominent walls are performed. De-epithelisation of the cyst walls is performed with a plasma flow of current intensity 15-30 A, argon gas flow rate 0.8 to 1.5 l/min, at the distance 5-10 mm from the cyst wall for 1-3 minutes to observe a whitish colour of an internal cyst wall. The prominent cyst wall is excised with a plasma scalpel of current intensity 20-40 A, at argon gas flow rate 1-2.5 l/min, at the distance 2-3 mm.

EFFECT: offered method allows improving a therapeutic effect, reducing injuries of liver, avoiding electric burn of skin, eliminating relapses of disease, reducing intra- and postoperative complications and a number of postoperative patient days.

2 cl, 1 ex

Description

The invention relates to surgery and can be used in the treatment of true liver cysts.

A known method of surgical treatment of non-parasitic liver cysts, including determining the location of mini-laparotomic access with an incision of not more than 5 cm, depending on the location of the cyst. Performing either edge resection, or fenestration of a cyst with cystomentopexy, or puncture of a cyst with sclerotherapy, or a puncture with occlusion, or husking of a cyst (RF Patent 2142743, IPC АВВ 17/00, publ. 1999).

The disadvantages of this method are the difficulty of access when localizing liver cysts on the diaphragmatic surface and with deep intraparenchymal cysts, cystomentopexy does not provide a sclerosing effect, does not prevent the production of epithelial lining of the discharge, relapses of cysts are possible, edge resection of the liver is possible only with superficial cysts.

A known method of treating true liver cysts (RF Patent No. 2216277, IPC AB 17/94, publ. 2003), including puncture of the liver cyst under ultrasound control, aspiration of the contents, followed by the introduction of 96% ethyl alcohol solution to sclerotize the cavity of the cyst.

The disadvantages of this method are the incomplete de-epithelization of the cavity of the liver cyst, the toxic effect of ethyl alcohol, the risk of alcohol entering the bile ducts with cystobiliary fistulas, frequent relapses of the cysts that require repeated surgical treatment.

Closest to the claimed invention is a method of laparoscopic treatment of non-parasitic liver cysts, including puncture, excision of the protruding wall and de-epithelialization of the residual cavity using hydrothermocoagulation or by introducing 96% ethanol into the cavity of the intraparenchymal cyst (Starkov Yu.G., Vishnevsky V.A., Shishin K.V. et al. Laparoscopic surgery for focal formations of the liver. Endoscopic surgery. - 2006. - No. 1. - P.3-8).

The disadvantage of this method is the risk of deep thermal damage to the liver parenchyma adjacent to the cyst wall, with prolonged electrocoagulation, damage to the parenchymal organs due to capacitive "breakdown" of electric power, the occurrence of skin burns from a passive electrode, the difficulty of performing complete de-epithelization.

The objective of the invention is the elimination of these disadvantages by complete de-ethelization of the residual intraparenchymal part of the cyst with a plasma stream.

The method includes puncture of the cyst, aspiration of its contents, excision of the protruding walls, de-epithelization of the walls of the cyst, new is that the de-epithelization of the walls of the cyst is carried out by plasma flow at a current of 15-30A, the flow rate of argon working gas from 0.8 to 1.5 l / min , from a distance of 5-10 mm from the cyst wall for 1-3 minutes, until a whitish color appears on the inner wall of the cyst.

In addition, it was proposed to excise the protruding wall of the cyst with a plasma scalpel with a current strength of 20-40 A, with an argon working gas flow of 1-2.5 l / min, from a distance of 2-3 mm.

The use of plasma epithelialization method allows to reduce the degree of damage to the liver parenchyma, reduce intraoperative blood loss, reduce the time of operation, when compared with other types of operations, especially when performing pericystectomy or liver resection, to conduct reliable de-epithelization of the residual intraparenchymal part of the cyst, which was confirmed by histological examination of excised walls of cysts, the risk of relapse of the disease is reduced.

The use of plasma flows makes it possible to achieve stable hemostasis with parenchymal bleeding and to perform reliable de-epithelization of the true liver cyst.

The method is as follows.

Laparoscopic excision of a true liver cyst using a plasma scalpel is performed in the patient’s position on the back with the head end of the operating table raised by 20 degrees and tilted left or right by 15-20 degrees. Creates carboxypneumoperitoneum under a pressure of 10-12 mm RT. Art. In the paraumbilical region, a trocar (diameter 10 mm) is inserted through a small skin incision. A laparoscope is inserted through the lumen of the trocar and the organs of the abdominal cavity and small pelvis are revised. The localization, size, structure of the cyst is evaluated. In the absence of contraindications and the possibility of laparoscopic excision of the liver cyst with de-epithelialization, points are determined for the introduction of trocars and instruments, which are located depending on the location of the cyst. Basically, these are points along the anterior axillary line (trocar - 5 mm), along the mid-clavicular line (trocar - 5 mm), in the epigastric region, along the midline, below the xiphoid process, a 10 mm diameter trocar is inserted.

