RU2405470C1 - Method of surgical treatment of abdominal aorta aneurysms of iii type - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, in particular to vascular surgery. Complete longitudinal median laparotomy is performed, abdominal aorta aneurysm and its bifurcation are isolated, aneurysm is opened, orifice of lumbar arteries is sewn and intralumen bifurcate prosthetics is carried out. Additionally carried out is mobilisation of intestine and isolation of external and internal iliac arteries from both sides. Prosthetics of aorta and iliac arteries is performed by two bifurcate prostheses: first, proximal anastomosis of main branch of first bifurcate prosthesis with aorta is formed, after that carried out is formation of distal anastomoses of bifurcate branches of prosthesis with external and internal iliac arteries on the right. After that formation of proximal anastomosis of main branch of second bifurcate prosthesis with main branch of first prosthesis is performed in "an end-to-side" manner and distal anastomoses of bifurcate branches of second prosthesis with external and internal iliac arteries are formed on the left.

EFFECT: method increases safety of operational process and improves perfusion of internal iliac arteries.

8 dwg, 2 ex

Description

The invention relates to medicine, in particular to vascular surgery, and can be used in the surgical treatment of type III abdominal aortic aneurysms.

The internal iliac artery is a major arterial line and plays a large role in the blood supply to the muscles and organs of the large and small pelvis. Having a relatively short trunk, the average length of which is 4.1 cm, this artery gives 12 branches to the muscles and organs of the pelvis. A large role belongs to this artery in the formation of collateral circulation with occlusion-stenotic lesions of the abdominal aorta and aortic ileum. All this determines the relevance of maintaining blood circulation along this highway during reconstructive operations on the abdominal aorta with type III aneurysms.

A known method of surgical treatment of type III abdominal aortic aneurysms with aneurysmal lesion of the common iliac arteries (P.O. Kazanchyan, V.A. Belov. Complications in surgery of abdominal aortic aneurysms. - M .: MPEI, 2002, p.302; A.A. .Spiridonov, E.G. Tutov, V.S. Arakelyan. - Surgical treatment of abdominal aortic aneurysm. - M .: NISSH named after A.N.Bakulev RAMS, 2000, p.205), including full longitudinal median laparatomy, mobilization aorta, isolation of the abdominal aortic aneurysm and its bifurcation with common iliac arteries, opening of the aneurysmal sac, flashing of the lumbar arteries and intraluminal formation of the proximal anastomosis of the main jaw of the bifurcation prosthesis with the aorta, and the distal anastomoses of the bifurcation jaw of the prosthesis with end-to-side femoral arteries with ligation of the common iliac artery above its bifurcation, while the iliac artery is perfused through the external iliac artery iliac arteries retrograde.

Retrograde pelvic revascularization through the system of external iliac arteries with the location of distal anastomoses on the femoral arteries is considered the least time-consuming and simple way.

However, this method has significant disadvantages:

two additional surgical accesses are required on the lower extremities in the area of the femoral triangle to the femoral arteries, where the main lymphatic collectors of the lower extremities are located, and this has a certain risk of developing lymphorrhea with infection and contamination of the prosthesis;

the adequacy of retrograde perfusion of the internal iliac artery may be compromised by the stenotic process in the external iliac artery;

ligation of aneurysmically dilated common iliac artery may be difficult due to its pronounced aneurysmal expansion or the presence of calcification and is associated with the risk of damage to large venous trunks. Moreover, ligature application near the mouths of the external and internal iliac arteries can lead to significant deformation of the mouths with their narrowing and ineffective retrograde perfusion.

The objective of the invention is to increase the safety of the process of operating aneurysms of the abdominal aorta type III and increase the efficiency of perfusion of the internal iliac arteries.

