RU2427335C1 - Method of vermiform appendix exposure during laparoscopic appendectomy through monoaccess - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to abdominal surgery and can be used in carrying out laparoscopic appendectomy through monoaccess. Monoaccess is performed through umbilicus or above lap. Endoscopes and holding threads for capturing vermiform appendix with its further exposure are introduced. Processing of mesenteriolum and transaction of vermiform appendix with its ablation are performed. Mesenteriolum of vermiform appendix is caught by means of endoscopic clip and through hole is created with dissector at the distance 1.2-1.5 cm from its base, through said hole by means of dissector passed is ligature, which is tightly tied up by intracorporal method on vermiform appendix, closing its lumen, ends of ligature are retained and used as holding thread. Traction by holding thread is performed towards anterior abdominal wall, vermiform appendiz is lifted above blind colon head, tightening its mesenteriolum, one of 5-mm trocars is replaced with 10-mm trocar, through which into abdominal cavity introduced is endoscopic clipper, which is used to fix holding threads with 8-mm first clip to parietal peritoneum of lateral abdominal wall ventrally, laterally and cephally from vermiform appendix base. Bipolar coagulation and transaction of mesenteriolum of vermiform appendix are performed. Second clip is applied on base of vermiform appendix. Vermiform appendix is transected between second clip and holding thread. Vermiform appendix together with holding thread and second clip are extracted in polyethylene container through umbilical wound.

EFFECT: method makes it possible to carry out laparoscopic appendectomy through monoaccess and carry out prevention of infectious complications.

1 dwg, 1 ex

Description

The invention relates to surgery, namely to abdominal surgery, and can be used when conducting laparoscopic appendectomy through mono-access.

A known method of laparoscopic appendectomy, including the introduction of three or four trocars, one of which is used to capture and hold the appendix during the entire duration of the intervention. (Schreiber J.H. Early experience with laparoscopic appendectomy in women. Surg. Endosc. - 1987. - VI. - P.211-216).

The known method involves the creation of one of the accesses for the introduction of the instrument, for fixing the vermiform process, which increases its invasiveness.

The closest is a way to improve visualization of the appendix during laparoscopic appendectomy through a single access (K.E. Roberts / True single-port appendectomy: first experience with the "puppeteer technique" // Surg Endosc, published online: 01.24.2009).

One 11 mm trocar is inserted through the navel or, alternatively, above the womb. After creating access, a 10-mm rigid endoscope with a 5-mm instrumental channel is used. A 5 mm 30 ° endoscope is used to use the 5 mm Ligasure device for dissection and coagulation of the mesentery of the appendix. The abduction of the appendix, which allows dissection between the appendicular artery and the base of the appendix, is achieved by stretching the appendix laterally, forward and in the cephalic direction. To reach the fulcrum, a block is created in the form of a loop (with Polysorb-0 thread) on the anterior abdominal wall inside the abdominal cavity, located cephalally and laterally with respect to the base of the appendix. A thread drawn around the appendix is passed through the loop. The thread is removed extracorporeally through the 11-mm port outside the endoscope without tension.

This allows the surgeon to carry out the tension, like a puppeteer, using a thread brought out to the outside, which leads to the displacement of the vermiform appendix laterally and forward to the abdominal wall, providing exposure to the base of the appendix

The Ligasure device is used to cross the mesentery of the appendix. Polysorb-0 ligatures are superimposed on its base, an additional thread is tied around the appendix 1 cm from the base, the process is scissored between the ligatures. The appendix in the container is removed from the abdominal cavity. The loop is removed. This concept allows you to create adequate tension to isolate, ligate and intersect the appendix at its base without difficulty. Access includes a “puppet (puppet) technique”, which uses a block in the form of an intra-abdominally located loop on the anterior abdominal wall, as an axis for raising the appendix with a thread. The thread is pulled by the surgeon extracorporeally similar to the movements of the puppeteer. This method is adopted as a prototype.

The main disadvantage of the prototype is the need to form a block in the form of a loop on the anterior abdominal wall, which complicates the technology, as well as the need to use expensive suture material - polysorb-0 thread.

The constant presence of the filament in the field of view of the laparoscope, when using the prototype, leads to a limitation of the range of motion of endoscopic instruments. Passing the thread through the soft tissue of the abdominal wall, when creating a loop, may be accompanied by their infection in acute appendicitis.

The objective of the invention is to simplify the method of exposing the vermiform appendix during laparoscopic appendectomy through mono-access, which allows surgical intervention to be performed faster, with greater convenience of manipulation with endoscopic instruments, to prevent infectious complications, with an atypical location of the appendix, to make an individual choice of its fixation location.

