RU2525019C1 - Method for video-assisted appendectomy through single laparoscopic approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: laparoscopic approach is formed along the abdominal midline below the navel at 1/3 distance between the navel and a projection of the pubic symphysis. A single laparoscopic approach device is positioned. A carboxyperitoneum is created. That is followed by electric coagulation of the mesentery of the vermiform appendix. The vermiform appendix and the head of the blind colon are removed outside, that is combined with removing the single laparoscopic approach device. The carboxyperitoneum is eliminated. Appendectomy is performed. The vermiform appendix stump is immersed into the abdominal cavity. The device is re-positioned. The carboxyperitoneum is created. That is followed by abdominal re-inspection and sanitation. The device is removed. The carboxyperitoneum is eliminated. The wound is sutured.

EFFECT: method enables extending and facilitating the video-assisted appendectomy procedure from the single laparoscopic approach, providing more reliable treatment of the vermiform appendix stump and higher quality of abdominal sanitation.

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Description

The invention relates to surgery, namely to abdominal surgery, and can be used when conducting laparoscopic appendectomy through a single access system.

A known method of laparoscopic appendectomy proposed by the German gynecologist K. Semm in 1982, which for the first time in the world performed a laparoscopic appendectomy. He applied the classic, technically more complex method of appendectomy with stitching the mesentery of the appendix in the ligature and immersing the stump of the appendix in the wall of the cecum with purse-string and Z-shaped sutures. Thus, the surgeon proved that the capabilities of laparoscopic surgery allow performing appendectomies in the most common way (Kasumyan S.A., Nekrasov A.Yu., Zhuravlev V.N. et al. Laparoscopic technology of appendectomy. Endoscopic surgery. - 1998. - No. 1 . - S.21-22).

The most prevalent variant was the laparoscopic appendectomy, including the installation of trocars paraumbilical, in the right and left iliac regions, sequential electrocoagulation of the mesentery of the vermiform appendix, followed by the application of the Roedera loop on the base of the appendix, intersection and removal of the appendix through 10 mm trocar.

The main disadvantages of the analogue are: an increase in the time of surgical intervention, a decrease in cosmetic attractiveness for the patient due to the appearance of several postoperative scars.

Closest to the claimed invention in terms of features is a method of video laparoscopic appendectomy (Vidal O. Ginesta C, and other. Suprapubic single -incision iaparoscopic appendectomy: anonvisible-scar surgical option. Surg Endosc (2011) 25: 1019-1023), in which after placement of the urinary catheter, a 25 mm transverse suprapubic incision is made at the intersection between the midline of the abdomen and the pubic hairline. Layered opening of the abdominal cavity, dissection of the aponeurosis is performed longitudinally. Under visual control, a SILS Port device is inserted into the anterior abdominal wall, through which three 5-mm cannulas are inserted into the abdominal cavity. A 5 mm laparoscope, standard endoscopic clamp and scissors are used. The mesentery of the process is crossed by monopolar coagulation. On the base of the appendage, two Raeder endo-loops are superimposed. The wound is sutured in layers.

The main disadvantages of the prototype are: an increase in the time of surgical intervention, as well as the need to process the base of the vermiform appendix and the formation of its stump in the abdominal cavity, which increases the duration of the operation and the risk of developing intraoperative and postoperative intra-abdominal complications.

The objective of the invention is to improve the method of appendectomy through a single laparoscopic approach to improve the quality of the operation and the prevention of postoperative intra-abdominal and wound complications.