The problem is solved due to the fact that in the method of surgical treatment of type III abdominal aortic aneurysms, including a complete longitudinal median laparotomy, isolation of the abdominal aortic aneurysm and its bifurcation, opening of the aneurysm, flashing of the lumbar arteries and intraluminal bifurcation prosthetics, and additionally carry out intestinal bifurcation prosthetics and additionally external and internal iliac arteries on both sides, and prosthetics of the aorta and iliac arteries are carried out by two bifurcation prostheses: first form a proximal anastomosis of the main jaw of the first bifurcation prosthesis with the aorta, then produce distal anastomoses of the bifurcation jaws of the prosthesis with external and internal iliac arteries on the right, then proximal anastomosis of the main jaw of the second bifurcation prosthesis with the main jaw of the first prosthesis according to the “end to end” type form the distal anastomoses of the bifurcation branches of the second prosthesis with the external and internal iliac arteries on the left.

The proposed method for the surgical treatment of type III abdominal aortic aneurysms is illustrated by drawings, in which the positions indicate:

1. ileocecal angle,

2. ascending colon

3. aorta,

4. inferior vena cava,

5. right common iliac artery,

6. right external iliac artery,

7. right internal iliac artery,

8. ureter,

9. sigmoid colon,

10. the descending colon,

11. left common iliac artery,

12. left external iliac artery,

13. left internal iliac artery,

14. aortic aneurysm,

15. the main branch of the first bifurcation prosthesis,

16. the outer bifurcation jaw of the first prosthesis,

17. internal bifurcation jaw of the first prosthesis,

18. the main branch of the second bifurcation prosthesis,

19. the outer bifurcation jaw of the second prosthesis,

20. The internal bifurcation jaw of the second prosthesis.

The inventive method for the surgical treatment of type III abdominal aortic aneurysms is as follows.

During surgery, endotracheal balanced anesthesia is used.

After antiseptic treatment of the patient’s skin from the nipples to the feet, a standard longitudinal median laparotomy is performed from the base of the xiphoid process to the pubic joint along the midline of the abdomen with the bypass around the navel on the left and mobilization of the aorta and its bifurcation. To ensure safe manipulations in the pelvic area and to obtain an adequate exposure of the external and internal iliac arteries, additional intestinal mobilization is performed. After dissection of the parietal peritoneum, the ileocecal angle 1 and the initial section of the ascending colon 2 are mobilized in the right lateral canal. The ascending section of the colon 2 and ileocecal angle 1 are mobilized, leading them upward and medially (Fig. 1). This achieves a wide extraperitoneal exposure of the aorta 3, inferior vena cava 4, total 5 and external 6 and internal 7 iliac arteries with the ureter 8 on the right (figure 2). On the left, the sigmoid colon 9 and the descending colon 10 are mobilized by dissection of the parietal peritoneum in the left lateral canal (Fig. 3). The sigmoid colon 9 and the descending colon 10 are removed medially, after which a wide exposure of the left common 11, external 12 and internal 13 iliac arteries in the extraperitoneal space opens (Fig. 4). Then perform a proximal clamping of the aorta 3. Distal clamping is carried out along the external 6, 12 and internal 7, 13 iliac arteries on the right and left. Aneurysm of the aorta 14 is opened, the mouth of the lumbar arteries is stitched (Fig. 5). Then, intraluminal prosthetics of the aorta 3 and iliac arteries 6, 7, 12, 13 are performed with two bifurcation prostheses. The main branch 15 of the first bifurcation prosthesis is proximally anastomosed with aorta 3, the distal anastomoses of the bifurcation branches 16, 17 are performed extraperitoneally with the right external 6 and internal 7 iliac arteries (Fig.6). The main branch 18 of the second bifurcation prosthesis is anastomosed with the main branch 15 of the first prosthesis according to the "end to side" type and, thus, a kind of new aortic bifurcation is created (Fig. 7). The bifurcation branches 19 and 20 of the second prosthesis are performed behind the sigmoid colon 9 and the descending colon 10 and perform distal anastomoses with the left external 12 and internal 13 iliac arteries extraperitoneally (Fig. 8).

