RU2468765C1 - Device for single-port lapariscopic sanitisation, omental bursa and abdominal cavity drainage in case of destructive forms of acute pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to abdominal surgery, and can be used in laparoscopic operations in patients with destructive forms of acute pancreatitis. Device contains four immobile supports in form of petals for fixation of omentum to internal surface of anterior abdominal wall and four parallel to each other working valves, two with internal diameter 5 mm and two with internal diameter 10 mm for introduction of laparoscope, drainages and instruments. Case of device has cylindrical shape with thread, on which mobile fixer of cylindrical shape is screwed. Fixer contains four supports in form of petals, channel with internal diameter 40 mm with thread. Cylindrical case of device is introduced into omental bursa and by means of mobile detachable fixer is fixed to abdominal wall by means of thread, thus making it possible to adjust depth of device installation with respect to anterior abdominal wall.

EFFECT: adequate drainage of omental bursa and abdominal cavity is ensured and iatrogenic injury in patients with expressed obesity is prevented due to regulation of device introduction depth.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used for laparoscopic surgery in patients with acute pancreatitis complicated by pancreatic necrosis with severe obesity.

A device for laparoscopic dissection of the pancreas is known, consisting of a source of compressed gas, an energy and an executive unit, while the executive unit (nozzle) is made in the form of a cylinder 30 cm long and 10 mm in diameter, having a rotating part with a nozzle system for supplying a laminar gas flow, and the actuator for activating the piston system is located on the foot pedal (application RU 95111458, published July 10, 1997).

A device for treating acute destructive pancreatitis is known, comprising an aspiration tube with side openings and an irrigation tube, the irrigation tube being connected at the working end to a jet nozzle, which is a hollow collapsible cylinder with holes, an ultrasonic emitter with a conductor to the ultrasonic generator is placed inside the cylinder frequency, the emitter with a conductor is configured to introduce ultrasonic vibrations into the antiseptic solution (patent RU 2248226, 2005).

A device for treating acute destructive pancreatitis is known, which comprises an aspiration tube, the working end of which has two perforated branches, the aspiration tube being equipped with a nikiliditit conductor with shape memory placed in a narrow longitudinal channel located on the outside of the aspiration tube, the aspiration tube contains an additional a window located in its central part from the side opposite to the conductor, and a video channel in the form of a branch located on the opposite side th its working end, wherein the channel for placing the conductor also has two branches, and the inner diameters of all the device channels are made equal to 20 mm (patent RU 85340, 2009).

The prototype of the invention is a device for omentobursostomy in acute dysfunctional pancreatitis, containing three working channels parallel to each other, including a channel for introducing a laparoscope with an internal diameter of 10 mm, and two working channels with an internal diameter of 5 mm, fixators to the abdominal wall in the form of two fixed supports. At the end of the device there is a cylindrical head for delimiting the abdominal cavity from the stuffing bag. The device is used as follows: the surgeon installs the device with three working channels through an incision on the anterior abdominal wall up to 2.5 cm long, located in the left hypochondrium. After that, trocars are installed in the working channels of the device - one 10 mm for introducing a laparoscope and two 5 mm for introducing working tools. In the area of the gastrointestinal ligament, the avascular site in which the window is made is determined. Then, a laparoscope and two instruments are inserted into the formed window through working channels leaving the cylindrical head of the device, which allows one to delimit the abdominal cavity from the stuffing bag. Sanitation of the omentum of the bag is carried out with solutions of antiseptics, the infected cavities are opened, sections of pancreatonecrosis and sequestration of parapancreatic fiber are removed. In the presence of hypertension of the gallbladder, a cholecystostomy is applied, in the presence of an effusion in the abdominal cavity, the latter is removed. Drain the stuffing bag under the control of a laparoscope through two working channels. Stress carboxyperitoneum is removed, trocars are removed from the device, the device is closed with a sterile napkin. According to the testimony, repeated sanitation of the stuffing bag, sequestrnecrectomy is carried out. After treatment, the device is removed, sutures are applied to the wound (patent RU 101349, 2011). Using the utility model allows for single-port laparoscopic sequestration necrectomy and debridement of the omental bursa, abdominal cavity, and prevention of iatrogenic damage. However, the prototype has disadvantages: the device is inconvenient for sequestration necrectomy and sanitation of the omental bursa in patients with severe obesity, since the prototype has fixed clips that do not allow you to adjust the installation depth relative to the anterior abdominal wall, which limits the capabilities of this device, and the presence of 3 channels does not allow adequate drainage through the working channels of the abdominal cavity and stuffing bag.

