RU2513800C1 - Method for short-scar incision of gall bladder and extrahepatic bile ducts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: skin and subcutaneous fat are incised longitudinally in a right hypochondrium 2-3 cm lower from an edge of a costal arch of the length up to 5 cm. An anterior leaf of an aponeurosis of an abdominal rectus muscle is incised longitudinally in compliance with the length of the skin incision. In an upper corner, the incision is extended to the right at an angle of 45 degrees, of the length up to 3 cm. In a lower corner of the wound, the incision of the leaf of the aponeurosis is similarly deflected to the left. Muscle fibres of the abdominal rectus muscle are bluntly layered, and a posterior leaf of the aoneurosis is exposed. The latter is gripped together with the peritoneum and dissected longitudinally up to 5 cm. The incision of the posterior leaf of the aponeurosis is formed similarly to the incision of the anterior leaf.

EFFECT: expansion of surgical manipulations on the gall bladder, hepatoduodenal elements, reduced intraoperative injuries and risk of developing postoperative hernias and other postoperative complications.

1 ex, 1 dwg

Description

The invention relates to medicine, namely to abdominal surgery, and can be used in operations for gallstone disease.

There is a method of surgical access to the gallbladder and common bile duct, which consists in the fact that layer-by-layer dissection of tissues of the anterior abdominal wall is carried out, access is formed by sequential dissection of the skin parallel to the costal arch at a distance of 2-3 cm below its edge, starting at 2-3 cm lateral to the midline, 4-5 cm long, of the anterior sheet of the vagina of the right rectus abdominis muscle, respectively, the length and direction of the skin incision, the longitudinal separation of the fibers of the right rectus abdominis muscle and dissection of the posterior sheet vagina right rectus abdominis and peritoneum, respectively, toward the skin incision (see. RF patent №2309682, publ. 10.11.2007).

The reasons that impede the achievement of the technical result indicated below when using the known method include the limited availability of the neck of the bile and common bile duct, since the muscle fibers have a longitudinal direction, it is difficult to separate them in the transverse direction, which leads to trauma to the fibers of the right rectus muscle and worsens healing of a postoperative wound.

The closest technical solution in relation to the proposed set of essential features is the mini-access method according to M. Prudkov. (see Prudkov MI "Minilaparotomy and open laparoscopy in the treatment of patients with gallstone disease." Abstract of a doctor of medical sciences. Moscow, 1993. S.13-16). This access is performed in the following way: a vertical transrectal incision of the anterior abdominal wall up to 5 cm long is performed over the projection site of the hepatoduodenal ligament onto the anterior abdominal wall. The skin, subcutaneous tissue, and anterior leaf of the aponeurosis are dissected. The muscle fibers of the right rectus abdominis muscle bluntly stratify along the fibers and expose the posterior leaf of the aponeurosis of the rectus muscle. The latter, along with the peritoneum, is captured and dissected also in the vertical direction.

The reasons that impede the achievement of the following technical result when using the known method adopted for the prototype include the limited availability of the neck of the bile duct and common bile duct.

The objective of the invention is to provide a method of mini-access to the gallbladder and extrahepatic bile ducts, providing a technical result consisting in expanding the scope of surgical procedures on the gallbladder, elements of the hepatoduodenal ligament, reducing the morbidity of the operation, the risk of developing postoperative hernias and other postoperative complications.

The specified technical result is achieved by the fact that the method of mini-access to the gallbladder and extrahepatic bile ducts includes a cut of the skin, subcutaneous tissue, dissection of the anterior leaf of the aponeurosis of the rectus abdominis muscle, blunt dissection along the muscle fibers of the right rectus muscle of the abdomen and exposure of the posterior leaf of the aponeurosis of the rectus muscle, which then along with the peritoneum capture and dissect.

The peculiarity is that a skin incision is made in the right hypochondrium below the edge of the costal arch by 2-3 cm, the lateral midline is 2-3 cm up to 5 cm long, in the upper corner of the wound, the incision of the anterior leaf of the aponeurosis is deflected to the right at an angle of 45 degrees up to 3 cm, and in the lower corner of the wound, the incision of the anterior leaf of the aponeurosis is deflected to the left at an angle of 45 degrees, up to 3 cm long, a section of the posterior leaf of the aponeurosis of the rectus muscle is similarly formed.

The invention is illustrated in the drawing, where 1 is a costal arch; 2 - an incision of the skin, subcutaneous tissue, anterior and posterior leaf of the aponeurosis of the rectus muscle; 3 - in the upper corner of the wound, the incision of the aponeurosis is deflected to the right at an angle of 45 degrees; 4 - in the lower corner of the wound, the incision of the aponeurosis is deflected to the left at an angle of 45 degrees.

The method is as follows.

