RU2531138C1 - Method for performing transvaginal appendectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method refers to medicine, namely to surgery. Two trocars of the diameter of 5 mm are inserted through a 10-mm umbilical approach into the abdominal cavity. That is followed by a visually controlled puncture of a posterior vaginal vault with the trocar of the diameter of 10 mm for laparoscopic transvaginal appendectomy. The vermicular appendix is mobilised by bipolar coagulation through an additional trocar from the umbilical approach. The appendix base is clipped with three 8-mm clips through the 10-mm trocar of the vaginal approach. The vermicular appendix is transacted between the distal clips. The appendix is removed through the 10-mm trocar of the vaginal approach. That is followed by a controlled inspection, lavage and drainage of the abdominal cavity. The trocar of the vaginal approach is removed under visual control. The posterior vaginal vault wound is not closed. A hydrogen peroxide tissue is inserted into the vagina. The umbilical approach wound is closed in layers.

EFFECT: method enables reducing the length of the operation, providing visual control through the umbilical approach, reducing the number of vaginal injuries and avoiding the instrumental conflict.

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Description

The invention relates to surgery, namely to abdominal surgery, and can be used for appendectomy in the treatment of acute appendicitis.

A known method of transvaginal laparoscopic appendectomy (Svyatovets S. S. The method of transvaginal (transluminal) laparoscopic appendectomy is our experience. // Endoscopic surgery, - No. 1. - 2009. - P.199), which consists in the following: the first stage in the left iliac region carboxyperitoneum is formed with a 3 mm trocar needle and an initial examination of the abdominal cavity with a 2 mm laparoscope (MiniSite) is performed. After confirming the diagnosis of acute appendicitis under the control of a 2 mm laparoscope, a posterior colpotomy is performed along the transitional fold of the vagina and an 11 mm trocar for a 30-degree laparoscope is introduced. Additionally, a 3 mm or 5 mm trocar for the manipulator is installed above the bosom on the right. The second step is the replacement of a 2 mm laparoscope in the left iliac region with a 10 mm laparoscope inserted transvaginally. The mobilization of the appendix is standard: the mesentery is crossed by a bipolar coagulator, two endo-loops and one on the distal are superimposed on the proximal stump of the appendix. The appendix is placed in a container and removed through the vaginal port under the control of a 2 mm laparoscope in the left iliac region. The colpotomy opening is sutured with one interrupted suture (vicryl 3/0). If necessary, drainage is established through the trocar wound in the right iliac region. Wounds from 5 mm trocars on the anterior abdominal wall are sealed with a sterile patch.

The disadvantages of this method are the need to use two optical systems, a kit for mini-laparoscopy, the need to move the optics from one trocar to another, perform several punctures on the anterior abdominal wall, which reduces the cosmetic effect, the introduction of a laparoscope through vaginal access, which complicates visualization of the organs of the small pelvis and limits the implementation of the technique in patients with a pelvic and subhepatic arrangement of the appendix.

The closest to the claimed invention in terms of features is a method of laparoscopic appendectomy with combined transumbilical and transvaginal access (Fedorova KE Optimization of laparoscopic surgical access in the treatment of acute appendicitis in women. Abstract of dissertation for the degree of candidate of medical sciences, Ufa, 2012). The first 5 mm trocar is transumbilical to insert an optical system (access No. 1). Diagnostic laparoscopy, revision of the abdominal cavity, and pelvis are performed. The cervix is exposed in the mirrors, single-tooth bullet forceps are applied, the posterior vaginal fornix is punctured with a 10-mm trocar (access No. 2) under visual control on the monitor. Additionally, a 5 mm trocar is installed in the rear arch (access No. 3). A laparoscope is inserted transvaginally through a 10 mm port with a 30-degree axis of view, and an exciting clip is inserted through a 5 mm port. The distal end of the appendix is captured by the clamp introduced through access No. 3, traction is performed. Using bipolar coagulation and endoscopic scissors installed through access No. 1, the mesentery of the appendix is processed. The formation of the appendix stump is performed by the “ligature” method with the application of three ligatures. On the cult of the appendix, 2 ligatures are left. After cutting off the appendix, the mucous membrane of the stump is coagulated by bipolar forceps. The appendix is removed through access No. 2, after moving the laparoscope into trocar No. 1. The colpotomy opening is sutured with an absorbable thread. Under the control of a laparoscope, drainage is established in the abdominal cavity through access No. 3.

This method is adopted as a prototype.

The main disadvantages of the prototype are the need to use two optical systems, the conflict of instruments in the perineum, the need to create two accesses through the posterior vaginal fornix, which increases its trauma, and also imaging from the side of the pelvic cavity, which complicates the visualization and movement of instruments in the abdominal cavity, limits the implementation of the technique in patients with a pelvic and subhepatic location of the appendix.