The task is achieved by the method of exposure of the vermiform appendix during laparoscopic appendectomy through mono-access, including performing mono-access through the navel or above the womb, introducing endoscopes, introducing a holding thread to capture the appendix and exposing it, processing the mesentery and intersecting the appendix with its removal.

An endoscopic clamp is taken over the mesentery of the appendix and the dissector creates a through hole at a distance of 1.2-1.5 cm from its base. A ligature is drawn through this hole by the dissector, which is tightly tied with an intracorporal method on the appendix, overlapping its lumen. Leave the ligature ends and use them as a thread-holder. Traction is carried out by the thread-holder in the direction of the anterior abdominal wall, the appendix is raised above the dome of the cecum, pulling on its mesentery.

One of the 5 mm trocars is exchanged for a 10 mm trocar through which an endoscopic clipper is inserted into the abdominal cavity, with which the ends of the holding thread are fixed with the 8 mm first clip to the parietal peritoneum of the lateral abdominal wall ventrally, laterally and cephalally from the base of the appendix.

Bipolar coagulation and intersection of the mesentery of the appendix are performed.

A second clip is placed on the base of the vermiform appendix, the appendix is intersected between the second clip and the thread-holder. The vermiform appendix together with the thread-holder and the first clip is removed in a plastic container through the umbilical wound.

The novelty of the invention.

- An endoscopic clamp is taken over the mesentery of the appendix and the dissector creates a through hole at a distance of 1.2-1.5 cm from its base. A ligature is drawn through this hole by the dissector, which is tightly tied with an intracorporal method on the appendix, overlapping its lumen. Leave the ligature ends and use them as a thread-holder. Traction is carried out by the thread-holder in the direction of the anterior abdominal wall, the appendix is raised above the dome of the cecum, pulling on its mesentery. This allows you to more securely fix the thread. Overlap of the lumen prevents contamination of the abdominal cavity, which allows for better processing of the stump of the vermiform process simultaneously with its traction.

- One of the 5 mm trocars is exchanged for a 10 mm trocar through which an endoscopic clipper is inserted into the abdominal cavity, with which the ends of the holding thread are fixed with the 8 mm first clip to the parietal peritoneum of the lateral abdominal wall ventrally, laterally and cephalally from the base of the appendix. This allows you to fix the ends of the thread-holders inside the abdominal cavity, which frees one of the surgeons from the need to be a “puppeteer”. The laparoscopic view of the access working space is improved, since the interference from the holder thread is shifted from the range of the instruments to the side. The method of attachment allows you to choose the best place to fix the thread-holder, given the location of the appendix.

- Conduct bipolar coagulation and intersection of the mesentery of the appendix. A second clip is placed on the base of the vermiform appendix, the appendix is intersected between the second clip and the thread-holder. The vermiform appendix together with the thread-holder and the first clip is removed in a plastic container through the umbilical wound. The intersection in the proposed location completely eliminates the infection of the wound tissue and the abdominal wall simultaneously with the processing of the stump of the appendix.

Using in clinical practice the proposed method allows to achieve several technical results:

- The method allows you to free one of the two working tools from the need to traction and hold the vermiform appendix, and also allows you to freely manipulate both working tools in the process of appendectomy.

- This method does not require suturing in the abdominal cavity in order to create a loop-block or through-through sutures through the anterior abdominal wall, which prevents infection and simplifies the procedure of intervention.

- The choice of the location of the fixation of the appendix to the peritoneum and the degree of traction may vary depending on the anatomical position, the length of the mesentery and the size of the appendix.

- There is no need to conduct the thread through the wound of the umbilical access, which completely eliminates the infection of the tissues of the wound and abdominal wall. Replacing a 5-mm trocar with a 10-mm trocar, with the aim of introducing a clipper, without increasing the invasiveness of the umbilical mono-access, allows the stump of the vermiform appendix to be treated by clipping, which reduces the time of intervention. The thread-holder used for traction of the appendix, simultaneously overlaps its lumen, preventing contamination of the abdominal cavity during the intersection of the appendix.

The invention is illustrated in the drawing.

In the drawing: 1 - the through hole of the mesentery of the vermiform appendix 2. The ligature, which is used as a filament-holder 3. The first clip 4 for attaching the filament-holder 3 to the parietal peritoneum of the lateral abdominal wall 5. The second clip 6 on the basis of the vermiform appendix.

The invention is as follows.

