RU2422096C1 - Method of laparoscopic treatment of true spleen cyst - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, surgery, and can be used for laparoscopic treatment of true spleen cyst. For this purpose puncture of cyst is performed. Cyst content is aspirated and cytologic analysis is carried out. Protruding walls of cyst are dissected. After that, remaining internal wall of cyst is processed with plasma flow by scanning or circular movements. Output of plasma flow at current intensity 15-20 A, consumption of working gas argon 0.8-1.0 l/min from the distance 5-10 mm for 1-3 minutes until effect of "wrinkling" and light gray colour of internal cyst wall appear. ^ EFFECT: method makes it possible to achieve complete de-epithelisation of residual intra-parenchymatous part of cyst, improve treatment results, eliminate disease recurrence, reduce intra- and post-operational complications, reduce post-operational bed/day, makes it possible to perform organ-preserving operations. ^ 1 ex

Description

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

There are various methods of treating non-parasitic spleen cysts: puncture, drainage of the liver cyst under ultrasound control, aspiration of the contents, followed by the introduction of a 96% solution of ethyl alcohol to sclerotize the cavity of the cyst. As well as open and laparoscopic fenestration of spleen cysts with drainage of the residual cavity, cyst resection and splenectomy.

It is believed that the puncture of the cystic formation of the spleen is quite dangerous because of the possibility of the outflow of its liquid contents into the abdominal cavity and the subsequent development of peritonitis, or bleeding from the site of puncture of the organ. According to some authors, transdermal puncture under the control of an ultrasound or CT scan for therapeutic purposes with subsequent sclerotherapy is ineffective. Other authors, on the basis of their own experience and literature data, believe that such an intervention is optimal for non-parasitic spleen cysts.

There is a method of treating true spleen cysts (J. "Annals of surgical hepatology", S. S. Harnas and others. Treatment of patients with non-parasitic spleen cysts. Volume 13, No. 2, 2008, p.40), including drainage of the cyst under ultrasound control , cytological examination of the obtained liquid, sclerotherapy with 96% ethanol or 40% glycerol solution until the sclerosant opalescence ceases.

The disadvantages of this method are: incomplete de-epithelization of the cavity of the spleen cyst, the toxic effect of ethyl alcohol, relapses of the cysts, which require repeated surgical treatment.

Closest to the claimed invention is a method of laparoscopic treatment of non-parasitic spleen cysts, including puncture, excision of the protruding wall and de-epithelialization of the residual cavity using electrocoagulation (Kubyshkin V.A., Ionkin D.A. Tumors and cysts of the spleen. - M .: Medpraktika, 2007 , p. 225-230).

The disadvantage of this method is the risk of "welding" of the electrode, the risk of deep thermal necrosis, adjacent to the wall of the cyst, parenchyma of the spleen. With prolonged electrocoagulation, damage to parenchymal organs is possible due to capacitive “breakdown” of electricity, the occurrence of skin burns from a passive electrode. Difficulty in performing complete de-epithelialization, relapse of cysts.

The objective of the invention is the elimination of these disadvantages, reducing the risk of relapse of the spleen cyst due to the complete de-ethelization of the residual intraparenchymal part of the cyst by plasma flow, ensuring reliable hemostasis, bactericidal effect, reducing the invasiveness of the operation.

For this, in the method of laparoscopic treatment of true spleen cysts, including cyst puncture, aspiration of its contents with cytological analysis, excision of the protruding walls of the cyst, it is suggested that after excision of the protruding walls of the cyst, the plasma stream is treated with the remaining cyst wall by scanning or circular movements with the exit of the plasma stream with force current of 15-20 A, argon working gas flow rate of 0.8-1.0 l / min from a distance of 5-10 mm for 1-3 minutes until the effect of "wrinkling" and the acquisition of a light gray color that of the inner wall of the cyst.

Exposure to the plasma flow can be carried out using a plasma torch apparatus plasma scalpel.

The use of plasma epithelialization method allows to reduce the degree of damage to the spleen parenchyma, reduce intraoperative blood loss, reduce the time of the operation, when compared with other types of operations, especially when performing pericystectomy or resection of the spleen, to conduct reliable de-epithelization of the residual inner wall of the cyst, as confirmed by histological examination, the risk of relapse is reduced. According to the results of a histological examination, in 100% of cases a complete de-epithelization of the inner wall of the cyst was achieved. The depth of the necrosis zone is not more than 1 mm.