In the right hypochondrium, cut the skin, subcutaneous tissue (item 2) below the edge of the costal arch 1 by 2-3 cm, the lateral midline by 2-3 cm, up to 5 cm long and the front sheet of the aponeurosis of the rectus muscle (pos. 2). In the upper corner of the wound, the incision of the anterior leaf of the aponeurosis is deflected to the right (pos. 3) at an angle of 45 degrees, up to 3 cm, then in the lower corner of the wound, the incision of the anterior leaf of the aponeurosis is deflected to the left (pos. 3) at an angle of 45 degrees, up to 3 cm The muscle fibers of the right rectus abdominis muscle bluntly stratify along the fibers and expose the posterior leaf of the aponeurosis of the rectus muscle. The posterior leaf of the aponeurosis of the rectus muscle along with the peritoneum is captured and dissected (pos. 2), then in the upper corner of the wound, the incision of the posterior leaf of the aponeurosis is rejected to the right (pos. 3) at an angle of 45 degrees up to 3 cm long. Then, in the lower corner of the wound, the incision of the posterior leaf aponeurosis is deflected to the left (pos. 4) at an angle of 45 degrees, up to 3 cm long. All this ensures adequate accessibility of the neck of the gallbladder and extrahepatic bile ducts.

Clinical example.

Patient K., 74 years old, was admitted to the 6th Department of Surgery of the Municipal Clinical Hospital of the UGKBSMP of Ulyanovsk on June 12, 2012 with a diagnosis of Gallstone disease. Acute destructive cholecystitis.

Upon admission, the patient's condition is moderate. The skin is of normal color. In the lungs, vesicular breathing. A / D 150/90 mm Hg Heart sounds are muffled, rhythmic. The abdomen is not swollen, soft, painful on palpation in the right hypochondrium, where an enlarged, tense, painful gall bladder is palpated.

With ultrasound, the gallbladder is enlarged 11 × 3.5 cm, the walls are thickened to 7 mm, and there are three large calculi in the lumen. Pathology of the liver, pancreas was not detected. The diameter of the common bile duct is 7 mm. Conducted preoperative preparation. 06/12/2012, the patient was urgently operated.

An incision was made of the skin, subcutaneous tissue below the edge of the costal arch by 2 cm, the lateral midline by 2 cm, 4 cm long, and the anterior leaf of the aponeurosis of the rectus abdominis muscle was dissected, and then in the upper corner of the wound, the incision of the anterior leaf of the aponeurosis was deflected to the right at an angle of 45 degrees , 2.5 cm long, then in the lower corner of the wound, the incision of the anterior leaf of the aponeurosis is deflected to the left at an angle of 45 degrees, 2.5 cm long. The muscle fibers of the right rectus muscle bluntly stratified along the fibers and exposed the posterior sheet of the rectus aponeurosis. The posterior leaf of the aponeurosis along with the peritoneum was captured and dissected according to the length of the skin incision, then in the upper corner of the wound, the incision of the posterior leaf of the aponeurosis is deflected to the right at an angle of 45 degrees, 2.5 cm long, and in the lower corner of the wound, the incision of the posterior leaf of the aponeurosis is rejected to the left at an angle 45 degrees, 2.5 cm long. Cholecystectomy from the neck. During the control ultrasound scan dated June 17, 2012, there is no free fluid in the subhepatic space and in the projection of the gallbladder bed. Postoperative course without features. Sutures were removed on the 7th day. Primary healing. Histological examination: acute phlegmonous cholecystitis.

Discharged in satisfactory condition on the 8th day after the operation. Examined after six months. She did not make any complaints, she tries to adhere to diets, and estimates the result of the operation as good.

Thus, the proposed method allows to provide an adequate amount of surgical procedures on the gall bladder, elements of the hepatoduodenal ligament, reduces the invasiveness of the operation, the risk of developing postoperative hernias and other postoperative complications and improves the healing processes of the postoperative wound.

Claims (1)

A method of mini-access to the gallbladder and extrahepatic bile ducts, including a cut of the skin, subcutaneous tissue, dissection of the anterior sheet of the aponeurosis of the rectus abdominis muscle, blunt dissection along the muscle fibers of the right rectus muscle of the abdomen and exposure of the posterior sheet of the aponeurosis of the rectus muscle, which is then captured and dissected together with the peritoneum characterized in that the skin incision is carried out in the right hypochondrium below the edge of the costal arch by 2-3 cm, the lateral midline is 2-3 cm up to 5 cm long, in the upper corner of the wound, the incision of the anterior foxes Single aponeurosis deflect to the right at an angle 45 degrees up to 3 cm, and the bottom corner of the front sheet wound incision aponeurosis deflect to the left at an angle of 45 degrees, a length of 3 cm, and then formed similarly cut back sheet rectus fascia.

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