RU2417058C1 - Method for measuring removed foreskin size in phimosis and instrument for implementing thereof - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to urology, andrology and paediatric surgery, and aims at measuring a foreskin resection extent in surgical management of phimosis. Synechias are separated. An used instrument for measuring the removed foreskin size in phimosis comprises a U-shaped spring-assisted flat elastic plate with two parallel branches of equal length and asymmetric in the centre of a wedge portion, a rounded face of radius 4.5 mm. One of the branches has a ruler with a millimetre scale on the outside. Another branch is wedge-shaped and passes smoothly into a rod with a rounded probe end. Its wedge portion comprises symmetrical grooves from both sides to hold the instrument properly and measure the removed foreskin size. The rounded end of the rod of the instrument is inserted to a bottom of a preputial cavity and around the foreskin circumferentially not less than in four fixed points of a sagittal plane. The instrument is turned around 90° sideways with continuing to compress the branches and knurling horizontally with a scalpel along the cutout surfaces of the probe branch on the outside of the cavity along a resection line of the preset foreskin portion. Then, with keeping the instrument in use, a grooved probe is inserted into the formed holes and dissecting alongside the foreskin leaves in combination with hemostasis. An incision formed by joining the cuts together is sutured at once with a blanket absorbable suture. The instrument stretches the foreskin cavity thereby avoiding incision narrowing. The last knot of the suture is used as a holder. The grooved probe is delivered once more from an incision place through the following incision thereby joining all measured points of the foreskin removal together. A longitudinal strip of skin is cut out in a segment of frenulum of prepuce for the purpose of preserving and lengthening frenulum of penis. The instrument is removed, and additional interrupted sutures are used to form the frenulum. As a health supplement, a solution of lidocaine and aqueous chlorhexidine are used.

EFFECT: method allows to measure the removed foreskin size precisely by means of the used instrument.

4 cl, 3 ex, 8 dwg

Description

The invention relates to medicine, namely to urology, andrology and pediatric surgery, and is intended to determine the volume of resection of the foreskin in the surgical treatment of phimosis and the prevention of its relapse.

In the well-known method of circumcision (circumcision of the foreskin) in children and adults with phimosis, the volume of resection of the foreskin is determined “by eye”, at the time the foreskin is pulled back with clamps, along the contour of the glans penis, which protrudes above the stem part of the penis. '' With the so-called “guillotine” method of circumcision of the foreskin, the entire skin of the outer sheet and inner sheet of the foreskin, which is located distal to the palpable head, is cut off above the clamp or forceps (Lopatkin N.A., Shevtsova I.P. Operational urology: (Manual). - L., 1986. - S.335-338).

Approximately the volume of resection is from half to two-thirds or more of the foreskin (on average, 50-75%).

As a prototype, the method of measuring the volume of the removed foreskin during phimosis was selected, which consists in the following: under general anesthesia, an erection test is performed, during which the marker along the contour of the head of the penis indicates the removal line of the outer leaf of the foreskin. After dissection of the preputial sac and excretion of the glans penis, the border of the dissection of the inner leaf of the foreskin is applied with a marker. A section of the skin of the foreskin with a scar ring is excised circularly between the lines indicated by the markers. Hemostasis. The edges of the sheets of the foreskin are sutured with separate catgut sutures with the formation of the frenum of the glans penis (Operational Urology. Hinman F. Atlas: transl. From English. - 2001. Publishing House GEOTAR - MED. - 1192 p.).

The above methods of measuring the volume of removal of the foreskin have the following disadvantages:

- in patients, especially children, it is difficult to get an erection during surgery and under general anesthesia. For artificial erection, it is necessary to resort to injecting physiological solution into the cavernous bodies, which is fraught with the formation of hematomas, as well as bleeding from the injection site with a needle;

- the method is not reliable, since it is carried out "by eye", without the use of a measuring tool. Due to the elasticity of the tissue of the penis, it is possible to obtain unreliable results and, as a result, either excessive or insufficient resection of the foreskin. Such measurement errors can lead to the development of postoperative deformation of the penis, or to relapse of phimosis;

- with the “guillotine” method of circumcision, the need for additional removal of the remaining portions of the foreskin against the background of ongoing bleeding from the crossed vessels, as well as the unevenness of the circumcision line, which worsens the healing conditions of the wound, provokes the formation of hematomas.

