RU2533030C1 - Method for creating end-to-side vascular microanastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: before sutured together, vascular walls are coloured with sterile 1% aqueous methylene blue. Thereafter a donor vessel end is fixed to a recipient vessel with two oppositely facing single sutures. A loose-looped continuous suture is applied from one single suture to another. The loops are cut, and each loop ends are ties in pairs. The similar technique is used to suture an opposite side of the anastomosis.

EFFECT: method enables improving the quality of the anastomosis formation, simplifying and accelerating the formation process.

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Description

The invention relates to medicine, namely to vascular surgery and microsurgery, and can be used in the formation of microvascular anastomoses.

Various methods of connecting vessels are known. Thus, there is a known method for applying an end-to-side vascular microanastomosis, which consists in preliminarily filing an extension thread to the wall of the recipient artery, passing it through the lumen of the donor artery and exiting through a linear section of the wall. Next, the donor artery is sewn in the type "end to side" around the exhaust thread, the end of which is pulled through the lumen of the tube having a cutting edge. The tube is inserted through a linear incision of the donor artery until the cutting edge comes into contact with the wall of the recipient artery, which is cut around the exhaust thread to form anastomosis anastomosis. A section of the wall together with the tube is removed and a linear incision is made on the donor artery (Method for applying a vascular microanastomosis: Pat. 2080832 Ros. Federation: A61B 17/11, A61B 17/32 / Galikeev MF, Tazetdinov G.V .; publ. 06/10/1997).

The disadvantages of this method include the impossibility of comparing the walls of the vessels with homogeneous layers, as well as the impossibility of evaluating the residual elements (adventitia, media) of the receptor vessel in the lumen of the donor vessel after the opening of the tube, which can lead to thrombosis.

Closest to the claimed is a method of applying a venous anastomosis of the type "end to side", performed by performing a section of the vein and suturing into the section of the vein of the vein graft. In this case, an oblique incision of the vein graft is performed, and an arched incision is made on the recipient vein with a length equal to the diameter of the sutured vein graft, then nodal sutures are applied to the posterior lip of the anastomosis. Next, the anterior wall of the vein is dissected in an arc and superimposed nodal sutures are applied to the anastomosis anterior lip (Method of applying an end-to-side anastomosis: Pat. 2292850 Russian Federation. Federation: A61B 17/11 / Zabirov E.M., Nuzov B.G., Kagan I.I., Laikov A.V., Kim V.I .; publ. 10.02.2007).

The disadvantages of this method include the fact that during the formation of the anastomosis impose a number of single nodal joints. It is known that tying a single knot deforms the vessel wall, changes its local tension, which complicates the conditions for applying the next seam at the same distance from the previous one. Moreover, each subsequent seam reduces the free distance between the comparable vessel walls, which complicates the introduction of the instrument into the lumen of the vessel to create counter pressure to the needle when piercing its wall. This can lead to the eruption of already imposed sutures and injury to the walls of the vessels.

In addition, when the anastomosis is formed by the known method, the vessel walls fall off due to their thinness and softness and difficulties arise with the correct injection of the needle into the wall of the anastomosed vessels - perpendicular to the plane of the vessel wall, without trapping the opposite vessel wall, without delamination.

The objective of the proposed technical solution is to develop a method of forming a vascular microanastomosis of the type "end to side", which facilitates the process of suturing.

The technical result of the proposed method is to ensure the possibility of uniform suturing due to the close location of the walls of the anastomosed vessels and the absence of their subsidence when suturing, as well as the simplification and acceleration of the anastomosis.

The technical result is achieved in that the method of applying a vascular microanastomosis of the type "end to side" includes the formation of the end of the donor vessel and the holes in the wall of the recipient vessel, followed by their stitching.

The distinctive methods of the proposed method include the preliminary tinting of the walls of stitched vessels with a sterile 1% aqueous solution of methylene blue.

Distinctive techniques of the proposed method also consist in the fact that after staining, the end of the donor vessel is fixed to the recipient vessel with two single seams located opposite each other.

The main differences of the proposed method are that from one single seam to another they impose a continuous seam with weakened loops, after which the loops are cut and the ends of each loop are connected in pairs. Similarly, sutures are placed on the opposite side of the anastomosis.

Comparative analysis with the prototype showed that the proposed method differs from the known above methods and, therefore, meets the criteria of patentability of the invention of "novelty."

From the analysis of patent and specialized literature, the authors found that the proposed method has features that distinguish it not only from the prototype, but also from other technical solutions in this field and related fields of medicine. The authors have not found a way to impose a vascular microanastomosis of the type "end to side" containing the distinctive techniques of the proposed method.

Pre-tinting of the walls of stitched microvessels with a sterile 1% aqueous solution of methylene blue contributes to their better visualization, which improves the conditions for uniform suturing.

Fixing the end of the donor vessel to the recipient vessel with two single seams located opposite each other allows you to compare and fix the holes of the anastomosed vessels in a given position.

Imposing a continuous seam with loose loops of thread from one single seam to another, i.e. on one side of the anastomosis, it is possible to achieve an equal distance between the seams and the absence of tension of the walls of the vessels. The gradual comparison of the walls of the vessels provides the ability to manipulate micro-tools in the space between the walls of the stitched vessels, as well as the ability to provide back pressure with micro forceps when the needle is punctured. In addition, due to the elasticity of the filament, the walls of the stitched vessels are kept from “sticking” and twisting, which also facilitates and accelerates the process of suturing.

Subsequent cutting of each loop of the thread and tying its ends together in pairs allows you to get a number of single nodal joints, evenly spaced along the side of the anastomosis and providing matching with the same layers of the walls of the anastomosed vessels.

A similar stitching on the opposite side of the anastomosis allows you to finish the formation of the anastomosis.

