RU2472463C1 - Method of safe access to abdominal cavity in patients with post-operative intra-abdominal complications - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to surgery and can be applied for safe access to abdominal cavity in patients with post-operation intra-abdominal complications. First trocar is introduced into abdominal cavity by means of "Step" system, installed directly between sutures of laparotomic wound or sewn trocar wound.

EFFECT: method makes it possible to reduce risk of purulent complications in wound, reduce risk of hemorrhages, reduce trauma.

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Description

The invention relates to medicine, namely to ensuring safe access to the abdominal cavity during surgical treatment of patients with postoperative intra-abdominal complications using endovascular surgery technologies, and can be used in endoscopic surgery.

Creating access to the abdominal cavity during laparoscopic surgery is one of the most critical stages of surgical intervention, and the risk of complications is significantly increased in previously operated patients.

Analysis of the literature shows that the introduction of the first trocar is the most dangerous stage of laparoscopic surgery (Baranov G.A., Zavyalova N.I., Karbovsky M.I. Danger of the "first trocar" in laparoscopic surgery // Endoscope, surgery. - 2006. - No. 2. - P.15. - Materials of the IX All-Russian Congress on Endoscopic Surgery; Laparoscopic Surgery for Adhesive Disease / A.G. Beburishvili, I.V. Mikhin, A.A. Vorobiev, etc. // Surgery. - 2004. - No. 6. - P.27-30; Injuries caused by Veress needle insertion for creation of pneumoperitoneum: a systematic iterature rewiew / JLAzvedo, OCAzvedo, SAMiyahira, GP Miguel, OMBecker et al. // Surg. Endosc. - 2009. - Vol.23, No. 7. - P.1428-1432), since a number of potential complications pose a direct threat to the patient's life (Ahmad G., Duffy JM, Watson. A. / Laparoscopic entry techniques and complications // Int. J. Gynecol. Obstet. - 2007. - Vol.99, No. 1. - P.52-55; Major vascular injuries in laparoscopic surgery / GCRoviaro, F. Faroli, L. Saguatti et al . // Surg. Endosc. - 2002 .-- Vol.16. - P.1192-1196). The threat of such complications increases significantly in patients who have previously undergone any operations on the abdominal organs, in patients with acute intestinal obstruction and intestinal paresis (Sedov V.M., Strizheletsky V.V. Complications in laparoscopic surgery and their prevention. - St. Petersburg .: St. Petersburg Medical Publishing House, 2002. - 180 s). According to the literature, the greatest number of intra-abdominal complications occurs with the "blind" introduction of the first trocar. Based on the analysis of 6106 laparoscopic interventions, G.A.Baranov, N.I. Zavyalova, M.I.Karbovsky found that at the stage of access to the abdominal cavity without prior application of pneumoperitoneum with the “single-puncture” technique, serious complications occurred in 0.13% of patients and mortality was 0.03%.

Thus, the danger of the "first" trocar cannot be considered exaggerated (Baranov G.A., Zavyalova N.I., Karbovsky M.I. The danger of the "first" trocar in laparoscopic surgery // Endoscope. Surgery. - 2006. - No. 2. - P.15. - Materials of the IX All-Russian Congress on Endoscopic Surgery).

It is known that the STEP system (www.laparoscopy.ru) provides a qualitatively new access to the cavity - more reliable, easier, safer. It significantly reduces the risk of damage to internal organs and structures during the first blind introduction of the trocar (Bhoyrul S, Way L. Radially Expanding Dilation: A Superior Method of Laparoscopic Trocar Access. - Surg Endosc. - 1996. - Vol.10. - P. 795-798; Feste JR, Bojahr B., Turner DJ Randomized Trial comparing a Radially Expandable Needle System With Cutting Trocars. - JSLS. - 2000. - Vol.4, No. 1. - P.11-15; Galen DI, Jacobsen A., Weckstein LN, Kaplan RA, DeNevi KL Reduction of Cannula-Related Laparoscopic Complications Using a Radially Expanding Access Device. - JAAGL. - 1999. - Vol.6, No. 1. - P.79-84; Turner D. Making The Case for the Radially Expanding Access System Gynaecological Endoscopy. - 1999. - Vol.8, No. 6. - P.391-395; Rothenberg SS, Georgeson K., DeCou JM, Downey EG, Lelli JL, Raschbaum G., Moores D. A Clinical Evaluation of the Use of Radially Expandable Laparosco pic Access Devices in the Pediatric Population. - Pediatric Endosurgery and Innovative Techniques. - 2000. - Vol. 4, No. 1. - P.7-11).

A device for applying pneumoperitoneum, designed to create an "air cushion" and the safe introduction of the trocar into the abdominal cavity (patent RU No. 40874, class A61B 17/32, 2004), containing a hollow needle, articulated with the body, inside which passes the mandrin in the form the rod, which acts as a pusher of the tip, the latter either closes or opens the hole of the hollow needle in the distal part of the instrument, forming a check valve that prevents gas from entering the tissue before the needle penetrates into the abdominal cavity. In addition, a knurled nut is located inside the housing, which regulates the course of the mandrel and eliminates unauthorized changes in its course.