Due to the strong or, conversely, insufficient stretching of the skin at the time of pulling the foreskin, either “excess” or insufficient removal of the foreskin occurs, which can lead to a relapse of the disease, erectile dysfunction.

Some of the patients require repeated surgical interventions for refimosis or additional surgical procedures, i.e. elimination of synechia that occurred in the postoperative period after circumcision (circumcizio), as well as treatment of balanoposthitis, which entails an increase in the patient’s rehabilitation time and parental disability. These complications are the result of insufficient circumcision of the skin (volume) of the foreskin. Thus, the amount of removal of the foreskin is determined on the basis of physical data (palpation, examination), which is a subjective criterion.

Closest to the proposed instrument is the "Surgical disposable scalpel." It is intended for all types of surgical interventions. Optimally safe use in plastic, reconstructive surgery, neurosurgery, orthopedics, dentistry. Actually when performing surgical interventions in infectious patients. The most convenient option for use in operating conditions is the handle of a surgical scalpel with a graduation applied on it and a rounded end (http://www.medtehno.ru/catalog/soecialist_instruments/instrum/).

The known scalpel meter has a number of significant drawbacks: the depth of the prepuce bag is determined by repeated measurements, since the measurement scale is not visible from the outside. The scalpel handle has significant dimensions and is not suitable for insertion into the narrow foreskin, it also deforms the prepuce bag and violates the measurement accuracy (Fig. 8).

The objective of the invention is to develop an objective, affordable and easily reproducible method and device for accurate measurement of a given volume of the foreskin removed during phimosis.

The purpose of the invention is to improve the results of surgical treatment of this disease, as well as to prevent its recurrence after surgical treatment, to create clear diagnostic criteria for determining the size of the removed skin of the penis during surgery.

The technical result is an accurate and high-quality measurement of a given volume and removal of the foreskin during phimosis, simplicity and ease of execution, without delaying the time of surgery, is painless for children.

The technical result of the invention is achieved by the fact that in the method for measuring the volume of the removed foreskin during phimosis, the synechia is preliminarily separated in a closed way by injecting physiological saline with medicinal additives into the prepuce bag under pressure, with tight fixation of its edges, until a “bubble” is formed and a “click” is formed », Straighten the foreskin with two clamps, introduce the rounded end of the measuring instrument rod to the very bottom of the prepuce sac and at least four around the foreskin at the fixed points of the sagittal plane (upper, lower, and two lateral), at the same time mark the line of removal of a given part of the foreskin on the outside of the preputial sac, then turn the measuring instrument sideways 90 °, and, without stopping compressing the branches, along the contoured surface of the branch - "probe" make a notch with a scalpel sequentially along the line marked on the outer side of the prepuce bag of the removal of a given part of the foreskin in the horizontal direction, then, without removing the tool, enter the next the grooved probe is cut into the holes obtained and the foreskin sheets are dissected along it, while hemostasis with the help of an electrocoagulator and the foreskin sheets are sewn together with a sewing seam, the formed weld node is pulled and the grooved probe is again carried out from the incision site into the next incision, connecting all the measured removal points in series the foreskin, while at the site of the frenum of the foreskin a longitudinal strip of skin is cut out to preserve and lengthen the frenum of the penis, the instrument is removed, yvayut additional nodal joints to form a bridle.

As a medicinal additive, lidocaine and an aqueous solution of chlorhexidine are used for local anesthesia of the inner leaf of the foreskin, sterilization of this surface until an incision is made, which improves the conditions for wound healing.

