RU2465836C1 - Single transumbilical laparoscopic approach technique - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and may be applied for a single transumbilical laparoscopic approach. It involves skin O-incision between internal and external portion with wedge-shaped excision of a skin cicatrix to an umbilical ring. The formed skin flaps are separated within a section line from substrates. An endoscopic trocar is introduced in the umbilical rings. Skin wound edges are gradually maximally separated in the mutually opposite direction with two force vectors directed to estimated approach points for instruments so that to form a conditional triangle with its base facing a zone of maximal operative intervention and an apex presented by an approach point for the endoscope between two approach point projected in left and right abdominal rectus muscles and an approach point for the endoscope. The principal stage of the operation and removal of the laparoscopic tools is followed by uniform closure of the O-defect edges with a non-absorbable suture with the edges of the closed umbilical ring.

EFFECT: method enables reducing a risk of postoperative hernias, improving a cosmetic effect.

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Description

The invention relates to medicine and can be used in surgery when performing a single transumbilical laparoscopic access.

A known method of performing a single transumbilical laparoscopic access, namely, that they perform the dissection of the umbilical ring and into the resulting direct entrance into the abdominal cavity, an integral device with holes or channels for introducing surgical instruments and optics is introduced. The most successful and applicable in international practice are X-Cona from Karl Storz; SILS port of Covidien, SLASS device of Ethicon, Air Seal from Surgiquest, Octoport from Daikin Surgical (Korea) and others [V. Kislov Single-port video endoscopic transumbilical cholecystectomy, first experiment / V.A. Kislov, V.E. Olovyanny, S.G. Likhno. Endoscopic Surgery - 2009, T.15, N 1 (p. 197-198); Saber AA, El-Ghazaly TH, Elian A (2009) Single-incision transumbilical laparoscopic sleeve gastrectomy. J Laparoendosc Adv Surg Tech A 19: 755-758; Saber AA, El-Ghazaly TH, Minnick DB (2009) Single port access transumbilical laparoscopic Roux-en-Y gastric bypass using the SILS Port: first reported case. Surg Innov 16: 343-347].

The disadvantage of this method are: firstly, the implementation of a large incision in the umbilical ring up to 3-5 cm. This increases the likelihood of the formation of a postoperative umbilical hernia; secondly, another serious drawback of this single laparoscopic approach is the loss of triangulation - the main rule of endosurgery, which ensures the convenience and maneuverability of any endoscopic operation [Daniel von Rentein et all., Triangulation; the holy grail of endoscopic surgery? Surg Endosc (2011) 25: 1355-135]. For this reason, there is a conflict between the instruments or between the instrument and the endoscope, while the conflict can be either inside the abdominal cavity or external, between the instrument handles and the camera head of the video system.

To reduce the lack of triangulation in ELD, two main methods are proposed that themselves cause inconvenience in practical use. The first method is associated with the need to manufacture and use specially curved tools. And the second method is the use of cross-triangulation, which involves the use of laparoscopic instruments bent at the end that are crossed during the operation. At the same time, they control the tool with the right hand that is suitable on the left to the object of operation, and vice versa, the tool that is located to the right of the object is manipulated with the left hand, which is extremely inconvenient. The need to use cross-triangulation, a method that has long been condemned and rejected in open surgery, but has been used in laparoscopic surgery, requires long-term retraining and creates inconvenience in practical application.

A known method of performing a single laparoscopic approach, selected as a prototype of the invention, which consists in performing one (single) umbilical incision through which three trocars are placed adjacent to each other, through which an endoscope and two laparoscopic instruments are inserted [Raman JD et al. (2007) Laboratory and clinical development of single keyhole umbilical nephrectomy. Urology 70: 1039-1042; Zhu JF, Ma YZ, Yu JL, Nu H (2008) Transumbilical endoscopic cholecystectomy with the trichannel trocar technique: a porcine feasibility study. Surg Innov 15: 95-99].

The disadvantage of the prototype is the proximity of the trocars, which, as in the previous analogue, reduces access triangulation, increases the likelihood of a conflict between instruments and optics, which requires the use of a curved instrument, and in case of an increase in the surgical incision, accordingly, increases the size of the formed scar in navel area. The reason for insufficient dilution of the skin wound is the presence of a natural scar in the navel, which is formed after the birth of a person. Most of the skin around the navel is fixed to the umbilical ring and this limits its mobility. Linear stitching of the skin wound in the navel after the operation is completed leads to the formation of a scar on the navel, which looks unnatural.

In addition, the introduction of three trocars at a close distance in the prototype worsens local blood supply in the navel and increases the likelihood of a hernia due to a sieve-like defect and promotes suppuration of the wound.

The objective of the invention was to develop a method for performing a single transumbilical laparoscopic approach with increasing the distance between instruments and optics to increase triangulation and reduce the likelihood of conflict between instruments, as well as reducing the size of the postoperative scar and improving the cosmetic effect in the navel, as well as preventing the formation of a postoperative umbilical hernia .

