RU2444309C1 - Method of performing laparoscopic splenectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for laparoscopic splenectomy. Laparoscopy is performe4d on patient in position on the right side. Partial mobilisation of spleen by coagulation and transaction of splenic-diaphragmatic ligament is carried out. Into abdominal cavity through trocar introduced is medical multi-channel silicon tube (MMCT) No 18, which by means of endoscopic clamps is wrapped around spleen pedicle, including short gastric arteries, splenic artery and vein. By means of endoscopic clamp by both ends in the middle of the tube grip is performed in such a way that formed loop compresses vascular spleen pedicle in the area of its orifice and its traction upwards is realised. Mobilisation, coagulation and transaction of vascular pedicle of spleen are performed. Ablated spleen is submerged into endocontainer and removed from abdominal cavity. MMCT No 24 is installed into the first subdiaphragmal space.

EFFECT: method makes it possible to reduce blood loss, reduce trauma of adjacent to spleen organs.

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Description

The invention relates to medicine, namely to laparoscopic surgery.

More than 88.3% of surgical interventions performed for concomitant trauma are performed for closed abdominal trauma. In this case, spleen damage occurs in 20-40% of cases. Surgical treatment of spleen rupture is performed against the background of acute blood loss, and factors such as the inconvenience of the anatomical location of the organ, difficulties in hemostasis, have led to a stereotype in the actions of most surgeons who choose “open” splenectomy in 99% of cases [1, 2, 3].

Currently, all clinical manifestations, in one way or another related to splenectomy, are combined in the syndrome of post-splenectomy hyposplenism. Post-splenectomy hyposplenism in the early postoperative period is determined by increased susceptibility to surgical infection, pulmonary-pleural complications; in the long term - with lightning-fast sepsis, a decrease in antimicrobial and anti-blast resistance. According to various sources, a high susceptibility to infection in the early postoperative period is manifested by the development of purulent-inflammatory complications in 13-30% of cases with a mortality rate of 16-30%. Among purulent-inflammatory complications, pulmonary pleural predominate, wound and intra-abdominal processes are less likely to develop. Also, with extensive injuries and after major surgical interventions, thromboembolic complications are noted. All these complications are associated both with the nature of the injuries in severe combined trauma, as well as with the performed laparotomy and traumatic manipulations on the abdominal organs during the “open” splenectomy [1, 3, 4].

It should be noted that with significant damage to the spleen and intense intra-abdominal bleeding, splenectomy via laparotomy access is a non-alternative operation aimed at saving the patient's life. However, according to various sources, 10-30% of patients with an isolated spleen injury have minor damage to the spleen or its subcapsular hematoma in combination with hemoperitoneum up to 500 ml. In this group of patients, it is possible to use both organ-preserving methods for treating spleen injuries (embolization or clipping of blood vessels) and minimally invasive surgical treatment (laparoscopic splenectomy) [1, 3, 4].

The first laparoscopic splenectomy was performed in September 1991 in a girl suffering from thrombocytopenic purpura. Currently, this operation is quite widely used in hematological practice. However, with damage to the spleen, laparoscopic splenectomy is not widespread. This is due both to limited indications for this operation, and to the cautious attitude of surgeons to perform minimally invasive interventions for abdominal trauma and intraperitoneal bleeding.

The advantages of laparoscopic splenectomy are obvious and they are common to all laparoscopic methods of treating most diseases (reducing the frequency of complications and the level of pain, a shorter postoperative period and the period of rehabilitation of patients, good cosmetic effect, etc.). However, given that some of these patients essentially have absolute contraindications to this method of treatment, such as thrombohemorrhagic conditions, the definition of indications for surgery is strictly individual.

"Open" splenectomy is performed with significant damage to the spleen and intense intra-abdominal bleeding, in which the preservation of the organ is not possible. The technique of this operation is worked out and does not cause questions. The average operation time is 40-50 minutes, while the mobilization of the spleen and ligation of its vascular pedicle is performed quickly, thereby preventing large blood loss.