The objective of the invention is to develop a device for adequate drainage, providing convenience and safety when performing single-port laparoscopic sanitation of the stuffing bag and abdominal cavity in patients with severe obesity by adjusting the depth of introduction of the device.

EFFECT: adjustment of the device insertion depth with respect to the anterior abdominal wall, adequate drainage of the stuffing box and abdominal cavity in patients with severe obesity, prevention of iatrogenic damage.

The specified technical result is achieved by the fact that in the device for laparoscopic omentobursopancreatostomy, made of latex and containing parallel to each other a working channel for introducing a laparoscope with an inner diameter of 10 mm and two working channels with an inner diameter of 5 mm for inserting instruments, fixators to the abdominal wall in the form of fixed supports , according to the invention, the housing of the device is made of a cylindrical shape with a thread onto which a removable movable retainer of a cylindrical shape, which has the morning channel with a diameter of 40 mm is threaded and equipped with four fixed supports, while the device casing is equipped with an additional working channel with an internal diameter of 10 mm for introducing double-lumen silicone drainage and two additional fixed supports, the channels of the device casing and the latch are parallel to each other, and their supports are made in the form of petals.

The invention is illustrated by the following figures: figure 1 shows the proposed device with a movable latch, General view; figure 2 - device without a movable latch, General view; figure 3 - movable latch.

The device contains four working channels 1 parallel to each other, two with an internal diameter of 5 mm and two with an internal diameter of 10 mm for introducing a laparoscope, drains and tools, four fixed supports 2 in the form of petals for fixing the gland to the inner surface of the anterior abdominal wall, device case has a cylindrical shape with a thread 3, on which a movable clamp 4 of a cylindrical shape is screwed, containing four supports 5 in the form of petals, a channel with an inner diameter of 40 mm with a thread 6 (Fig. 1). The cylindrical body of the device is inserted into the stuffing bag, and by means of a movable removable latch is fixed to the abdominal wall using threads, thereby allowing you to adjust the installation depth of the device relative to the front abdominal wall.

This device is used for single-port laparoscopic sanitation of the abdominal cavity and omental bursa in destructive forms of acute pancreatitis, when there is a need for repeated sanitation of the omental bursa to evaluate drainage of infected cavities, removal of pancreatonecrosis and sequestration of parapancreatic tissue.

The device is used as follows: the surgeon installs the device through an incision on the anterior abdominal wall up to 2.5 cm long, located in the left hypochondrium. After that, trocars are installed in the working channels of the device - two of 10 mm for the introduction of a laparoscope and drainage and two 5 mm for the introduction of working tools. In the area of the gastrointestinal ligament, the avascular site in which the window is made is determined. Then, the proposed device is introduced into the formed window under the control of a laparoscope and, using supports in the form of petals, the gland is fixed to the inner surface of the anterior abdominal wall. Then the device is mounted on the front abdominal wall by screwing onto the thread of the movable retainer. The installation of the device in this way allows you to delimit the abdominal cavity from the stuffing bag and adjust the depth of installation of the device in relation to the thickness of the abdominal wall. After that, working tools are introduced through the working channels and an omenobursopancreatoscopy is performed. The gland bag is sanitized with antiseptic solutions, the infected cavities are opened, the areas of pancreatic necrosis and sequestration of parapancreatic fiber are removed. In the presence of hypertension of the gallbladder, a cholecystostomy is applied, in the presence of an effusion in the abdominal cavity, the latter is removed. The stuffing bag is drained under the control of a laparoscope through two working channels with tubular PVC drainages, and after 10 mm a double-lumen silicone drainage is installed in the channel. Gas is desfused from the abdominal cavity, trocars are removed from the device, and the device is closed with a sterile napkin. According to the testimony, repeated sanitation of the stuffing bag, sequestrnecrectomy is carried out. After treatment, the device is removed, sutures are applied to the wound.

