RU2554329C2 - Method of baker's cyst surgery - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be applied in the treatment of Baker's cyst. An aspirating needle is introduced into the Baker's cyst cavity under the control of a US-sensor. A butt end light conductor is introduced into the needle lumen and passed to the fistula under the control of the US-sensor. An impact with laser radiation is realised with the wavelength of 1470 nm, radiation power of 8 W, pulse duration of 0.2-0.5 s and duration of 4-7 s until the fistula is obliterated. From the same puncture and by the same light conductor the coagulation of cyst walls is carried out with the radiation power of 8 W, pulse duration of 0.2-0.5 s and duration of 7-10 s.

EFFECT: method ensures the effective obliteration of the large cavity formation without the thermal injury of surrounding tissues, absence of disease recurrences due to heating remains of the intra-cavity serous fluid and denaturation of the internal layer of the cyst and fistula, which results in their strong adhesion.

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Description

The invention relates to surgery, and more particularly to laser surgery.

The knee joint is a large synovial joint. This joint has many supporting elements. Among them, synovial bags occupy a special place. Baker's cyst is a hollow saccular mass that develops from the tissue lining the bag of the knee joint. For a Baker cyst, the posterior surface of the joint is a typical arrangement. The pathological process that causes the clinical manifestation of Baker's cyst is hyperproduction and fluid accumulation in the popliteal fossa of the knee joint. Most often, this phenomenon accompanies synovitis in patients with osteoarthrosis, rheumatoid arthritis (Lugovets S.G., 1998).

Known treatment methods used in the treatment of Baker cysts are conservative and surgical.

Conservative therapy includes the following methods: joint unloading, anti-inflammatory physiotherapy, cyst puncture with aspiration of the contents and subsequent administration of drugs (or without it). There is a method of treating Baker's cyst, according to which, after evacuation of the contents of the cyst, the cyclophosphamide is introduced into it by the cytostatic drug (Babich I.I., Chepurnoy G.I., Babich I.V., 1989). However, after conservative treatment, relapses occur in 30-51.5% of cases (Doherty, M., 1993, Kariev, M.X., 1980). In modern medicine, it is a well-known fact that to achieve a complete cure in people with a chronic inflammatory process of the cyst can only be done using active surgical tactics.

The following method of treating Baker's cyst is known, the technical result of which is to reduce the invasiveness of treatment, to prevent postoperative complications (formula RU 2277878 C 06/20/2006). The synovial cysts are extracted and removed operatively with suturing of the anastomosis with nodal sutures and tendon-muscle plastic by suturing the tendon of the medial head of the gastrocnemius muscle to the oblique popliteal ligament and the tendon of the semimembranous muscle, layer-by-layer suturing of the wound and fixation of the knee joint by the gypsum splint, color contrast is performed through the introduction of 20-40 ml of a 0.5% methylene blue solution with 3-5 times maximum flexion and extension into the upper inversion of the knee joint by lowering the lower leg, then operative isolation and excision of the cyst is performed, after which the lower leg is flexed and extended 2-3 times, the localization and extent of the lower leg are infused from the knee joint through the methylene blue through the anastomosis, the anastomosis is sutured with nodal sutures, and then 2-3 times flexion and extension of the tibia check the tightness of suturing the anastomosis in the capsule of the knee joint and in the absence of a tight joint cavity in the places where the methylene blue solution flows out you have to complete sealing. After this, tendon-muscle plastic surgery is performed by suturing the tendon of the medial head of the gastrocnemius muscle to the oblique popliteal ligament and to the tendon of the semi-membranous muscle, then the wound is sutured in layers.

The disadvantage of this method is that it is performed under general anesthesia, open access, which increases the risk and invasiveness of the operation. The technical difficulties of implementing this method cause thin shells of the cyst and the presence of adhesions with surrounding tissues, as well as the proximity of large neurovascular formations complicates total removal and significantly increases the risk of iatrogenic. Given these features, the surgeon is forced to initially expand access, which in turn leads to significant surgical trauma and a long period of immobilization.