The objective of the invention is to improve the technique for performing transvaginal appendectomy by simplifying the visualization of the surgical field and the abdominal cavity, creating a mutual arrangement of instruments that exclude their collision inside the abdominal cavity and beyond, reducing trauma and improving the cosmetic result by reducing the number of accesses to the abdominal cavity.

The task is achieved by a method of performing transvaginal appendectomy, including performing umbilical and vaginal approaches, applying a carboxyperitoneum, placing a 5-mm trocar into the umbilical access to introduce an optical system. Exposure of the cervix in the mirrors, the application of single-tooth bullet forceps, under visual control, puncture the posterior vaginal fornix with a 10-mm trocar, insertion of a direct endoscopic clamp through the 10-mm trocar, capture and traction of the appendix, performing appendectomy, removing the appendix after 10 mm trocar.

A 10 mm long umbilical access is performed and an additional second 5 mm trocar is installed in it, one trocar for a direct laparoscope with a viewing angle of 30 ° and the second for instruments. The mesentery of the appendix is treated with bipolar coagulation to the dome of the cecum through a 5 mm umbilical access trocar. Then, through the 10-mm vaginal access trocar, the base of the vermiform appendix is clipped with three 8-mm clips, it is intersected between the distal clips, the vermiform appendix is extracted through the 10-mm vaginal access trocar. A control audit, lavage, drainage of the abdominal cavity are performed, a 10-mm trocar is removed under visual control, the carboxyperitoneum is eliminated, trocars are removed from the umbilical access. The wound of umbilical access is sutured in layers, a napkin with hydrogen peroxide is introduced into the vagina.

The novelty of the method

- Two trocars with a diameter of 5 mm are introduced into the abdominal cavity through the wound of umbilical access. Laparoscopy is performed with a direct laparoscope with a diameter of 5 mm and a viewing angle of 30 degrees; a second instrument with a diameter of 5 mm is inserted into the abdominal cavity. The operation is performed using one laparoscope, without the need for two visualization systems, which simplifies and speeds up the intervention, reduces its cost.

- Under visual control, the posterior vaginal fornix is punctured with a trocar with a diameter of 10 mm, a direct endoscopic clamp is inserted into the abdominal cavity, which captures and holds the tip of the vermiform appendix towards the anterior abdominal wall, visualizing its mesentery and base. The mesentery of the appendix is treated with bipolar coagulation to the dome of the cecum through umbilical access. At the same time, the usual visual picture of the surgical field is preserved, the stages of the operation are performed through access on the anterior abdominal wall, as in a conventional laparoscopic operation.

Using in clinical practice the proposed method allows to achieve several technical results:

1. The usual way of visualizing the appendix and performing the appendectomy stages is preserved.

2. The duration of the operation is reduced due to the use of one laparoscope and work through the umbilical access on the anterior abdominal wall.

3. The number of wounds is reduced to two when creating surgical access to the abdominal cavity.

4. Eliminates the need for setting the second instrument through the posterior vaginal fornix, which reduces organ trauma and prevents conflict between the instruments in the perineum.

The invention is illustrated by the diagrams presented in Fig.1 and 2.

Figure 1 shows the moment of traction of the appendix and the processing of its mesentery by bipolar coagulation.

Figure 2 presents the stage of crossing the base of the vermiform appendix after applying clips.

In the figures 1 - umbilical access, 2 - a direct laparoscope with a viewing angle of 30 °, 3-5 mm working umbilical access trocar, 4 - vermiform appendix, 5-10 mm vaginal access trocar, 6 - atraumatic clamp to capture the vermiform appendix 7 - endoscopic scissors; 8 - vaginal access.

The invention is as follows.