The above methods of the proposed method provide the possibility of uniform suturing, as well as facilitate and accelerate the process of suturing during the formation of vascular microanastomosis of the type "end to side".

From the above it follows that the proposed method meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in healthcare. This method can be used in microsurgery when applying a vascular microanastomosis of the type "end to side". The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The essence of the proposed method of applying a vascular microanastomosis of the type "end to side" is illustrated in FIG. 1-3, which shows the stages of its implementation. So, in Fig.1 - the stage of applying a continuous suture with loosened loops of threads, in Fig.2 - the stage of cutting a loop of threads, in Fig.3 - the stage of formation of single nodal joints, where 1 is the artery of the donor, 2 is the artery of the recipient, 3 and 4 - single seams located opposite each other, 5 - loosened loops, 6 - cut loops, 7 - knitted loops - single nodal seams.

The proposed method is carried out using optical zoom in 12-30x and microsurgical instruments. The end of the artery of the donor and the hole in the side of the artery of the recipient form comparable in size. For better visualization, the walls of arteries 1 and 2 are tinted with the tip of a micro-forceps soaked in a sterile 1% aqueous solution of methylene blue. The end of the vessel of the donor 1 is fixed to the vessel of the recipient 2 with two single seams 3 and 4 located at 0 and 180 degrees, i.e. opposite each other along the axis of the recipient vessel. Then, without tightening the thread, a continuous seam is formed on one side of the anastomosis. After a continuous seam with weakened loops from one single seam 3 to another 4 is finished (Fig. 1), weakened loops 5 of the thread are cut with micro scissors (Fig. 2). The ends of the threads of each cut loop 6 are connected in pairs with each other, thereby forming a series of single nodal joints (figure 3). Then, in a similar manner, the second side of the anastomosis is formed.

The essence of the proposed method is illustrated by an example of a specific implementation.

Patient X., 44-year-old woman, right-hander. Anamnesis: in 2010, began with a complaint of passing weakness in the right hand, stenosis of the left middle cerebral artery (SMA) was revealed, and a diagnosis was made: Ischemic stroke in the left SMA pool, Moya-Moya syndrome. In 2012, patient X. again suffered a transient ischemic cerebrovascular accident - weakness in the right arm lasting up to 5 minutes and dysarthria.

After discussing the advantages and disadvantages of different types of treatment, the patient chose surgical treatment. Since stenosis of the left SMA was symptomatic, the operation is planned immediately after correction and stabilization of concomitant somatic pathology.

Examination data: At the time of admission to the hospital in July 2012, the patient did not have a neurological deficit. On the MRI of the brain, chronic ischemic changes in the left hemisphere, SMA stenosis on the left, and aplasia of the right anterior cerebral artery were detected. Arteriography data confirmed stenotic changes in the Willis circle, revealed a slight increase in the network of vessels of the base of the brain - pathological vessels of Moya-Moya, visualized so far only near the bifurcation of the carotid arteries. A study of cerebral blood flow using positron emission tomography and magnetic resonance imaging confirmed cerebral hypoperfusion. Diagnosed with Moya-Moya syndrome, stage 2 (according to the 6-stage classification of Suzuki).

Operation. The patient underwent double bypass surgery - two anastomoses were placed between the branches of the superficial temporal artery and the cortical branches of the middle cerebral artery. Anastomoses are formed according to the proposed method under an optical magnification of the microscope from 12 to 30 times using microsurgical instruments. For this, the end of the artery of the donor and the hole in the wall of the artery of the recipient are formed, comparable in size. For better visualization, the walls of the arteries were tinted with a sterile 1% aqueous solution of methylene blue. For this, the tip of the micro-tweezers was moistened in the indicated solution and touched them to the walls of the stitched vessels. The end of the donor vessel was fixed to the vessel of the recipient with two single seams located opposite each other along the axis of the vessel of the recipient. Then, without tightening the thread, on one side of the anastomosis a continuous suture was applied with loosened loops. After the continuous seam with weakened loops from one single seam to another is finished, the weakened stitches of the thread were cut with micro scissors. The ends of the threads of each cut loop were tied together, thereby forming a series of single nodal joints. Then, similarly, sutures were applied to the second side of the anastomosis.

The formation time of one anastomosis was 20 minutes.

Postoperative course. On the postoperative CT control, no new ischemic lesions and hemorrhages were detected. 4 days after surgery, no new ischemic lesions were found on an MRI scan, an increase in cerebral blood flow in the left hemisphere was noted.

The patient was discharged without neurological deficit and in the next 6 months there were no new symptoms.

According to the proposed method, 5 patients were treated. 10 anastomoses were performed between the superficial temporal artery and the cortical branches of the middle cerebral artery. In all cases of thrombosis or failure of the anastomosis, no deterioration of the neurological condition was noted.

Thus, the proposed method improves the quality of the formation of the anastomosis, simplify and speed up the process of its application. When performing microanastomosis, the proposed method simplifies the process of choosing a needle injection site, which contributes to the uniformity of suturing. In this case, the vessel wall is less injured during the execution of the anastomosis. The walls of the anastomosed vessels during suturing are in close contact with each other, do not collapse, are not rigidly fixed, which allows manipulation with them.

Claims (1)

The method of applying a vascular microanastomosis of the type "end to side", including the formation of the end of the donor vessel and the hole in the wall of the recipient vessel and their subsequent stitching, characterized in that before stitching the vessel walls are tinted with a sterile 1% aqueous solution of methylene blue, after whereby the end of the donor vessel is fixed to the recipient vessel with two single seams located along the axis of the recipient vessel opposite each other, then from one single seam to the other a continuous seam is applied with loops loosened, follows this loop is cut and the ends of each loop link pairs, then likewise sutured to the opposite side anastomosis.

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