RU2553192C1 - Laparolifting technique from single laparoscopic approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: incision 2-2.5cm long is made within a navel ring. A thin-wall silicone cylinder with an expanded, thickened and rounded bottom is placed into the incision as a trocar. A retractor is screwed into the abdominal cavity through the top of the cylinder. The cylinder is left in the wound throughout the operation.

EFFECT: technique prevents intraoperative complications and reduces a risk of postoperative complications by providing gas-free laparolifting during laparoscopic operations.

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Description

The invention relates to medicine, mainly to endoscopic surgery, in particular endogynecology, when performing single-incision (single-port) laparoscopic operations to reduce postoperative complications.

It is known that any operation on the abdominal organs is accompanied by the formation of adhesions, leading in women to adhesions in the pelvis with the involvement of the fallopian tubes and the development of tubal-peritonial infertility and ectopic pregnancy.

To eliminate abdominal adhesions, preference is given to laparoscopic surgery, which is less traumatic, which eliminates the direct contact of the surgeon's hands with the abdominal organs, which reduces the risk of re-adhesions in the early and long-term postoperative period (Elkdani OAN, Binda MM, Molinas CR, Koninckx Ph.R. Effect of adding more 3% oxygen to carbon dioxide pneumoperitoneum on adhesion formation in laparoscopic mouse model. Fertil. Steril. - 2004. - Vol.82, - No. 6. - P.1616-1622).

Inside the abdominal cavity during laparoscopic surgery create an operating space for free and safe manipulation of instruments.

The most common way to create an operating space in the abdominal cavity is gas peritoneum, and any inert gas is introduced into the abdominal cavity. Often use air (pneumoperitoneum) or carbon dioxide CO ₂ (carboxyperitoneum) under a pressure of up to 2 kPa (15 mmHg) in a volume of about 2.5-3.0 liters. Gas entering the abdominal cavity exerts uniform pressure in all directions, inflates the abdominal cavity and raises the front abdominal wall above the internal organs, creating an internal operating space (G. Maddern. University of Adelaide, Australia. Hypothermia: a serious but preventable complication of laparoscopic surgery R.Zh. “Endosurgery today.” - Kazan: Association of Endosurgery of Tatarstan. - 1996, No. 2. - p.4).

During the surgical operation, there is a constant leak of gas from the artificially created cavity - through punctures and incisions, valve-sealing instruments and during the replacement of instruments, leading to pumping gas into the abdominal cavity to maintain a constant volume of the internal operating space.

The main disadvantages of gas peritoneum for women of childbearing age and for women who underwent surgical treatment to eliminate tubal-peritoneal infertility are: hypothermia of the internal organs, local drying effect of the gas on the serous membrane of the internal organs, compression of the peritoneal microcapillaries with subsequent development of ischemia and hypoxia; squeezing of large venous vessels of the abdominal cavity and retroperitoneal space with the development of ischemia, impaired circulation and nutrition of organs and tissues, the formation of adhesions due to diffusion of carbon dioxide into the general bloodstream, leading to blood oversaturation with carbon dioxide, impaired blood circulation in the vessels of the lower extremities due to stagnation of blood and thrombosis, with the development of DIC, to impaired cardiac activity, impaired respiratory process.

To eliminate these drawbacks, a method of lifting laparoscopy has been developed, in which the surgical space in the abdominal cavity is created using various mechanical devices of laparolifts. Laparolifts consist of retractor (s) and rotary locking devices. Lifting laparoscopy is free from the disadvantages of traditional gas laparoscopy and is therefore attractive for practical surgery (Hanney RM, Alle KM, Cregan P.C. Department of Surgery, University of Sydney, Nepean Hospital, Pentrith, NSW, Australia. Damage to the main vessels during laparoscopy R.Zh. “Endosurgery today.” - Kazan: TATARSTAN ENDOSURGERY ASSOCIATION. - 1996, No. 1. - P.16; Paolucci V., Schaeff B., Gutt CN Gasless Laparoscopy - why and how? J. “Minimally Invasive Therapy”, 1995, No. 4, p.165-172; Sedov V.M., Yurlov V.V., Yeltsin S.S., Ivanikha E.V. Prevention of complications of laparoscopic cholecystectomy. Volume 155. №2 surgery. "-. 1996. - P.72).

A known method of laparolifting, including laying the patient with his back on the operating table, performing general anesthesia, making a 0.3-cm incision on the patient’s belly below the navel, inserting the stylet from the trocar into the incision with the protective casing previously put on it and making a puncture that penetrates the abdominal cavity removing the stylet from the wound, while the protective casing remains in the operating wound, connecting the abdominal cavity with the external environment, screwing the retractor through the protective casing into the abdominal cavity, performing the retractor from the control deformable material in the form of a rod bent in perpendicular planes, having a straight vertical shoulder with a bend at the end for fixation and a horizontal shoulder twisted in a spiral, traction of the abdominal wall with a retractor and creation of an operating space in the abdominal cavity for subsequent manipulations of instruments, fixation of the retractor in the lifting and locking device, leaving the protective cover worn on the retractor.