The operation is performed under combined endotracheal anesthesia. The patient's position is on her back, her legs are divorced. The operating surgeon and assistant stand to the left of the patient. The monitor is placed above and to the right of the patient’s head. After processing the surgical field perform umbilical access 1 with a length of 10 mm Carboxyperitoneum is superimposed with a Veress needle using the double-click method. Normal are considered indicators of resting pressure up to 10 mm Hg. Through a wound of umbilical access 1, two trocars with a diameter of 5 mm are introduced into the abdominal cavity. Laparoscopy is performed by a direct laparoscope 2 with a diameter of 5 mm and a viewing angle of 30 degrees. In the second trocar 3, a working tool with a diameter of 5 mm is inserted into the abdominal cavity - a direct atraumatic clamp 6. The cervix is exposed in the mirrors, single-tooth bullet forceps are applied. Under visual control, a puncture of the posterior vaginal fornix with a trocar 5 with a diameter of 10 mm is performed on the monitor. The direct endoscopic clamp 6 is rearranged into the trocar 5 of the vaginal access 8, which capture and hold the top of the appendix towards the anterior abdominal wall, visualizing its mesentery and base. Mobilization of the appendix is performed as follows: the mesentery of the appendix is treated with bipolar coagulation through the trocar 3 of the umbilical access, through the 10-mm trocar 5 of the vaginal access, the base of the appendix is clipped with three 8-mm clips, endoscopic scissors 7 intersect the appendix between the vermiform appendix. Then the vermiform appendix is removed from the abdominal cavity through a 10-mm trocar 5 of vaginal access. Perform a control audit, lavage, drainage of the abdominal cavity. Then the vaginal access trocar 5 is removed from the abdominal cavity under visual control. Carboxyperitoneum is eliminated, trocars are removed from umbilical access. The wound of the posterior vaginal fornix is not sutured; a napkin with hydrogen peroxide is introduced into the vagina. The wound of umbilical access is sutured in layers.

Clinical example

Patient M., 33 years old, was hospitalized on July 14, 2013 to the General Surgery Department of MBLPU GKB ", 29, Novokuznetsk, with a diagnosis of acute appendicitis. The duration of the disease is 17 hours. Local pain in the right iliac region with moderate muscle tension and peritoneal reaction, accompanied by hyperthermia of 37.8 ° C and blood leukocytosis of 19.2 × 10 ⁹ / L. Under endotracheal anesthesia using a Veress needle, a 10 mm umbilical access was performed. Two trocars with a diameter of 5 mm were introduced into the abdominal cavity through the wound. A panoramic view was performed using a direct laparoscope with a 30 ° angle of view with a diameter of 5 mm. Through the second 5-mm trocar of umbilical access, an atraumatic forceps was introduced into the abdominal cavity. The uterus, appendages of usual sizes and shapes, a serous effusion of 20 ml in the small pelvis, a vermiform appendix located in the ascending direction is visualized in the right iliac fossa, it is tense, hyperemic, with a plaque of fibrin, 6 cm long. The dome of the cecum is not changed. The cervix was exposed in the mirrors; single-tooth bullet forceps were applied. Under visual control, the posterior vaginal fornix was punctured with a 10 mm diameter trocar, a direct endoscopic clamp was inserted into the abdominal cavity, which captured and held the top of the appendix in the direction of the anterior abdominal wall. The mesentery of the vermiform appendix was treated with bipolar coagulation through the umbilical access trocar, through the 10-mm vaginal access trocar, the base of the vermiform appendix was clipped with 3 8-mm clips, the appendix was intersected between the distal clips, and it was removed from the abdominal access through the 10 mm abdominal cavity. A control audit, lavage, drainage of the abdominal cavity were performed. Then the vaginal access trocar was removed from the abdominal cavity under visual control. Carboxyperitoneum was eliminated, trocars were removed from the umbilical access. The wound of the posterior vaginal fornix was not sutured, a napkin with hydrogen peroxide was introduced into the vagina. The wound of umbilical access was sutured in layers. The duration of the operation was 64 minutes. No postoperative complications were noted, the wound healed by first intention. The maximum cosmetic result was noted. There was no pain at the sites of trocar injection. The length of stay in the hospital is 4 days. The recovery has come.

Claims (1)

A method for performing transvaginal appendectomy, including performing umbilical and vaginal approaches, applying a carboxyperitoneum, placing a 5-mm trocar in the umbilical access for introducing the optical system, exposing the cervix in the mirrors, applying single-tooth bullet forceps, under visual control, puncturing the posterior vaginal fornix with a 10-mm trocar , insertion of a direct endoscopic clamp through a 10-mm trocar, capture and implementation of traction of the appendix, appendectomy, removal of the worm shaped shoot through a 10 mm trocar, characterized in that they perform a 10 mm long umbilical access and install an additional 5 mm trocar, one trocar for a direct laparoscope with a viewing angle of 30 ° and the second for instruments, the mesentery of the vermiform process is treated with bipolar coagulation to the dome of the cecum through the 5-mm trocar of the umbilical access, then through the 10-mm trocar of the vaginal access, the base of the appendix is clipped with three 8-mm clips, it is intersected between the distal using plots, the vermiform appendix is removed through a 10-mm vaginal access trocar, a control audit, lavage, draining of the abdominal cavity are performed, the 10-mm trocar is removed under visual control, the carboxyperitoneum is removed, the trocars are removed from the umbilical access, the umbilical access wound is sutured, inserted into the vagina napkin with hydrogen peroxide.

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