The above device, in contrast to the prototype, allows for single-port laparoscopic debridement of the omental bursa, abdominal cavity in patients with severe obesity by using four working channels and adjusting the installation depth of the proposed device with respect to the abdominal wall.

This device was used in 2 patients with acute destructive pancreatitis during laparoscopic surgery.

Example. Patient 3., 46 years old, was admitted on an emergency basis with a diagnosis of acute pancreatitis, hemorrhagic pancreatic necrosis. Osl .: Spilled enzymatic peritonitis. Reactive phase. Sop .: Obesity II Art. The patient began intensive care in the intensive care unit. According to the ultrasound of the OBP: ECHO - signs of pancreatic necrosis, the presence of free fluid in the abdominal cavity. After the treatment, a positive effect was not observed, to solve further tactics, the patient underwent diagnostic laparoscopy. In the abdominal cavity revealed a significant amount of enzymatic effusion, edema of the greater omentum. A 2.5 cm skin incision was made on the anterior abdominal wall in the left hypochondrium along the midclavicular line, a developed device with four working channels was installed for single-port laparoscopic debridement and drainage of the omental bursa and abdominal cavity. Trocars were introduced into the device: two - 5 mm and two - 10 mm. The effusion was removed from the abdominal cavity, the cavity was washed with a solution of aqueous chlorhexidine. In the gastrocolic ligament, an avascular site is determined, with technical difficulties, due to edema and obesity, the patient has a window formed using a dissector and a suction. Then, under the control of a video laparoscope, the device is inserted into the stuffing bag, the latter is fixed by means of supports made in the form of four petals. Then, using a movable retainer, the device is mounted on the abdominal wall. When performing omentobursopancreatoscopy revealed foci of hemorrhagic pancreatic necrosis. The effusion was drained using a suction through a 5 mm trocar, the stuffing bag was washed with an antiseptic solution. With the help of a dissector, scissors and suction, parapancreatic fiber is opened. Sequestries are removed, hemostasis is achieved by the dissector in monocoagulation mode. The stuffing bag is re-washed with an antiseptic solution. Three tubular drainages were installed through the working channels of the device: two through a 5 mm channel and double-lumen silicone drainage through a 10 mm channel, a flow-through drainage system with an antiseptic solution was connected to the latter. Hypertension of the gallbladder was not detected. In the postoperative period, the stuffing bag was washed through the installed drainage. On days 2, 6 and 10, planned reorganizations of the stuffing bag were completed, the cavities of the abscesses of the stuffing bag beginning to form were opened. The device is removed on the 14th day after the first operation. The patient was transferred from the intensive care unit. Discharged on the 24th day in satisfactory condition.

Claims (1)

A device for laparoscopic omentobursopancreatostomy made of latex and containing a working channel parallel to each other for introducing a laparoscope with an inner diameter of 10 mm and two working channels with an inner diameter of 5 mm for fixing instruments, fixators to the abdominal wall in the form of fixed supports, characterized in that the body of the device is made a cylindrical shape with a thread onto which a removable movable clamp of a cylindrical shape is screwed, which has an internal channel with a diameter of 40 mm with a thread and is equipped with four there are two fixed supports, while the device case is equipped with an additional working channel with an inner diameter of 10 mm for introducing double-lumen silicone drainage and two additional fixed supports, the channels of the device body and the clamp are parallel to each other, and their supports are made in the form of petals.

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