The retractor for the implementation of this method is made of an elastically deformable material in the form of a rod, with a cross-sectional diameter of 0.4 cm, curved in perpendicular planes, having a straight vetric shoulder with a bend at the end for fixing and twisted in a spiral no more than 3/4 turn, horizontal shoulder, with a spiral diameter of not less than 4.0 cm and not more than 8.0 cm, the end of the spiral is bent downward by no more than 10 ° (RF Patent No. 2337636, IPC A61B 17/07; publ. 10.11.2008 BP No. 31).

In this method of laparolifting and a retractor for its implementation, which is closest to the proposed method, although pneumoperitoneum with its attendant attachment to gas sources and pathophysical influences leading to complications is excluded, the likelihood of adhesions after surgery is reduced, trauma is reduced when creating an operating space, the period is reduced recovery of the patient’s disability, however, there are also disadvantages, such as: performing an incision and a puncture on the patient’s stomach, resulting to an increase in trauma to the anterior abdominal wall and, as a result, the presence of ugly scars, the use of trocars with a rigid metal structure, which violates trophic tissue with possible necrosis of the surrounding tissue and the severity of the structure itself.

The technical result to which the invention is directed is to create a laparolifting method with a single laparoscopic access, which allows, through a single incision in the navel, using a domestic production trocar, to provide an adequate overview of the abdominal organs, to reduce only the appearance of a scar preserving the cosmetic effect, reduce the trauma of the anterior abdominal wall, improve working conditions and reduce fatigue of surgeons, provide the possibility of using general surgery FIR tools and improve clinical outcomes.

To achieve this technical result, in the method of laparolifting, including laying the patient with his back on the operating table, performing anesthesia, performing an incision on the patient’s stomach, inserting a trocar into the incision, screwing a retractor into the abdominal cavity, made of elastically deformable material in the form of a rod bent in perpendicular planes, having a straight vertical shoulder with a bend at the end for fixation and a horizontal shoulder twisted in a spiral, traction of the abdominal wall using a retractor and with creating an operating space in the abdominal cavity for subsequent manipulations with instruments, fixing the retractor in a lifting and fixing device, the incision is performed in the abdominal wall in the region of the umbilical ring 2-2.5 cm long, and a thin-walled silicone cylinder with an expanded, thickened and rounded is used as a trocar the lower part, which is squeezed with a standard clamp and inserted into the cut of the umbilical ring, and through the upper part of the silicone cylinder, made in the form of a truncated cone, the larger base of which upward and bent inward at an angle of 90 °, a retractor is screwed into the abdominal cavity, while the silicone cylinder remains in the surgical wound until the end of the operation.

Distinctive features of the proposed method of laparolifting with a single laparoscopic access from the above are performed in the abdominal wall in the region of the umbilical ring of the incision 2-2.5 cm long, using a thin-walled silicone cylinder with an expanded, thickened and twisted lower part as a trocar, compressing it with a typical clamping and introducing the lower part of the silicone cylinder into the incision of the umbilical ring, screwing the retractor into the abdominal cavity through the upper part of the silicone cylinder, made in de truncated cone, the larger base of which is directed upward and bent at an angle of 90 °, leaving the silicone cylinder in the surgical wound until the end of the operation, which allows for an adequate view of the abdominal organs through a single incision in the navel using a domestic production trocar, to reduce the operation only to one cosmetic scar on the anterior abdominal wall, reduce the trauma of the anterior abdominal wall, improve working conditions and reduce fatigue of surgeons, provide the possibility of using schehirurgicheskih tools and improve clinical outcomes.

The method is carried out using a well-known trocar (part No. 20131235996/14 with a decision to grant a patent dated September 18, 2013) and a retractor (RF patent No. 23337636, IPC A61B 17/02, published on November 10, 2008).

The essence of the proposed method is illustrated by the drawings shown in figures 1-3.

Figure 1 shows the trocar used to implement the method, where: 1 - thin-walled silicone cylinder; 2 - the lower part of the silicone cylinder; 3 - the upper part of the silicone cylinder.

Figure 2 shows a cross section of the patient’s body with a trocar, the introduction through the incision of the umbilical ring into the abdominal cavity, where: 1 - a thin-walled silicone cylinder; 2 - the lower part of the silicone cylinder; 3 - the upper part of the silicone cylinder; 4 - patient; 5 - operating table; 6 - section of the umbilical ring; 7 - abdominal cavity.