After removing the clamps and starting the blood flow, the parietal peritoneum in the right and left side channels is sutured. An aneurysmal suture is sutured over the dentures.

The inventive method for the surgical treatment of type III abdominal aortic aneurysms with lesions of the common iliac arteries and preserved patency of the external and internal iliac arteries improves the safety of surgical procedures on the external and internal iliac arteries in the pelvic cavity by obtaining a wide exposure of large arterial and venous trunks, ureters. Provides the ability to freely perform arterial anastomoses with external and internal iliac arteries and hemodynamically adequate antegrade revascularization of the pelvic organs and lower extremities. The entire reconstruction is performed in one cavity stage, without additional surgical access on the hips in the zone of increased risk of infection.

Example 1

Patient K., 57 years old, was admitted to the GUK “SOKB№1” in Yekaterinburg with complaints of periodically occurring aching pain in the lumbar spine with radiation to the left lumbar region, intensifying during physical exertion.

From the anamnesis it is known that he considers himself sick since 2004, when the above complaints appeared. He underwent prophylactic antiulcer treatment annually and was observed by a gastroenterologist at his place of residence. An ultrasound revealed an abdominal aortic aneurysm. He was hospitalized for surgical treatment.

An objective examination of the mesogastric region palpates a pulsating formation of 10 × 8 cm, painful, not displaced. The pulsation of the peripheral arteries at all levels, pathological auscultatory murmurs over the arteries is not heard.

Data of laboratory parameters, fluorography of the lungs, echocardiographic and electrocardiographic studies of the heart are within normal limits.

Angiography of the abdominal aorta: aneurysm in the infrarenal aorta 27 mm below the mouth of the right renal artery with a diameter of 46 mm with a transition to the common iliac arteries. Internal and external iliac arteries without significant pathology on both sides.

Multispiral computed tomographic angiography of the abdominal aorta and lower limb arteries: the infrarenal aorta is 32 mm below the renal arteries expanded to 60 mm, the true lumen is 47 mm, and there is a thrombus on the posterior wall. The additional renal artery on the right departs from the enlarged part of the aorta. The common iliac artery on the right is expanded to 32 mm, on the left to 21 mm. The internal iliac arteries are passable, 8 mm in diameter. Femoral, popliteal arteries without features.

Diagnosis: Atherosclerosis. Abdominal aortic aneurysm, type III.

Operation: intraluminal aortic-external-internal iliac prosthesis of the abdominal aorta with two bifurcation prostheses. Resection of the additional right renal artery, inferior mesenteric artery with implantation in the prosthesis.

Operation progress:

Median laparotomy. Aneurysm of huge sizes 15 × 8 × 7 cm with spread to the common iliac arteries. Additional mobilization of the external and internal iliac arteries on both sides by mobilization of the intestine. Proximal clamping of the aorta below the renal arteries, distal clamping at the level of the external and internal iliac arteries throughout. Aneurysmotomy, removal of thrombus cups, flashing of the mouth of bleeding lumbar arteries. An intraluminal prosthesis of the infrarenal aorta was performed with two bifurcation prostheses 16-8-8: the first bifurcation prosthesis - the proximal anastomosis of the main branch of the prosthesis with the infrarenal aorta, distal anastomoses of the bifurcation branches of the prosthesis with the external and internal iliac arteries on the right. The second bifurcation prosthesis - the main jaw of the second prosthesis is anastomosed with the main jaw of the end-to-side type under partial (parietal) clamping, the distal anastomoses of the bifurcation jaws of the second prosthesis are anastomosed with the external and internal iliac arteries on the left. Additionally, the right additional renal and inferior mesenteric arteries were implanted into the prostheses. Operation time 3 hours 35 minutes.

The postoperative period was uneventful. Transfer to spontaneous breathing 5 hours after surgery. In the control multispiral computed tomographic angiography, abdominal aortic prostheses, implanted vessels are passable.

Pulsation of the arteries of the lower extremities at all levels. In satisfactory condition, was discharged on the 9th day after the operation.