The task is achieved by the method of video-assisted appendectomy through a single laparoscopic access, including access, installation of a device for a single laparoscopic access into the wound, insertion of instruments, and appendectomy. Laparoscopic access is performed along the midline of the abdomen below the navel at a distance equal to 1/3 of the distance between the navel and the projection of the pubic symphysis. Open the anterior abdominal wall in layers. After installing the device for a single laparoscopic access create a carboxyperitoneum 12-14 mm RT.article Electrocoagulation of the mesentery of the appendix is performed and its intersection. The vermiform appendix and the dome of the cecum are removed through the wound to the outside with simultaneous removal of the device for a single laparoscopic access. Eliminate carboxyperitoneum. Perform an appendectomy. After treatment, immerse the stump of the appendix in the abdominal cavity. Reinstall the device for a single laparoscopic access. Create carboxyperitoneum 12-14 mm Hg A control examination of the abdominal cavity is carried out and, if necessary, its additional rehabilitation is performed. Remove the device for a single laparoscopic access, eliminate carboxyperitoneum. The peritoneum, aponeurosis are sutured, sutures are applied to the skin of the postoperative wound.

Novelty of invention

1. Laparoscopic access is performed along the midline of the abdomen below the navel at a distance equal to 1/3 of the distance between the navel and the projection of the pubic symphysis. The point for access and installation of the device for a single laparoscopic access was selected, based on the data of anatomical examination, which allows to reduce the distance between the base of the appendix and the surgical wound, while maintaining the adequacy of visualization of the surgical area, which in turn extends and simplifies the ability to perform video-assisted appendectomy from a single laparoscopic access.

2. After installing the device for a single laparoscopic access create a carboxyperitoneum 12-14 mm RT.article Electrocoagulation of the mesentery of the appendix is performed and its intersection. The vermiform appendix and the dome of the cecum are removed through the wound to the outside with simultaneous removal of the device for a single laparoscopic access. Eliminate carboxyperitoneum. In this case, the abdominal wall drops and the distance between the base of the appendix and the surgical wound is reduced, which allows us to remove the appendix and the dome of the cecum from the abdominal cavity for appendectomy.

3. Perform an appendectomy outside the abdominal cavity. After treatment, immerse the stump of the appendix in the abdominal cavity. Treatment of the stump outside the abdominal cavity reduces the time of the operation, increases reliability and ensures the prevention of intra-abdominal postoperative complications due to better treatment of the stump.

4. Reinstall the device for a single laparoscopic access. Create carboxyperitoneum 12-14 mm Hg A control examination of the abdominal cavity is carried out and, if necessary, its additional rehabilitation is performed. Remove the device for a single laparoscopic access, eliminate carboxyperitoneum. The peritoneum, aponeurosis are sutured, sutures are applied to the skin of the postoperative wound. The quality of abdominal sanitation is improved, the development of complications is prevented.

Use in clinical practice of the proposed method allows to achieve a new technical result:

1. To expand and simplify the possibilities of video-assisted appendectomy from a single laparoscopic approach.

2. To increase the reliability of processing the stump of the vermiform appendix and to solve the problem of insolvency of the stump of the vermiform appendix in the postoperative period and the quality of sanitation of the abdominal cavity if necessary.

In an anatomical study, it was found that the location and mobility of the cecum dome allows the base of the vermiform appendix / cecum dome to be displaced into the access displaced along the midline of the abdomen 1/3 below the navel in 77.19% of cases. This access point can be used to perform video-assisted appendectomy using a mono-access system.

The invention is illustrated by the diagrams presented in figure 1 - figure 2.

Figure 1 shows a top view of the anterior abdominal wall and access point.

Figure 2 shows the installation of the device for a single laparoscopic access and instruments.