The introduction under pressure of a general physiological saline solution with medicinal additives into the preputial sac as a qualitatively soft, easily accessible and individually controlled (until a “click” is formed) means for separating synechiae in a closed way allows their separation to be completed without injuring the foreskin, as occurs with mechanical methods separation. The use of the previously indicated very mild and physiologically natural method for the separation of synechiae (barosanation) is very important for children. Complete separation of synechiae increases the accuracy of measuring the volume of the removed part of the foreskin.

Using the tool shaft additionally when piercing the foreskin with a scalpel at the measurement points allows this to be carried out without the risk of damage to the head, since it is protected by an internal metal jaw. In the future, such punctures are connected in one line, which ensures the subsequent circumcision of the foreskin according to the specified parameters.

An additional introduction of the umbrella through two adjacent notches on the foreskin at the indicated position of the tool allows you to fix the measurement taken of the volume of the removed part and more accurately dissect the sheets of the foreskin without damaging the head itself.

The problem is also solved by the claimed measuring instrument, including a measuring element, made in the form of a U-shaped spring-loaded flat elastic plate with two branches parallel in equal length, one of which is equipped with a ruler on the outside with a millimeter scale, and the other is wedge-shaped , smoothly turning into a rod with a rounded end-probe, and on its wedge-shaped part, recesses are symmetrically made on both sides for convenient use of the tool.

The branches, which are equal in length and different in form of execution, allow, on the one hand, to penetrate the tip of the instrument as deep as possible to the very bottom of the prepuce sac and, at the same time, make precise measurements from the outside and determine the line of removal of a given volume of the foreskin.

The proposed "U" -shaped form is spring-loaded due to the bending of the top of the measuring instrument in the form of a rounded end of the tool in the center of the wedge-shaped part, with a radius of 4.5 mm, asymmetrically. This allows you to achieve a parallel arrangement of the jaws relative to each other with a minimum clearance of 5 mm, and as a result, provides gentle uniform fixation of the leaf of the foreskin.

Thus, the proposed set of operations, their sequence using a tool of a given shape, allows you to accurately determine the volume of the removed part of the foreskin during phimosis in children.

The set of essential features of the proposed method for measuring a given volume of the removed part of the foreskin during phimosis and the proposed form of a measuring instrument for its implementation in the available literature were not found.

Figure 1. Determination of the length of the foreskin by a fixed upper sagittal point A (by dorsal surface).

Figure 2. Determination of the length of the foreskin by fixed lateral lateral points B.

Figure 3. Determination of the length of the foreskin by a fixed lower sagittal point B (in the frenum).

Figure 4. A tool for measuring the volume of the removed foreskin during phimosis (prepuceiometer), side view.

Figure 5. Instrument for measuring the volume of the removed foreskin during phimosis (prepuceiometer), top view.

6. Development of the measuring instrument of the foreskin (prepuceiometer).

7. Measurement of the volume of the removed foreskin during phimosis by the proposed instrument.

Fig. 8. Measurement of the foreskin using a scalpel handle with a ruler (prototype).

The tool for measuring the volume of the removed foreskin is made in the form of an “U” -shaped spring-loaded flat metal plate, consisting of two branches equal in length and parallel to each other (1, 2), which have a rectangular shape of different widths and are connected by a smooth transition in the form of a wedge (3) (from 8 mm to 3.5) on the bend of the plate. The plate is curved in the indicated wedge-shaped part with an indentation of its parallel parts (branches) by 5 mm. A bend in the form of a rounded end (4) is made in the center of the wedge-shaped part of the plate with a radius of 4.5 mm. The distal rectangular end parts of the branches are rounded (6) (radius of curvature is 10 degrees). The jaw (1) (length 100 mm, width 8 mm, thickness 1.5 mm), having a large width, is equipped with a measuring ruler in millimeter terms on its outer side. The opposite end of the plate is represented by a “probe” jaw (2), which is made in the form of a rod of rectangular shape (100 mm long, 3.5 mm wide and 1.5 mm thick), ending with a rounded end (6), for insertion of the prepuce bag into the inside . The ends of the jaw-ruler (1) and the jaw-“probe” (2) are located at the same level and are the working ends (6) of the proposed measuring device. The thickness of the plate over the entire length is up to 1.5 mm. On the wedge-shaped part of it, two symmetrically located recesses (5) with a radius of up to 4.5 mm and a length of up to 7 mm are made for the convenience of gripping the instrument and measuring the volume of the removed foreskin.