Figure 3 shows a cross section of the patient’s body with a trocar and a retractor inserted into the abdominal cavity through the upper part of the silicone cylinder and the raised abdominal wall, where: 1 - thin-walled silicone cylinder; 2 - the lower part of the silicone cylinder; 3 - the upper part of the silicone cylinder; 4 - patient; 5 - operating table; 6 - section of the umbilical ring; 7 - abdominal cavity (operating space); 8 - anterior abdominal wall of the patient; 9 - retractor, a) - horizontal arm of the retractor, b) - vertical arm of the retractor; 10 - internal organs;

The essence of the proposed method is that patients 4 are laid back on the operating table 5, anesthetized, a single incision 6 is made of the umbilical ring skin 6 in the abdominal wall 7 with a length of 2-2.5 cm, then a trocar is inserted through this incision 6 (Fig. 1, 2), which is a thin-walled silicone cylinder 1 with an expanded, flattened and twisted lower part 2. Before introducing the trocar with a standard clip from general surgery, the lower, expanded, flattened and twisted part 2 of the silicone cylinder 1 is pressed, and then inserted into Res 6 wound, after which the clamp is removed. Under the action of elasticity, the silicone cylinder 1 straightens in the wound and takes its original shape and remains in the operating wound, connecting the abdominal cavity 7 with the external environment. Then, through the upper part of the silicone cylinder 1, made in the form of a truncated cone, the larger base of which is directed upward and bent inward at an angle of 90 °, a retractor 9 is screwed into the abdominal cavity 7 (Fig. 3), made of an elastically deforming material in the form of a rod bent into perpendicular to the planes and having a straight vertical shoulder (b) with a bend at the end for fixation and a horizontal shoulder (a) twisted in a spiral. First, a horizontal shoulder (a) of the retractor 9 is introduced into the abdominal cavity 7, then traction is performed upward behind the vertical shoulder (b) of the retractor 9, as a result of which the abdominal wall 8 rises above the internal organs 10, forming a conical shape in the abdominal cavity 7. Then, the vertical arm (b) of the retractor 9 is fixed in a lifting-fixing device (not shown), and an operating space is created in the abdominal cavity 7 for further work of the surgeon with tools in the operating space. Instruments are introduced into the abdominal cavity 7 through the upper part 3 of the trocar. In this way, safety is achieved, as when screwing the retractor into the abdominal cavity 7, the metal retractor remains inside the silicone cylinder 1 of the trocar, as well as with the further introduction of the instrumentation, and does not come into contact with the peritoneum and abdominal cavity 7. If necessary, the amount of surgical space in the abdominal cavity 7 can be change by raising or lowering the retractor 9 in the lifting-fixing device. The movement of the retractor 9 is made without removing it from the abdominal cavity.

In the proposed method, a retractor 9 is used, made of an elastically deformable material, for example, stainless steel, which is a rod curved in perpendicular planes with a cross-sectional diameter of 0.4 cm, having a straight vertical shoulder (b) and a horizontal arm (b) curved in a spiral. The vertical shoulder at the end has a bend for fastening, and the horizontal shoulder is rounded in a spiral, no more than 3/4 turn. The end of the spiral for the convenience of introducing the retractor into the abdominal cavity is bent downward by no more than 10 °.

Thus, the proposed laparolifting method with a single laparoscopic approach allows for an adequate view of the abdominal organs through a single incision in the navel using a domestic-made trocar, reduce the operation to only one cosmetic scar on the anterior abdominal wall, reduce the trauma of the anterior abdominal wall, improve working conditions and reduce surgeon fatigue, provide the ability to use general surgical instruments and improve clinical outcomes.

The proposed method was tested in Kazan State Healthcare Institution GB No. 11 in 15 patients with gynecological diseases requiring surgical treatment, which made it possible to provide a good overview of the abdominal organs through one incision in the navel, achieve a good cosmetic effect, and reduce the invasiveness of the anterior abdominal wall.

Claims (1)

A method of laparolifting with a single laparoscopic approach, including laying the patient with his back on the operating table, performing anesthesia, performing an incision on the patient’s stomach, inserting a trocar into the incision, screwing a retractor into the abdominal cavity made of elastically deformable material in the form of a rod curved in perpendicular planes having a straight line a vertical shoulder with a bend at the end for fixation and a horizontal shoulder twisted in a spiral, traction of the abdominal wall using a retractor and creating in b the vestibule of the operative space for subsequent manipulations with the instruments, retractor fixation in a lifting and fixing device, characterized in that the incision is made in the abdominal wall in the region of the umbilical ring 2-2.5 cm long, and a thin-walled silicone cylinder with an expanded, thickened is used as a trocar and a rounded lower part, which is squeezed with a standard clamp and inserted into the cut of the umbilical ring, and through the upper part of the silicone cylinder, made in the form of a truncated cone, the larger base of which about upwardly directed and is bent inwardly at an angle of 90 °, screwed into the abdominal cavity of the retractor, wherein the silicone cylinder remains in the surgical wound to the end of the operation.

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