The closest in technical essence to the claimed method is a method of treating a synovial ganglion (RU 2302840 C2 07/20/2007 formula, description p. 3), under the control of an ultrasound, a puncture needle is inserted into the ganglion cavity, its contents are aspirated. A quartz fiber is introduced into the needle lumen, the tip of which extends beyond the needle by 3-5 mm. Hyperthermia of the walls of the ganglion is carried out by laser light with a wavelength of 810 nm, a pulse duration of 0.2-0.5 seconds, a radiation power of 6 W, exposure is performed until a hyperechoic shadow forms over the capsule of the ganglion. A crystal diode laser apparatus is used as a source of laser radiation. The method allows to reduce the morbidity of treatment of the synovial ganglion, to prevent the occurrence of a cosmetic defect and postoperative complications.

The disadvantage of this method is that it uses a wavelength of 810 nm, which coincides with the absorption spectrum of hemoglobin. When implementing the known method, most of the energy is absorbed by hemoglobin located in the perifocal vessels, which can lead to overheating and necrosis of the surrounding tissues, but with the preservation of the cyst wall (Proebstle T.M., 2005). This is very dangerous with deep interventions in the popliteal region containing many large vessels located very close to the anastomosis of the cyst. Also, the prolonged use (more than 1 minute) of radiation with a wavelength in the "hemoglobin-absorbing" spectrum causes a predominance of radiative energy transfer over convection, causing damage to tissues located outside the zone of interest of manipulation. From the literature data, two basic facts are known that determine the advantages of "water-absorbing" laser radiation in the treatment of deep located synovial cysts of the popliteal region. The first is that the main substance of the Baker’s cyst wall is collagen saturated with up to 65% water (Makushin V.D., 2000), and the second, that the use of lasers with a wavelength of at least 1470 nm can significantly reduce the exposure time while maintaining the coagulating effect (Shaydakov E.V., 2013). The second limitation of the use of the known method for the treatment of Baker cysts is associated with its anatomical structural features, consisting in sizes significantly exceeding the ganglion of the wrist joint, and the presence of an anastomosis connecting to the joint cavity. From the foregoing, it is obvious that the energy generated by the indicators indicated in the known method will be insufficient to uniformly and sufficiently coagulate the heating of a significant amount of tissue, which will lead to the preservation of the functioning anastomosis, which causes a relapse of the disease. Lengthening the exposure will only lead to an increase in the duration of the intervention and uncontrolled hyperthermia of the surrounding tissues, followed by the development of necrosis.

The objective of the proposed solution is the development of a method of treating Baker cysts using laser irradiation in sequence and with energy parameters that allow obliteration of the cavity formation in less time, without thermal damage to surrounding tissues, while maintaining the effectiveness of the intervention.

This problem is solved by the fact that in the claimed method for the surgical treatment of Baker’s cysts, including sealing of the anastomosis and total coagulation of the walls of the Baker’s cyst, a puncture needle is inserted into the cavity of the Baker’s cyst under the control of an ultrasound probe, then an end fiber is inserted into the lumen of the needle and under the control of ultrasound -sensor bring it to the anastomosis, after which they are exposed to laser radiation with a wavelength of 1470 nm, an output power of 8 W, a pulse duration of 0.2-0.5 s and a duration of 4-7 s until obliteration of the anastomosis, then from puncture of the same optical waveguide produce coagulation cyst wall radiation power 8 W, pulse duration of 0.2-0.5 sec and a duration of 7-10 seconds.