The essence of the invention lies in the fact that in the proposed method for performing a single transumbilical laparoscopic access, a single incision is made of the anterior abdominal wall in the navel region, in which devices for introducing surgical instruments and optics are placed. Unlike the prototype, the skin incision between the inner and outer parts of the navel is O-shaped with a wedge-shaped excision of the skin scar to the umbilical ring, then the formed skin flaps are separated in the region of the incision line from the underlying layers, after which a trocar for the endoscope is inserted into the umbilical ring, and the edges of the skin wound are gradually bred as much as possible in the opposite direction with two force vectors directed to the planned access points for the working tools, so that between the two access charts, which are projected in the left and right rectus abdominis muscles, and an access point for the endoscope would form a conditional triangle with the base facing the zone of maximum operative impact, and the access point for the endoscope would serve as the vertex after completion of the main stage of the operation and removal of laparoscopic instruments of the edge An O-shaped navel skin defect is evenly sutured with an absorbable thread with the edges of the sutured umbilical ring.

Thus, the essential features that distinguish the claimed invention from the prototype are as follows. Performing a skin incision between the inner and outer parts of the navel in an O-shape provides an increase in the distance between the working tools by removing the natural scar tissue of the navel associated with the umbilical ring. The separation of the skin flap from the underlying cicatricial adhesions in the navel also increases the elongation of the skin. The gradual free stretching of the surgical wound along a conditional line drawn through the planned points of installation of working tools allows you to maintain the viability of the dilated skin and subsequently adapt the skin with its plastic at the end of the operation. The introduction of an optical trocar through a slightly expanded umbilical ring increases the non-invasiveness of the method. And the introduction of two other trocars through the rectus abdominis prevents the development of a postoperative hernia due to the backstage closure of the defect in the anterior abdominal wall due to massive muscle tissue.

The maximum possible distance between the working ports provides good triangulation and the prevention of external and internal conflict between tools. In this case, conventional, relatively cheap, direct laparoscopic instruments can be used. Cutting off the skin-scar umbilical umbilical flap by subsequent connection of the edges of the skin wound with the edges of the umbilical ring provides the most cosmetically advantageous plastic of the umbilicus with the formation of a point retracted scar, similar to a natural umbilical scar.

Comparative analysis with the prototype shows that all of the above significant distinguishing features provide new useful technical results: in the form of reducing the morbidity of access, increasing the distance between working tools, increasing the extensibility of the skin wound, a significant increase in the triangularity between instruments and optics; reduce the likelihood of conflict between instruments; no need for a curved tool; reducing the amount of scar tissue in the area of the excised navel, the concentration of the scar in the center of the navel plastic and ensuring the prevention of the formation of postoperative umbilical hernia.

The figure schematically shows the stereometry of a method for performing a single transumbilical laparoscopic approach for cholecystectomy. Shows the shape of the skin incision in the navel, the direction vectors of traction during the expansion of the surgical wound with the formation of a triangular wound and the distance between the conditional lines reflecting the location of the optics and working tools.

The proposed method for performing a single transumbilical laparoscopic access is implemented as follows.

Perform (Fig.) The only circular incision 1 of the skin around the umbilicus O-shaped between its inner deep and outer part with a wedge-shaped excision of the skin scar to the umbilical ring. Then the edges of the skin incision are separated from the underlying layers. A trocar for the endoscope is introduced into the umbilical ring at point A. Then, the skin wound is diluted with a retractor with force vectors F1 and F2 to the planned access points C and B, intended for working tools.

Then, through points B and C, at the maximum possible distance from each other, trocars are installed in the anterior abdominal wall for insertion of laparoscopic instruments into the abdominal cavity. These trocars are placed in the left and right rectus abdominis muscles, which are located on the sides of the conditional line (a), corresponding to the projection of the white line of the abdomen. Line (a) intersects with conditional line (b), which passes through line B and C and always reflects the base of triangle 2, formed by the edges of the wound and created by three access points A, B and C.

During laparoscopic removal of the gallbladder 3, the distance L1 and L2 between the endoscope line (c) and the right laparoscopic instrument (d) and the left instrument line (e) also led to a lesser likelihood of a conflict of instruments.

After the main stage is completed and the instruments are removed, the skin defect formed from the previous single incision 1 is sutured, with the edges of the skin gathered into a single purse string suture, using a Vicril 2/0 absorbable suture (not shown in Fig.). The ends of the purse string suture are stitched with the edges of the umbilical ring to enhance the retraction effect.

We operated on 19 patients with cholelithiasis using the developed unified transumbilical laparoscopic approach for cholecystectomy. Patient data are compared with the results of operations in patients using the prototype. All operations were performed laparoscopically; there were no transitions to the standard multiport laparoscopic or laparotomic cholecystectomy. A significant cosmetic effect was noted in the form of an imperceptible intra umbilical scar with a diameter of up to 10 mm after 6 and 12 months when using the developed method, in contrast to the prototype, where the scar was more visible, had a rough outline and was at least 30 mm long.

Claims (1)

A method of performing a single transumbilical laparoscopic approach, which consists in performing a single incision of the anterior abdominal wall in the navel area, in which devices for introducing surgical instruments and optics are placed, characterized in that the skin incision between the inner and outer parts of the navel is O-shaped with a wedge-shaped excision of the skin scar to the umbilical ring, then the formed skin flaps are separated in the region of the cut line from the underlying layers, then into the umbilical ring a trocar is inserted for the endoscope, and the edges of the skin wound are gradually bred as much as possible in opposite directions with two force vectors directed to the planned access points for the working tools, so that between the two access points that are projected in the left and right rectus abdominis muscles, and an access point for the endoscope would form a conditional triangle, the base facing the zone of maximum operational impact, and the top would be the access point for the endoscope, after completing the basics th stage of the operation and the removal of laparoscopic instruments edge O-shaped navel skin defect uniformly crosslinked absorbable thread with stitched edges umbilical ring.

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