The technique of laparoscopic splenectomy, at present, remains a debatable issue. Laparoscopic mobilization of the spleen and ligation of its vascular pedicle takes from 50 to 90 minutes and depends on adequate visualization of the area of operation, organ mobility and the intensity of intraoperative blood loss.

Thus, one of the main problems facing the surgeon after deciding to perform laparoscopic splenectomy is the most rapid ligation of the spleen vascular pedicle in order to stop blood loss and prevent postoperative complications associated with posthemorrhagic anemia. Priority stopping of bleeding is also necessary for adequate visualization of the operation area during laparoscopic splenectomy in order to prevent damage to adjacent anatomical structures: pancreas and stomach.

The technique of laparoscopic splenectomy described by various authors [5, 6, 7] is similar and includes phased mobilization of the spleen ligamentous apparatus with subsequent ligation of the spleen vascular pedicle either with a stapler (for example, Endo GIA) or using instruments with the LigaSure effect. However, the method of priority stopping of intra-abdominal bleeding before the mobilization of the spleen during laparoscopic splenectomy is not covered in these works and remains open.

The problem solved by the present invention is the development of a method that, when performing a laparoscopic splenectomy, reduces the duration of surgery and reduces intraoperative blood loss.

The technical result achieved is:

- stopping intra-abdominal bleeding by creating temporary hemostasis before performing the main stage of laparoscopic splenectomy;

- reduction of intraoperative blood loss (does not exceed 100-200 ml);

- reducing the risk of developing postoperative complications associated with posthemogogaric anemia;

- reducing the risk of trauma to the abdominal organs adjacent to the spleen: the stomach and pancreas, by improving the visualization of the operation area, which in turn reduces the time it takes to perform an operation.

The proposed method is as follows

In patients with abdominal trauma and isolated damage to the spleen with a hemoperitoneum volume of up to 500 ml, as well as in patients with subcapsular spleen hematoma and the risk of its “two-stage” rupture with stable hemodynamics and the absence of general contraindications for laparoscopy, indications for laparoscopic splenectomy are established. After creating pneumoperitoneum, performing diagnostic laparoscopy and deciding to remove the spleen into the abdominal cavity (with the patient’s position on the right side), a medical multichannel silicone tube (TMMK) No. 18 is inserted through the trocar, which, after partial mobilization of the spleen by coagulation and intersection of the splenic-diaphragmatic ligaments wrap around the legs of the spleen, including short gastric arteries, splenic artery and vein. An endoscopic clamp is grasped at both ends in the middle of the tube so that the loop formed squeezes the spleen vascular pedicle in the area of its gates and traction upwards. After temporary hemostasis is achieved, complete mobilization of the spleen, coagulation and intersection of its vascular pedicle with an instrument with the LigaSure effect are performed. The removed spleen is immersed in the endocontainer, after which the container is removed from the abdominal cavity. TMMK No. 24 is installed in the left subphrenic space. Then they perform desufflation, trocar wounds are sutured.

Clinical example No. 1.

Patient U., 63 years old. Diagnosis: Closed abdominal injury. Two-moment rupture of the spleen. Complication of the main: Subphrenic abscess on the left. Posthemorrhagic anemia. Bilateral reactive pleurisy. Concomitant diagnosis: Stage II hypertension, 2 degrees, medium risk. COPD: chronic obstructive bronchitis. Complete blockade of the right leg of the bundle of Giss. Micronephrolithiasis.

From the anamnesis: For 5 years, suffers from hypertension (blood pressure (blood pressure) 170/100 mm RT. Art.). I did not take hypotensive drugs constantly. Deterioration on April 20, 10, when she woke up from chest pains. I did not apply for medical care. Repeated attack on April 23, 10, was delivered to the institute on April 23, 10, with a diagnosis of coronary heart disease, unstable angina, thromboembolism of small branches of the pulmonary artery.