The described tool makes it possible to safely apply pneumoperitoneum, but it has drawbacks, in particular, it does not allow to control the process of introducing the first trocar and, therefore, cannot fully guarantee the prevention of trocar damage.

The closest technical solution is a device for laparoscopy (patent RU No. 2375976, class A61B 17/34, 2009), adopted as a prototype containing a tubular sleeve and stylet. The stylet is made in the form of a rod with a tip, which consists of three detachable parts. The central part of the rod has a pointed end. The sleeve is made of elastic material and has an end protrusion at the end on the opposite side of the pointed end of the stylet, and each side part is provided with an end protrusion. The device has an increased reliability of fixation, reduces the invasiveness of laparoscopy and reduces the time of manipulation.

However, the known technical solution has disadvantages.

It does not allow to apply pneumoperitoneum after the introduction of the trocar, cannot exclude damage to internal organs when the trocar is introduced, since the stylet is equipped with a pointed tip, and, in addition, the tool does not allow the use of larger diameter trocars without expanding surgical access, which increases the invasiveness of the intervention and the risk of complications.

The task of the invention is to increase the safety of the process of introducing the first trocar into the abdominal cavity when performing laparoscopic interventions in patients with postoperative intra-abdominal complications after surgery on the organs of the abdominal cavity.

The task is achieved in that in patients with postoperative intra-abdominal complications when performing repeated interventions, the laparoscopic first trocar is introduced into the abdominal cavity using the Step system, which is installed directly between the sutures of the laparotomy wound or the sutured trocar wound.

The technical result of the proposed method is to increase the safety of laparoscopic surgical interventions, reduce the risk of damage to internal organs and reduce trauma to the postoperative wound.

The essence of the proposed method is illustrated by drawings, where in Fig. 1, where A is the Step system, installed between the sutures of the laparotomy wound and ready for use, in Fig.2, where B is the working part of the system, consisting of a mesh braid and able to adapt to the diameter of the introduced trocar.

The method is as follows.

A radially expanding cuff-cannula with a Veresh needle inserted into its lumen is inserted directly between the sutures of the laparotomy wound or the sutured trocar wound. Then, according to the Veress needle, pneumoperitoneum is applied, the needle is removed and the system is ready for use (Fig. 1). Next, a trocar with an atraumatic stylet is inserted into the lumen of the cannula (Fig. 2), then the stylet is removed and pneumoperitoneum is applied over the trocar.

Comparative analysis with prototypes shows that the working part of the system, namely the radially expanding cuff-cannula, consisting of a mesh braid and not having rigid structures (Fig. 2), and the atraumatic stylet introduced with its use, equipped with a blunt tip, minimize the possibility of damage to internal organs. In addition, the use of this system allows the imposition of pneumoperitoneum after the introduction of the first trocar. The working part of the system, represented by a radially expanding cuff-cannula, is installed using a 2 mm needle. In the course of work, it is able to adapt to the diameter of the introduced trocar (Fig. 2), i.e. accept the corresponding diameter, which allows the use of trocars of various diameters - from 5 to 12 mm without additional adapters and expanding operative access, therefore, reducing the risk of damage to internal organs during surgery, as well as reducing the trauma of the postoperative wound itself.

The Step system was used to introduce the first trocar in order to create safe access to the abdominal cavity in 12 patients with postoperative intraperitoneal complications, such as postoperative peritonitis, abdominal abscesses, postoperative intestinal obstruction, intraperitoneal bleeding and bile duct. Complications at the stage of access to the abdominal cavity in these patients were not observed (Vishnevskaya A.N. Laparoscopy in the diagnosis and treatment of postoperative complications in abdominal surgery: abstract of dissertation of the candidate of medical sciences. - Vladivostok, 2011. - 24 p.).

Clinical examples of the method.

Example No. 1:

Patient V., 49 years old, was admitted to the surgical department of the Department Clinical Hospital of JSC Russian Railways at Vladivostok station on January 17, 2008 with a diagnosis of Gallstone disease. Chronic calculous cholecystitis. In connection with a suspicion of choledocholithiasis according to ultrasound data (0.4 cm signal in the projection of the common bile duct), the patient was referred to retrograde cholangiopancreatography on January 18, 2008, in which no pathology was detected, and subsequent laparoscopic cholecystectomy on January 19, 2008. From the first day of the postoperative period, the patient complained of pain in all parts of the abdomen, nausea, and dry mouth. On examination, the patient's condition was regarded as moderate. Hemodynamics is stable. The abdomen is soft, swollen, painful in the epigastrium, right and left hypochondrium, without symptoms of peritoneal irritation. Gases departed. There was no discharge from the abdominal cavity by drainage; the latter was removed. Postoperative wounds are calm. The presence of acute pancreatitis was suspected, infusion therapy with antispasmodics and sandostatin was prescribed. In biochemical blood tests dated January 21, 2008: ast 1.13 μmol / L, alt 0.5 μmol / L, amylase 12 mg / (s · l), urine diastase 43 mg / (s · l). During treatment, the patient’s condition with a positive effect, pain in the abdomen decreased significantly, with ultrasound from 01/23/2008: the gall bladder was removed, bile duct 7 mm, the pancreas with a smooth contour of 2.8 cm × 1.1 cm × 1, 8 cm low echogenicity. In control analyzes dated January 23, 2008: amylase 6.5 mg / (s · l), urine diastase 43 mg / (s · l). In a clinical blood test dated January 23, 2008: leukocytes 4.0 × 10 ⁹ / l, stab nuclear 7%, ESR 5 mm / hour. Given the reduction of pain, the absence of significant changes in ultrasound and a decrease in amylasemia, treatment was continued. However, on January 24, 2008, the patient's condition worsened, pain in the abdomen increased sharply. On examination, tachycardia was observed up to 96 in 1 minute. The abdomen is painful in the epigastrium and right hypochondrium. There were no obvious symptoms of peritoneal irritation. With a diagnosis of acute pancreatitis, pancreatic necrosis, the patient was taken for diagnostic relaparoscopy. Access to the abdominal cavity was carried out using the Step system. A radially expanding cannula cuff, worn on a Veress needle, was inserted between the sutures of the sutured trocar wound in the paraumbilical region. Pneumoperitoneum 15 mm Hg was applied. The insufflation needle is removed, a 10 mm trocar with a blunt stylet is inserted into the radially expanding cuff-cannula, then the stylet is removed and the laparoscope is inserted. During the audit: in the abdominal cavity along the right and left flank, in the small pelvis effusion of a light color. On a large omentum - traces of pancreatic necrosis. An omentum bag was opened in which there was effusion. The abdominal cavity is washed, drained, drained by tubular drains: into the small pelvis, along the right flank, along the left flank, into the stuffing bag.

Postoperative diagnosis: Condition after laparoscopic cholecystectomy. Fatty pancreatic necrosis. Spilled enzymatic peritonitis.

In the postoperative period, the patient was given infusion therapy, antibacterial therapy (abactal 400 mg intravenously drip × 2 times a day in combination with cefotaxime 1.0 × 4 times a day intramuscularly) for 7 days, prevention of thromboembolic complications with clexane 0.4 × 1 times per day subcutaneously for 5 days. Smooth postoperative period. The patient was discharged on the 10th day.

Example No. 2:

Patient V., 59 years old, was admitted to the surgical department No. 1 of the Primorsky Regional Clinical Hospital No. 1 on November 27, 2007 with a diagnosis of Gallstone disease. Acute calculous cholecystitis. The patient underwent conservative therapy, which turned out to be ineffective, and on November 29, 2007, the patient under urgent indications underwent laparotomy, cholecystectomy for phlegmonous gangrenous acute cholecystitis. From the 1st day of the postoperative period, the patient complained of moderate pain in the right hypochondrium and leakage of bile past the drainage. On examination, the abdomen is soft, moderately painful in the right hypochondrium without peritoneal symptoms. On drainage - poor serous-hemorrhagic discharge. Infusion and antibiotic therapy were prescribed. December 4, 2007, the condition of the patient with negative dynamics in the form of increased pain in the right hypochondrium. On examination, weakly positive symptoms of peritoneal irritation appeared, the bandage in the area of the drainage standing was abundantly wet with bile. In view of the clinic of peritonitis, the patient was shown laparoscopy. Operated on December 4, 2007. The abdominal cavity was accessed using the Step system. A radially expanding cannula cuff, worn on the Veress needle, is inserted between the sutures of the sutured laparotomy wound below the navel. The pneumoperitoneum of 12-15 mm Hg was applied. The insufflation needle is removed, a 10 mm trocar with a blunt stylet is inserted into the radially expanding cuff-cannula, then the stylet is removed and the laparoscope is inserted. During the audit: in the subphrenic space on the right, up to 20 ml of bile and fibrin. The place of bile leakage was found - Lyushka's course, clipped. The abdominal cavity is sanitized, a drainage tube and a glove are installed in the gallbladder bed. Subsequently, the usual course of the postoperative period, the drainage was removed on the 3rd day, on December 14, 07, was discharged in a satisfactory condition.

The inventive method allows to secure the process of introducing the first trocar into the abdominal cavity in previously operated patients with postoperative intra-abdominal complications, including after laparotomic interventions, and to avoid the development of access-related complications, such as damage to the abdominal organs and vascular injuries.

Claims (1)

A method of safe access to the abdominal cavity in patients with postoperative intra-abdominal complications, including the use of the Step system, characterized in that, in order to increase the safety of laparoscopic surgery and reduce the risk of damage to internal organs, the first trocar is introduced into the abdominal cavity using the Step system "Installed directly between the sutures of the laparotomy wound or sutured trocar wound.

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