The invention is as follows. At the access point 1 along the midline of the abdomen at a distance of 1/3 below the navel 2 relative to the distance between the navel 2 and the projection of the symphysis 3, a transverse or longitudinal section of the skin 4 is performed 2.5 cm long. Subcutaneous fat is dissected until imaging of the aponeurosis, then dissected aponeurosis, peritoneum. A device for a single laparoscopic access 5 "ENDOPORT PPP", or Endocone, or X-Conne, or Covidien is installed in the surgical wound. By supplying carbon dioxide create carboxyperitoneum 12-14 mm RT.article The patient is transferred to the Trendelenburg position with the operating table tilted to the left by 15 °. Through a device for a single laparoscopic access, a video laparoscope 6 and two 5-mm working endoscopic instruments 7, 8 are inserted into the abdominal cavity. After a review video laparoscopy, confirmation of the diagnosis of acute appendicitis and assessment of the prevalence of the inflammatory process, the mesentery of the appendix is coagulated and intersected. Visually assess the mobility of the dome of the cecum by moving the apex of the appendix in the direction of the access wound and when moving the dome of the cecum from the localization site more than 2/3 of the distance to the access wound, they consider mobility sufficient. The appendix is captured by an endoscopic clamp and removed through the surgical wound, while the device for a single laparoscopic access is removed from the surgical wound. Two ligatures are applied to the base of the vermiform appendix, the appendix is intersected, the mucous membrane of the stump of the appendix is electrocoagulated, and the stump is immersed in the abdominal cavity. The wound is sutured in layers with suture material with a long resorption period with separate interrupted sutures with grasping of the peritoneum and aponeurosis. Skin sutures are applied to the postoperative wound.

Clinical example

Patient N., 27 years old, medical history No. 4879/4886, was hospitalized in the Department of General Surgery, MDLP GKB No. 1 of Novokuznetsk with a diagnosis of Acute appendicitis. The duration of the disease is 9 hours. An access point is planned along the midline of the abdomen below the navel at a distance of 1/3 between the navel and the projection of the pubic symphysis. The distance between the navel and the projection of the symphysis pubis was 15 cm, respectively, a transverse skin incision was made 2.5 cm long 5 cm below the navel. Dissected subcutaneous fat, aponeurosis, peritoneum. A device for a single laparoscopic access SILS Port (X-Cone) was installed in the wound. Pneumoperitoneum 12-14 mm Hg An examination was made, the diagnosis was confirmed: acute appendicitis, other acute pathology was excluded. The patient is shown surgery - appendectomy. The mobility of the dome of the cecum is sufficient, since traction beyond the apex of the appendix in the direction of the wound of access, noted the possibility of moving the dome of the cecum 2/3 of the distance to the wound of access. The mesentery of the appendix is coagulated and crossed. The appendix is captured by an endoscopic clamp. The SILS Port device was removed from the wound through which the vermiform appendix and the dome of the cecum were brought out. The appendix is twice ligated at the base and crossed. The mucous membrane of the stump of the appendix is electrocoagulated and immersed in the abdominal cavity. The device for a single laparoscopic access SILS Port (X-Cone) is reinstalled in the wound. Pneumoperitoneum 12-14 mm Hg Inspection performed. The stump of the appendix is examined - wealthy. An additional rehabilitation of the right iliac fossa was performed. The wound was sutured in layers with the application of individual nodal sutures on the peritoneum, aponeurosis, cosmetic intradermal suture on the skin. The duration of the operation was 43 minutes. No postoperative complications were noted, the wound healed by first intention.

Thus, the proposed method allows to increase the reliability of processing the stump of the appendix and to solve the problem of insolvency of the appendix stump in the postoperative period by performing processing outside the abdominal cavity.

Claims (1)

The method of video-assisted appendectomy through a single laparoscopic access, including access, installation of a device for a single laparoscopic access into the wound, insertion of instruments, appendectomy, characterized in that laparoscopic access is performed along the midline of the abdomen below the navel at a distance equal to 1/3 of the distance between the navel and a projection of the pubic symphysis, open the anterior abdominal wall in layers, after installing the device for a single laparoscopic approach, create carboxyperitonea m 12-14 mm Hg, electrocoagulation of the mesentery of the vermiform appendix and its intersection is performed, the vermiform appendix and the dome of the cecum are removed through the wound to the outside with simultaneous removal of the device for a single laparoscopic access, the carboxyperitoneum is eliminated, appendectomy is performed, and the appendix is immersed process in the abdominal cavity, re-install the device for a single laparoscopic access, create a carboxyperitoneum 12-14 mm Hg, carry out a control examination ryushnoy cavity and if necessary operate extra its sanitation is removed laparoscopic device for single access eliminate karboksiperitoneum, sutured peritoneum, the fascia, skin sutured surgical wounds.

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