On admission: The patient is in serious condition. Complaints of pain behind the sternum, shortness of breath, dizziness. Independent breathing, through the natural airways, is carried out on both sides, somewhat weakened in the lower sections, more on the left. Heart sounds are muffled, rhythmic. Heart rate (heart rate) 104 per min. HELL 180/100 mm Hg The abdomen is not swollen, on palpation it is soft, painless, without peritoneal symptoms. Intestinal noises are heard. Urination through the urethral catheter, urine is light.

Chest x-ray 04/23/10 g. - Pulmonary fields with the phenomena of pneumosclerosis. The aperture is clear. The mediastinum is not expanded, not displaced.

Pulmonary scintigraphy 04/23/10, - no signs of pulmonary embolism.

Electrocardiography 04/23/10 g. - sinus rhythm, heart rate 71 per minute. Normal position of the electrical axis of the heart. Complete blockade of the right leg of the bundle of Giss, syndrome SI, Q III.

Echocardiography 04/23/10 g. - left ventricular myocardial hypertrophy.

Anticoagulant, infusion, detoxification therapy, bronchodilators, vitamin therapy were carried out. She noted a worsening condition on 04.29.10 g in the form of the appearance of pain in the left hypochondrium, mesogastrium.

Ultrasound (ultrasound) of the pleural cavities and abdominal cavity 04/29/10 - Separation of the leaves of the peritoneum is not revealed. The spleen is 14.2 × 6.3 cm, the contours are clear, even, the echostructure is heterogeneous in the upper pole: hypoechoic zone 6 × 3.5 cm subcapsular along the diaphragmatic surface. With color Doppler mapping, blood flow (CDC) is not determined. Separation of pleura leaves on the left at the sine level of 1.7 cm.

CT (computed tomography) of the abdominal cavity 04/29/10, the signs of subcapsular spleen hematoma with a volume of 280 cm ³ .

CT of the chest 04/29/10, signs of left-sided hydrothorax with a volume of 110 cm ³ .

Given the high risk of a two-stage rupture of the spleen and the development of intra-abdominal bleeding, the patient underwent emergency surgery (using the proposed technique).

April 29, 10, laparoscopy was performed, a small amount of blood and clots of various prescription was revealed. The spleen is slightly enlarged, there was a hematoma along the diaphragmatic surface and a capsule rupture of 2/3 of the length with minor bleeding into the free abdominal cavity. A strand of a large omentum was soldered along the visceral surface of the spleen, upon separation of which an abscess was opened with a separation of 50 ml of creamy pus. Pus aspirated, sowing taken.

Fusion around the spleen is divided. The splenic-diaphragmatic ligament is coagulated and crossed. TMMK No. 18 was introduced into the abdominal cavity, wrapped around the spleen. The TMMK was grasped at both ends in the middle by an endoscopic clamp and the spleen traction was upward closer to the diaphragm. Bleeding from a capsule defect almost stopped. Complete mobilization of the spleen, coagulation and intersection of the vascular pedicle using a bipolar clamp with the LigaSure effect was performed. The removed spleen is immersed in the endocontainer and, after the destruction of its pulp, is removed from the abdominal cavity with a Luer clamp. Sanitation of the cavity of the subphrenic abscess on the left, sanitation and drainage of the abdominal cavity. Intraoperative blood loss 150 ml.

Due to the high risk of developing post-traumatic pancreatitis and the presence of a subphrenic abscess on the left, antibiotic therapy was performed - invanence 1000 mg × 1 r / d iv for 13 days, specific anti-enzyme therapy - octreotide 0.03 mg × 4 r / d s / c 5 days, gordoks 500 thousand 1 r / d 5 days, fluconazole 150 mg × 1 r / d 5 days, infusion therapy.

Smooth course of the postoperative period. Drainage from the abdominal cavity was removed on the 5-12th day.