The measurement of the volume of the removed foreskin is carried out as follows.

The first step is the procedure for the separation of synechiae (barosanation), which is performed in a closed way, without dissecting the foreskin, without using a tool, using a disposable syringe, injecting saline with the addition of antiseptics (aqueous chlorhexidine) and 1% lidocaine solution into the prepuce space, thereby freeing the head of the foreskin from adhesions. The introduction of saline with medicinal additives (antiseptic solution, lidocaine solution) is carried out through the cannula of the syringe, without a needle, while the opening of the prepuce bag tightly tightens the cannula, thereby preventing the solution from flowing out. When the solution is injected under pressure, bloating of the skin of the prepuce sac in the form of a “bubble” appears, at this moment we feel a “click” of the straightened foreskin that has exfoliated from the glans penis. Next, the edges of the preputial sac, freed from adhesions, are taken onto two hemostatic clamps (holders), without tension, after which the jaw-probe (2) of the measuring instrument is inserted between the head of the penis and the inner sheet of the foreskin, while the measuring jaw with a ruler (1 ) are placed on top of the skin of the penis. The “probe” branch (2) with the working end (6) abuts against the bottom of the coronal groove of the prepuce sac; at the same time, the depth of the prepuce bag is determined (Fig. 7). Measurement of the depth of the bag is carried out on the dorsal surface (Fig. 1), lateral surfaces (Fig. 2) and in the region of the bridle on both sides (Fig. 3), where they mark the marker and connect all the marks obtained in a line with each other. If necessary, the number of measurements can be increased to 5 or more. Then the measuring instrument is turned 90 ° on its side and, without ceasing to squeeze the jaws, according to the marks, and also directly pierce both sheets of the skin of the foreskin with the tip of the scalpel, using the “probe” jaw as protection for the head. After this, without removing the measuring instrument, a standard surgical grooved probe is inserted through the punctures obtained and the foreskin sheets are sequentially dissected using a needle-shaped electrocoagulator, thereby performing hemostasis at the same time, after which the penis frenum is formed and the distal and proximal edges of the skin are sutured separately nodular absorbable catgut sutures. The result is a smooth cut line, symmetrical on both sides, while maintaining the bridle. Apply an aseptic dressing.

The invention is illustrated by the following examples.

Example 1

Patient E-min Egor, 1 year, 7 months, was admitted with a diagnosis of phimosis, bilateral inguinal hernia. The operation was performed on March 12, 08 - bilateral laparoscopic hernioraphia, circumcision of the foreskin. The first stage was the separation of synechiae (barosanation), without dissection of the foreskin, injection of physiological saline, with the addition of antiseptics (aqueous chlorhexidine) and 1% lidocaine solution, using a disposable syringe into the prepuce space, after the appearance of a swelling of the skin of the prepuce sac in the form of a “bubble” , the edges of the preputial sac freed from adhesions were captured with 2 clamps without tension, after which the measuring instrument rod was inserted between the head of the penis and the inner sheet of the foreskin, all the way into the bottom of the putsialnogo bag; determined the depth of the prepuce sac, which was 2.5 cm in the frenum on both sides, and at the remaining points 3.1 cm, 2.7 cm. We measured the volume of the removed foreskin, making punctures with a scalpel at a distance of 0.6, 0, 8 and 0.7 cm, respectively, i.e. 25% of the skin of the preputial sac is left. After that, without removing the measuring instrument and turning it through 90 °, the leaves were cut along the probe along the dorsal surface, according to the estimated level of the circumcision of the foreskin using a grooved probe drawn through the skin incisions. They excised a round flap of the skin (inner and outer leaf of the foreskin), leaving a frenum. The distal and proximal edges of the skin of the foreskin were stitched with separate nodular absorbable catgut sutures. Aseptic dressing. Examined a year after the operation: the head is open, no relapse.