Puncture and aspiration of the contents of the cyst is performed with taking on the cytological and microbiological analysis of the discharge. The cyst wall is held by a laparoscopic clamp. A plasma torch with a plasma exit angle of 45 degrees is inserted through the manipulation trocar into the abdominal cavity. Under visual control, it turns on, the plasma jet is directed to the protruding wall of the cyst, excision is performed with simultaneous coagulation of the parenchyma of the edges of the liver, the current intensity of the plasmatron arc is from 20 A to 40 A, the flow rate of the working gas (argon) is from 1 to 2.5 l / min, s 2-3 mm distances. Excision of the thin wall of the cyst is performed quite quickly and bloodlessly. A gentle coagulation stupus forms along the resection zone. The resulting smoke from the operation of the plasma torch is effectively evacuated through a trocar. Before the introduction of the plasmatron, the pressure in the abdominal cavity is reduced to 8 mm RT. Art. Excised walls are removed through a 10 mm trocar. For signs of cyst infection, a plastic container is used. For the purpose of de-epithelization of true cysts, the cyst cavity is treated with a plasma stream, the current strength of the plasmatron arc is from 15 to 30A, the flow rate of the working gas (argon) is from 0.8 to 1.5 l / min, from a distance of 5-10 mm.

Also, the wall of the cyst can be excised using endoscopic scissors with monopolar coagulation, etc.

De-epithelialization is carried out by scanning or circular motions of plasmatrons for 1-3 minutes, depending on the size of the cyst, until the effect of "wrinkling" and the whitish color of the remaining inner wall of the cyst. For this, it is better to use a plasma torch with a plasma exit at an angle of 45 degrees. The time of de-epithelialization depends on the size, shape, and localization of the residual cavity.

After de-epithelialization, with preserved pneumoperitoneum, a control examination of the abdominal cavity is carried out with repeated washing and aspiration of the antiseptic in the subhepatic, subphrenic space. The operation ends with drainage of the residual cavity of the liver cyst, subhepatic and subphrenic region, extraction of trocars, removal of gas from the abdominal cavity and suturing of the aponeurosis and skin.

Example

Patient S., 62 years old (No. ib. 17626), was admitted to the surgical department No. 1 of MONIKI on 10.10.07 in a planned manner with a diagnosis of Cyst of the left lobe of the liver. Upon admission, the patient complained of a feeling of heaviness, bursting in the epigastrium. Ultrasound of the abdominal organs in the left lobe of the liver revealed a cyst of 90 × 80 × 80 mm, located in the projection of 2-3 segments.

The operation was performed as planned: laparoscopic excision of the cyst of the left lobe of the liver with de-epithelialization of the remaining inner wall by a plasma scalpel. During laparoscopy, a cystic mass with a size of about 80 × 90 mm was revealed in a projection of 2-3 segments of the left lobe of the liver. The wall protruding above the parenchyma of the liver is thin, about 2-3 mm. A cyst puncture was performed. Received about 400 ml of a clear, colorless discharge. Sowing for sterility and cytology was taken. The protruding wall of the cyst is excised with a plasma scalpel with a current of 40A plasmatron arc, the flow rate of argon working gas 2.5 l / min from a distance of 2-3 mm, extracted through a trocar. The inner wall was examined to exclude the cystobiliary fistula - no signs of bile leakage were detected. In order to de-epithelialize the remaining inner wall of the cyst, the residual cavity was treated with a plasma scalpel with scanning movements at a current of the arc of the plasma torch 30A, with an argon working gas flow rate of 1.5 L / min from a distance of 5-10 mm for 2 minutes. Drainage of the residual cavity of the cyst and subphrenic region on the left. Drainages are removed on the 2nd and 3rd day after surgery. With ultrasound in the early and distant period, data for a relapse of the disease were not identified, no complaints.

Histological examination: the wall of the liver cyst is represented by fibrous tissue with foci of hyalinosis lined with cubic epithelium. After treatment with a plasma scalpel, the epithelial lining is necrotic. Foci of coagulation necrosis are present in the connective wall of the cyst and adjacent liver parenchyma up to 1 mm.

The proposed method was applied in 25 patients with true liver cysts. With an ultrasound scan in the long term after 6, 12, 24, 36 months, no data were found for the relapse of the disease, no complaints were made.

The proposed method allows to improve the results of treatment, to exclude relapses of the disease, reduce intra- and postoperative complications by 2 times, reduce postoperative hospital bed by 2 times.

Claims (2)

1. The method of laparoscopic treatment of non-parasitic liver cysts, including puncture of the cyst, aspiration of its contents, excision of the protruding walls, de-epithelization of the walls of the cyst, characterized in that the de-epithelization of the walls of the cyst is carried out by plasma flow at a current of 15-30 A, the flow rate of argon working gas is from 0, 8 to 1.5 l / min, from a distance of 5-10 mm from the cyst wall for 1-3 minutes, until a whitish color appears on the inner wall of the cyst. 2. The method according to claim 1, characterized in that the excision of the protruding wall of the cyst is carried out with a plasma scalpel with a current strength of 20-40 A, with an argon working gas flow of 1-2.5 l / min, from a distance of 2-3 mm.