Example 2

Patient V., 68 years old, was admitted to the GUK “SOKB№1” in Yekaterinburg with complaints of periodic aching pain in the mesogastric region on the right, aggravated by physical exertion, and increased blood pressure.

From the anamnesis it is known that the patient considers himself from December 2008, when there were aching pains in the mesogastric region with radiation to the inguinal region, unrelated to food intake. Hypertension for several years. Examination by abdominal ultrasound revealed an abdominal aortic aneurysm with a transition to the iliac arteries. She was hospitalized for surgical treatment.

An objective examination: in the mesogastric region, a pulsating formation of 8 × 6 cm is palpated, painless, non-displaced. A systolic murmur is heard above the abdominal aorta. Ripple of peripheral arteries at all levels.

Data of laboratory parameters, fluorography of the lungs, echocardiographic and electrocardiographic studies of the heart are within normal limits.

Abdominal aortic angiography: pronounced tortuosity of the terminal aorta and iliac arteries with aneurysmal dilatation.

Multispiral computed tomographic angiography of the abdominal aorta: the abdominal aorta has bends and several calcified plaques, expanded to 40 mm. The common iliac artery on the right has an extension of up to 50 mm with spreading up to bifurcation, true clearance of 39 mm. The left common iliac artery expanded to 25 mm. The internal iliac arteries are passable, 8 mm in diameter.

Diagnosis: Atherosclerosis. Abdominal aortic aneurysm, type III.

Operation: intraluminal aortic-external-internal iliac prosthesis of the abdominal aorta with two bifurcation prostheses.

Operation progress:

Median laparotomy. Aneurysm in the infrarenal segment with a transition to the common iliac arteries on the left and right. Additional mobilization of the external and internal iliac arteries on both sides by mobilization of the intestine. Proximal clamping of the aorta below the renal arteries, distal clamping at the level of the external and internal iliac arteries throughout. Aneurysmotomy, removal of thrombus cups, flashing of the mouth of bleeding lumbar arteries. An intraluminal prosthesis of the infrarenal aorta was performed with two bifurcation prostheses 16-8-8: the first bifurcation prosthesis - the proximal anastomosis of the main branch of the prosthesis with the infrarenal aorta, distal anastomoses of the bifurcation branches of the prosthesis with the external and internal iliac arteries on the right. The second bifurcation prosthesis - the main jaw of the second prosthesis is anastomosed with the main jaw of the end-to-side type under partial (parietal) clamping, the distal anastomoses of the bifurcation jaws of the second prosthesis are anastomosed with the external and internal iliac arteries on the left. Additionally performed implantation of the inferior mesenteric artery into the prosthesis. Operation time 4 hours 45 minutes.

The postoperative period was uneventful. Transfer to spontaneous breathing 9 hours after surgery. In the control multispiral computed tomographic angiography, abdominal aortic prostheses, implanted vessels are passable.

Pulsation of the arteries of the lower extremities at all levels. In satisfactory condition, was discharged 12 days after surgery.

Claims (1)

A method of surgical treatment of type III abdominal aortic aneurysms, including complete longitudinal median laparatomy, isolation of the abdominal aortic aneurysm and its bifurcation, opening of the aneurysm, flashing of the lumbar arteries and intraluminal bifurcation prosthetics, characterized in that they additionally mobilize the intestines and the external and external arteries on both sides, prosthetics of the aorta and iliac arteries are performed by two bifurcation prostheses: first, the proximal anas is formed tamosis of the main branch of the first bifurcation prosthesis with the aorta, then the distal anastomoses of the bifurcation branches of the prosthesis with the external and internal iliac arteries on the right are formed, then the proximal anastomosis of the main branch of the second bifurcation prosthesis with the main branch of the first prosthesis is of the end-to-side type and they are formed anastomoses of the bifurcation branches of the second prosthesis with the external and internal iliac arteries on the left.

Images