Example 2

Patient K-bov Ivan, 16 years old, was admitted with a diagnosis of phimosis. The operation was performed: March 5, 2008 - circumcision of the foreskin. Before the operation, synechiae was separated (barosanation), without dissection of the foreskin, injection of 10.0 ml of physiological saline, with the addition of aqueous chlorhexidine and 1% lidocaine solution, using a disposable syringe without a needle. The edges of the preputial sac freed from adhesions were captured with 2 clamps, after which the jaw-probe of the measuring instrument was inserted between the head of the penis and the inner sheet of the foreskin until it stops in the bottom of the prepuce sac; determined the depth of the prepuce sac, which was 3.6 cm in the frenum on both sides, and at the other points it was 3.8 cm, 4.2 cm, respectively. Marks were made with a marker at a distance of 0.9 cm, 1.0 cm and 1 , 2 cm from the bottom of the preputial sac. After that, without removing the measuring instrument, they turned it sideways and performed punctures with a scalpel according to the marks made, a grooved probe was inserted through the punctures and sheets were cut along the dorsal surface. Hemostasis by electrocoagulation. The shortened bridle is dissected transversely and stitched in the longitudinal direction. The distal and proximal edges of the skin of the foreskin are sewn with separate interrupted absorbable catgut sutures. Aseptic dressing.

Example 3

Patient Mr. Viktor, 5 years old, was admitted with a diagnosis of congenital phimosis. Parents of the child before surgery insisted on the maximum preservation of the foreskin. The first step was the separation of synechiae (barosanation), without dissection of the foreskin, injection of physiological saline, with the addition of antiseptics (aqueous chlorhexidine) and a 1% lidocaine solution, using a disposable syringe into the prepuce space, we inserted the measuring instrument rod into the bottom of the prepuce bag until it stops ; determined the depth of the prepuce sac, which ranged from 2.0 cm to 2.5 cm and barely covered the glans penis. It was decided to perform plasticity of the prepuce ring. After that, without removing the measuring instrument, which played the role of tensioning the tissues of the foreskin and straightened the prepuce ring, the outer sheet of the foreskin was cut longitudinally with three z-joints of 0.8-1.0 cm in length. Using a blunt, clamp tip " mosquito ”bred the underlying fascial tissue in the transverse direction, which greatly expanded the prepuce ring. The edges of the incisions were superficially sewn with catgut sutures in the transverse direction, which ensured the free excretion of the foreskin head.

This method and device was used in surgical treatment in 21 patients with phimosis, aged 3 years to 54 years, with good long-term results. All patients underwent excision of a predetermined volume of the foreskin. In 4 patients, plastic of the foreskin was performed without circumcision. There were no relapses.

The advantages of the proposed method for measuring the volume of the removed foreskin during phimosis and the device for its implementation is to accurately quantify the depth of the prepuce sac and the length of the excised skin flap, which eliminates the excess of the foreskin (which leads to relapse of phimosis, relapse of adhesions). The preparatory measurement step - barosanization of the prepuce sac - provides for local anesthesia of the inner sheet of the foreskin, sterilization of this surface until the incision is made, which improves the conditions for wound healing. Excessive excision of the skin of the penis is also excluded, which can lead to its deformation, curvature and erectile dysfunction. It is possible to determine in advance the volume of the excised foreskin and inform the patient and his parents about it before the operation, and, thus, perform a resection of the foreskin. The bridle of the glans penis is fully preserved, with the preservation of the erogenous zone. The circumcision line is smooth, hemostasis is easy to carry out, since the skin of the foreskin straightens with the jaws of the prepuceometer. Another advantage of this method is the ability to dissect the foreskin over the second jaw-probe and into the grooved probe, without fear of damaging the soft tissues of the glans penis and causing bleeding, since the metal probe and probe protect it from dissection . The listed advantages of the circumcision method, its low invasiveness, are provided by the very design of the measuring instrument (prepuceiometer): different widths of the ruler-jaw and jaw-probe (from 8 mm to 3.5 mm, respectively, in a ratio of 2.23: 1), the presence of rounding of the working ends (4) of the prepuceometer with a radius of curvature of ten degrees (10 °). The rounded protrusion (6) on the apex (3) and the parallel arrangement of the jaws, with a gap of 5 mm, ensure uniform spreading of the foreskin sheets.