Ultrasound of the pleural cavities and abdominal cavity 04/30/10 g. - Dissociation of the leaves of the peritoneum was not detected. A subphrenic area on the left has a zone of increased echogenicity with clear contours with a small amount of delimited fluid of 2.1 × 1.2 cm in size. Separation of pleura leaves on the left at a sinus level of 2 cm, on the right, was not detected.

Chest x-ray 04/30/10 g. - Pulmonary fields with the phenomena of pneumosclerosis. Minimal left-sided hydrothorax. The aperture is clear. The mediastinum is not expanded, not displaced.

Ultrasound of the pleural cavities and abdominal cavity 05/04/10 g. - Separation of the peritoneal sheets was not detected. Subphrenic on the left is a zone of increased echogenicity with clear contours with a small amount of delimited fluid 0.9 cm. Separation of pleura leaves on the left at a sine level of 2 cm, on the right - 0.6 cm.

Ultrasound of the pleural cavities and abdominal cavity 05/06/10 g. - Separation of the peritoneal sheets in the pelvis 0.6 cm. Left subdiaphragmatic tissue infiltration zone with a small amount of delimited fluid 0.3 cm. Separation of the pleural sheets on the left at a sinus level of 2 cm, on the right - 0.6 cm.

CT scan of the abdominal cavity on May 8, 10 — signs of infiltrate subdiaphragm on the left 6 × 3 × 5 cm, no fluid accumulations were detected.

Chest X-ray 05/12/10 - Pulmonary fields with pneumosclerosis. Minimal left-sided hydrothorax. The aperture is clear. The mediastinum is not expanded, not displaced.

Fistulography 05/12/10 g. - Drainage without any cavities is contrasted subdiaphragm on the left - phased out.

Ultrasound of the pleural cavities and abdominal cavity 05/13/10, g. - Separation of the peritoneal sheets was not detected. Subphrenic area of tissue infiltration on the left. Dissociation of pleura leaves on the left at the sine level of 2 cm, on the right - 0.6 cm.

Postoperative wounds healed by first intention, the sutures were removed.

The patient in satisfactory condition was discharged on May 18, 2010 under the supervision of a cardiologist.

Clinical example No. 2.

Patient K, 51 years old, was admitted on August 19, 2010. Diagnosis: Combined injury: Closed chest injury, fractures of 5-8 ribs on the left. Left-sided hydrothorax. Closed abdominal injury. Subcapsular spleen hematoma. Received with complaints of pain in the left half of the chest.

From the anamnesis: According to the patient, an injury in everyday life on August 15, 10, fell in the country from a height of about 3 meters. 08/19/10, he turned to the emergency room in connection with the deterioration of his condition, from where he was delivered to the institute.

On admission: The patient's condition is moderate. Complaints of pain in the left half of the chest, shortness of breath, dizziness. Independent breathing, through the natural airways, is carried out on both sides, somewhat weakened in the lower sections, more on the left. Heart sounds are muffled, rhythmic. Heart rate 100 per minute. HELL 120/80 mm Hg The abdomen is not swollen, on palpation it is soft, painful in the left hypochondrium, without peritoneal symptoms. Intestinal noises are heard.

Chest x-ray 08/19/10 - Fractures of 5-8 ribs on the left. Left-sided minimal hydrothorax. Pulmonary fields with the phenomena of pneumosclerosis. The aperture is clear. The mediastinum is not expanded, not displaced.

Ultrasound of the pleural cavities and abdominal cavity 08/19/10 - No separation of the peritoneal sheets was found. The spleen is 10.5 × 4.3 cm, the contours are clear, even, the echostructure is inhomogeneous in the lower pole: hypoechoic zone 3.6 × 3.5 cm subcapsular along the diaphragmatic surface. Blood flow is not detected with CDC. Separation of pleura leaves on the left at the sine level of 1.4 cm.

Ultrasound of the pleural cavities and abdominal cavity 08/20/10, g. - Separation of the peritoneal sheets was not detected. The spleen is 10.5 × 4.3 cm, the contours are clear, even, the echostructure is inhomogeneous in the lower pole: hypoechoic zone 3.6 × 3.5 cm subcapsular along the diaphragmatic surface. Blood flow is not detected with CDC.