In order to create a single access, the umbilicus is stitched with two stitches-holders and turned out. A skin incision of 1.5-2.0 cm long is performed in the center of the navel without going beyond the umbilical ring. The subcutaneous connective tissue is pulled apart with a Billroth clamp. Direct puncture of the abdominal cavity with a 10 mm trocar is performed. After the start of the carbon dioxide supply, a pneumoperitoneum of 12-14 mm Hg is created. The patient is transferred to the Trendelenburg position with the operating table tilted to the left by 15 °. After a review video laparoscopy, confirmation of the diagnosis of acute appendicitis and assessment of the prevalence of the inflammatory process, two 5-mm trocars are placed in the umbilical access wound by separate puncture of the aponeurosis, 2-3 mm from the first trocar. Through a 5 mm trocar, an atraumatic endoscopic forceps and an endoscopic dissector are inserted into the abdominal cavity. An endoscopic clamp captures the mesentery of the appendix, in which the dissector creates a through hole 1 near the wall of the appendix 2 at a distance of 1.2-1.5 cm from its base. Through the hole 1 in the mesentery, a ligature is carried out by the dissector, which is tightly tied with an intracorporeal method on the vermiform appendix, blocking its lumen and used as a holding thread 3. Carrying out traction for the supporting thread 3 towards the anterior abdominal wall, the vermiform appendix is raised above the dome of the blind gut pulling on his mesentery. One of the 5 mm trocars is changed to a second 10 mm trocar, through which an endoscopic clipper is inserted into the abdominal cavity. Using the 8 mm first titanium clip 4, the thread-holder 3 is fixed to the parietal peritoneum of the lateral abdominal wall 5 ventrally, laterally and cephally from the base of the appendix, pulling on its mesentery. Thus, an adequate visualization of the base of the appendix and its mesentery is created. After bipolar coagulation of the mesentery of the vermiform appendix, it intersects, the second clip 6 is superimposed on the base of the vermiform appendix 6. The appendix is intersected by scissors between the second clip 6 and the thread-holder 3, which overlaps its lumen, preventing the contents from entering the abdominal cavity. The vermiform appendix 2 together with the thread-holder 3 and the fixing clip 4 is removed in a plastic container through the umbilical wound.

Clinical example.

Patient L., 41 years old, medical history No. 389, was hospitalized in the General Surgery Department of the MDLP GKB No. 29 of Novokuznetsk with a diagnosis of Acute appendicitis. The duration of the disease is 12 hours. Transumbilical access to the abdominal cavity up to 1.5 cm long was carried out. Pneumoperitoneum 12-14 mm Hg Three trocars were installed in the umbilical access wound - two 10 mm trocars and one 5 mm trocar. The appendix is typically located, phlegmonically altered. Through the hole in the mesentery of the appendix, made at a distance of 1.5 cm from the base, a ligature is carried out. The ligature serves as a holding thread, it is fixed with the first clip to the parietal peritoneum of the lateral abdominal wall with the creation of an exposure of the base and mesentery of the appendix. A second clip is placed on the base of the appendix. A transumbilical laparoscopic appendectomy was performed with bipolar processing of the mesentery of the appendix. The intersection was carried out between the second clip and the thread-holder. The vermiform appendix together with the thread-holder and the fixing first clip are removed in a plastic container through the umbilical wound. The postoperative period is without complications. Surgery time was reduced by 15 minutes.

When performing the inventive method, the exposure of the mesentery and base of the appendix was significantly improved, which facilitated the implementation of laparoscopic appendectomy through mono-access. The method allows the prevention of infectious complications.

Claims (1)

A method for exposing the vermiform appendix during laparoscopic appendectomy through mono-access, including performing mono-access through the navel or above the womb, introducing endoscopes, introducing a holding thread to capture the appendix and exposing it, processing the mesentery and intersecting the appendix with its removal, characterized in that with a clamp, they capture the mesentery of the appendix and the dissector creates a through hole at a distance of 1.2-1.5 cm from its base, through this hole for the ligature is carried out by the sector, which is tightly tied intracorporeally on the vermiform appendix, overlapping its lumen, the ends of the ligature are left and they are used as a holding thread, traction is carried out by the holding thread towards the anterior abdominal wall, the vermiform process is lifted above the dome of the cecum its mesentery, one of the 5-mm trocars is replaced with a 10-mm trocar, through which an endoscopic clipper is inserted into the abdominal cavity, with which the ends of the filament are fixed with the 8-mm first clip to the parietal the peritoneum of the lateral abdominal wall ventrally, laterally and cephally from the base of the appendix, bipolar coagulation and intersection of the mesentery of the appendix are carried out, a second clip is applied to the base of the appendix, the appendix is intersected between the second clip and the filament is filament and the first clip is removed in a plastic container through an umbilical wound.

Images