New in the proposed method is that

- a preliminary closed separation of adhesions (synechia of the prepuce sac by barosanation) is performed, before the dissection of the foreskin;

- local anesthesia and sterilization of the prepuce sac is carried out by adding 1% r-ra of lidocaine in a solution for barosanization and adding a solution of an antiseptic (aqueous solution of chlorhexidine);

- measurement of the volume of the removed foreskin is carried out by the proposed device (prepuceometer tool), which simultaneously allows you to share the synechia of the foreskin in a closed way, without cutting the foreskin;

- circumcision of the leaves of the foreskin is carried out on a grooved probe conducted through the planned punctures of the leaves; at the same time hemostasis is performed by an electrocoagulator.

The method and device for measuring provide a good cosmetic and functional result of the operation, the method is a low-impact, effective method of measurement, and the device for its implementation is inexpensive and easily manufactured. This method can be applied in pediatric and general urology, andrology in the surgical treatment of phimosis.

Information sources

1. Lopatkin N.A., Shevtsova I.P. Operative urology: (Manual). - L., 1986. - S.335-338.

2. Operative urology. Hinman F. Atlas: Per. from English - 2001. Publishing house GEOTAR - MED. - 1192 p.

3. Email address http://www.medtehno.ru/catalog/soecialist_instruments/instrum/).

Claims (4)

1. A method of measuring the volume of the removed foreskin during phimosis, characterized in that the synechia is preliminarily separated by a closed way by injecting physiological saline with medicinal additives into the prepuce bag under pressure, tightly fixing its edges to form a “bubble” and producing a “click”, the foreskin with two clamps, use a tool to measure the volume of the removed foreskin during phimosis according to claim 4, including a U-shaped flat plate with two branches in parallel, asymmetric otherwise fixed in the center of the wedge-shaped part with a fixed end, one jaw with a ruler, the other jaw-shaped jaw with a rounded end-probe, the rounded end of the jaw is inserted to the bottom of the prepuce sac and around at least four fixed points along the circumference of the foreskin, mark on the outside of the prepuce bag line to remove a given part of the foreskin, then turn the tool sideways by 90 °, and, without stopping compressing the jaws, make a notch with a scalpel along the contoured surface of the “probe” jaws In addition, along the line marked on the outer side of the preputial sac to remove a predetermined part of the foreskin in the horizontal direction, then without removing the tool, a grooved probe is inserted sequentially into the holes obtained and the foreskin sheets are dissected along it, while performing homostasis with the help of an electrocoagulator and stitching the sheets together the foreskin, and the formed site of the suture is pulled up and the grooved probe is again carried out from the incision site to the next incision, sequentially connecting all measured points adenia of the foreskin, and at the site of the frenulum of the foreskin, a longitudinal strip of skin is cut out to preserve and lengthen the frenum of the penis, the instrument is removed, additional nodal sutures are applied to form the frenum. 2. The method according to claim 1, characterized in that lidocaine is used as a medicinal additive. 3. The method according to claim 1, characterized in that aqueous chlorhexidine is used as a drug additive. 4. A tool for measuring the volume of the removed foreskin during phimosis, including a measuring element, characterized in that it is made in the form of a U-shaped spring-loaded flat, elastic plate with two branches parallel to each other with equal length and with a rounded end asymmetrically located in the center of the wedge-shaped part with a radius of 4.5 mm, while one of the jaws is equipped with a ruler on the outside with a millimeter scale, and the other jaw is wedge-shaped, smoothly turning into a rod with a rounded end-probe moreover, on its wedge-shaped part, recesses are symmetrically made on both sides for the convenience of gripping the instrument and measuring the volume of the removed foreskin.

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