The inventive method of treating Baker’s cyst is as follows: The ultrasound (ultrasound) method determines the depth of location, size, signs of multi-chamber, contours of the fistula of Baker’s cyst, as well as the location of nearby large vessels and nerves. The ultrasound picture in real time determines the most convenient and safe area for puncture. The skin over the selected area is treated with a 70% solution of ethyl alcohol, and a sterile gel is applied. Then, under the control of an ultrasound probe (10-14 MHz) located in a sterile cover, a cyst is punctured with a G-15-18 needle. Puncture adequacy control - clear visualization of the needle in the cyst cavity and the release of serous discharge from the cannula. The contents of the cyst are partially aspirated. Then, a sterile end light guide with a diameter of 0.4-0.6 mm is introduced into the lumen of the needle and brought to the anastomosis, which is also controlled by an ultrasound probe. The optical fiber is connected to a diode surgical laser device with a radiation wavelength of 1470 nm. The radiation power is 8 W, the duration of the radiation pulse is 0.2-0.5 s. The use of this treatment regimen causes heating of the remains of intracavitary serous fluid and denaturation of the inner layer of the anastomosis, which subsequently leads to strong adhesion. The exposure time is 4-7 seconds and is controlled by the ultrasound picture in real time. The anastomosis is processed to complete obliteration, which is controlled by an ultrasound probe. Then the light guide is brought back into the needle so that its tip extends beyond the tip of the needle inserted into the cavity of the cyst by 3-5 mm. Repeated laser exposure. The radiation power is 8 W, the duration of the radiation pulse is 0.2-0.5 s. The use of this treatment regimen causes heating of the remains of intracavitary serous fluid and denaturation of the inner layer of the cyst, which subsequently leads to their strong bonding. The exposure time is 7-10 seconds and is controlled by the ultrasound picture in real time. The end of the treatment session is the formation of hyperechoic shadow covering the entire capsule of the cyst. If necessary, all Baker cyst chambers are similarly processed. After the session, a pressure bandage-knee band for a period of 7-10 days is applied to the treated area. Dynamic monitoring is carried out 10 days, 1 month, 6 months and 12 months after treatment.

Clinical example 1. Patient M., 37 years old. Complaints upon receipt of a rounded formation under the skin on the posterior surface of the knee joint of the right lower limb. Considers himself ill for more than 5 years, when he began to celebrate "tumor growth under the knee" after exercise. Education was punctured annually with the subsequent administration of various sclerotherapy drugs (iodine, alcohol, etc.), but after 3 months after the manipulation, the formation appeared again. Intracavitary administration of diprospan was carried out - without effect. The last year began to notice increased pain and limitation of flexion of the knee joint, the appearance of numbness of the lower leg skin. The patient underwent ultrasound examination of soft tissues, which revealed a round anechogenic formation with dimensions 47 × 22 mm of regular round shape. The connection of the cystic cavity with the joint cavity is determined. The diameter of the anastomosis is up to 3 mm. The patient was diagnosed with Baker's cyst of the right lower limb. After obtaining the consent of the patient, it was decided to conduct laser destruction of the cyst. The skin over the cyst is treated with a 70% solution of ethyl alcohol. Under the control of the ultrasound probe, a cyst was punctured in real time with a G-18 needle. Then, a sterile end light guide with a diameter of 0.4-0.6 mm is introduced into the lumen of the needle and brought to the anastomosis, which is also controlled by an ultrasound probe. The optical fiber is connected to a diode surgical laser device with a radiation wavelength of 1470 nm. Selected parameters: radiation power 8 W, radiation pulse duration 0.2-0.5 s. The exposure time is 6 seconds. Anastomosis processed to complete obliteration. Then the light guide is brought back. Repeated laser exposure. A hyperechoic shadow appeared on the sonogram in real time, which began to slowly spread along the length of the capsule of the cyst. The treatment procedure was discontinued, the light guide and the puncture needle were removed from the tissues. The skin is re-treated with a 70% solution of ethyl alcohol and fixation is made in an elastic pressing knee pad. At the control examination 10 days after the treatment session, the patient has no complaints. Palpation in the treated area, there is a slight painless swelling of the tissues. The function of the knee joint in full. On the sonogram of the soft tissues treated, there is a slight hyperechoic shadow. Wearing a pressure bandage is canceled.

The application of the claimed method will reduce the invasiveness of treatment.

Claims (1)

A method of surgical treatment of Baker’s cysts, including sealing of the anastomosis and total coagulation of the walls of the Baker’s cysts, characterized in that a puncture needle is inserted into the cavity of the Baker’s cyst under the control of the ultrasound probe, then an end light guide is inserted into the lumen of the needle, and it is brought under the control of the ultrasound probe to the anastomosis, after which they are exposed to laser radiation with a wavelength of 1470 nm, a radiation power of 8 W, a pulse duration of 0.2-0.5 s and a duration of 4-7 s until obliteration of the anastomosis, then from the same puncture and the same light vodom produce coagulation cyst wall 8 W output power, pulse duration of 0.2-0.5 sec and a duration of 7-10 seconds.