The use of plasma flows allows you to achieve stable hemostasis with parenchymal bleeding and perform reliable de-epithelization of the true spleen cyst.

The method is as follows.

Laparoscopic excision of the true spleen cyst using a plasma scalpel is performed under endotracheal anesthesia in the position of the patient on the back with the head end of the operating table raised by 20 degrees and tilted to the right by 15-20 degrees. Creates carboxypneumoperitoneum under a pressure of 10-12 mm Hg 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 spleen 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 on the left (trocar - 5 mm), along the midclavicular line on the left (trocar - 5 mm), in the epigastric region, along the midline, below the xiphoid process, a 10 mm diameter trocar is introduced.

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. Through the manipulation trocar, a plasmatron is introduced 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 spleen edges: current of the plasmatron arc current from 20 A to 40 A, working gas (argon) flow rate from 1 to 2.5 l / min, from a distance of 2-3 mm. Excision of the thin wall of the cyst is performed quite quickly and bloodlessly. Before the introduction of the plasmatron, the pressure in the abdominal cavity decreases to 8 mm Hg. Excised walls are removed through a 10 mm trocar. In order to de-epithelialize true cysts, the cyst cavity is treated with a plasma stream, the current intensity of the plasmatron arc is from 15 to 20 A, the flow rate of the working gas (argon) is from 0.8 to 1.0 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 the plasmatrons for 1-2 minutes, until a light gray color and the effect of "wrinkling" of the remaining inner wall of the cyst are acquired. 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 with washing and aspiration of an antiseptic is carried out. The operation ends with drainage of the residual cavity of the spleen cyst and subphrenic region on the left, trocar extraction, removal of gas from the abdominal cavity and suturing of the aponeurosis and skin.

Example.

Patient G., 18 years old (No. ib. 14121), was admitted to the surgical department with a diagnosis of Nonparasitic cyst of the lower pole of the spleen. At admission, the patient complained of a feeling of heaviness in the left hypochondrium. Ultrasound of the abdominal cavity in the lower pole of the spleen revealed a 130 × 120 mm cyst.

The operation was performed as planned: laparoscopic excision of the cyst of the lower pole of the spleen with de-epithelialization of the remaining inner wall by a plasma scalpel. During laparoscopy, a cystic mass with a size of about 130 × 120 mm was revealed in the projection of the lower pole of the spleen. The wall protruding above the parenchyma of the spleen is thin, about 2-3 mm. A cyst puncture was performed. Received about 600 ml of a clear, colorless discharge. Sowing for sterility and cytology was taken. The protruding wall of the cyst is excised with coagulation scissors and a plasma scalpel, removed through a trocar. In order to de-epithelialize the remaining inner wall of the cyst, the residual cavity is treated with a plasma scalpel with scanning movements in the current strength of the plasmatron arc current of 20 A, the flow rate of the working gas (argon) is 1.0 l / min, from a distance of 5-10 mm for 1 minute. 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 spleen cyst is represented by a hyalinized connective tissue lined with a flattened monolayer epithelium. The epithelial lining is partially desquamated. The spleen capsule is hyaline. After treatment with a plasma scalpel, the epithelial lining in the cyst wall was not detected.

The proposed method was applied in 7 patients with true spleen cysts. In the long-term period, data for relapses of cysts were not revealed.

The proposed method allows to improve the results of treatment due to the complete de-epithelialization of the cyst wall, to exclude relapses of the disease, reduce intra- and postoperative complications, reduce postoperative hospital stay, allows you to perform organ-preserving operations.

Claims (1)

A method of laparoscopic treatment of a true spleen cyst, including puncture of the cyst, aspiration of its contents with cytological analysis, excision of the protruding walls of the cyst, characterized in that after excision of the protruding walls of the cyst, the plasma is treated with a stream of the remaining inner wall of the cyst with scanning or circular movements with the exit of the plasma stream with force a current of 15-20 A, an argon working gas flow rate of 0.8-1.0 l / min from a distance of 5-10 mm for 1-3 minutes until the effect of "wrinkling" and a light gray color of the inner wall cyst ki.