Given the high risk of a two-stage rupture of the spleen and the development of intra-abdominal bleeding, the patient was performed laparoscopy on 08/20/10. Scanty hemorrhagic effusion in the left subphrenic space. The spleen is 12 × 7 cm, in the region of the lower pole, the subcapsular hematoma is 5 × 4 cm with a tear section of 1 × 0.2 cm and moderate bleeding. TMMK No. 18 was introduced into the abdominal cavity, wrapped around the spleen (using the proposed technique). Bleeding from a capsule defect almost stopped. A laparoscopic splenectomy was performed using a bipolar clamp with the LigaSure effect, rehabilitation and drainage of the abdominal cavity.

A course of antibacterial (cefatoxime 1.0 × 3 r / d in / m), infusion and anti-inflammatory therapy, ultraviolet radiation, inhalation.

Smooth course of the postoperative period. Abdominal drainage removed on the 5th day.

Chest X-ray 08/25/10 - Fractures of 5-8 ribs on the left. Left-sided minimal hydrothorax. Pulmonary fields with the phenomena of pneumosclerosis. The aperture is clear. The mediastinum is not expanded, not displaced.

Ultrasound of the pleural cavities and abdominal cavity 08/24/10 10:00 p.m. - No separation of the peritoneal sheets was revealed. Separation of pleura on the left at a sine level of 1.7 cm.

The patient in satisfactory condition was discharged on September 4, 2010.

Literature

1. Abakumov M.M., Smolyar A.N. Indications for organ-preserving surgery for spleen injury. Guidelines. Moscow Research Institute of Ambulance named after N.V. Sklifosovsky. M., 1997; 10.

2. Bryusov P.G., Rozanov V.E. Surgical tactics in patients with combined trauma. In the book: "Assisting with combined trauma." M., 1997; 64-66.

3. Safronov EP et al. The role of organ-sparing operations on the spleen in case of combined trauma. M .: Actual issues of emergency specialized care in the city clinical hospital in Moscow. November 2001: 134-137.

4. Organ-preserving techniques in the treatment of closed spleen injury with intra-abdominal bleeding in children / V.V. Podkamenev, P.S. Yurkov, N.I. Mikhailov, V.O. Ivanov, N.R. Nigmadyanov // Surgery. - 2010. - No. 4. - S. 47-50.

5. Optimization of the technique of laparoscopic splenectomy in children / Poddubny IV, Tolstov KN, Isaev AA, Ternavsky AP and others // Surgery. - 2007. - No. 8. - S.60-65 (prototype).

6. The rational use of laparoscopy in the treatment and diagnostic tactics of spleen injuries with a closed abdominal injury / Alimov AN, Isaev AF, Safronov EF, Otlygin Yu.V. and others // Surgery. - 2006. - No. 2. - S.4-5.

7. Puchkov K.V., Ivanov V.V., Poddubny I.V., Tolstov K.N. Laparoscopic splenectomy: surgical tactics and technical aspects: Monograph. - M., - 2007. - 88 p.

Claims (1)

A method for performing laparoscopic splenectomy, including performing laparoscopy with the patient on the right side, partial mobilization of the spleen by coagulation and intersection of the splenic-diaphragmatic ligament, insertion of a medical multichannel silicone (TMMK) No. 18 tube through the trocar into the abdominal cavity, using endoscopic clamps wrap around the legs of the spleen, including the short gastric arteries, splenic artery and vein, and grab with an endoscopic clamp at both ends in the middle of the tr in such a way that the loop formed squeezes the vascular pedicle of the spleen in the area of its gates and carries out its traction upward, mobilizes, coagulates and intersects the vascular pedicle of the spleen, immerses the removed spleen in the endocontainer and removes it from the abdominal cavity, sets TMMK No. in the left subphrenic space 24, desufflation, suturing of trocar wounds.