RU2595002C1 - Method of determining possibility of performing laparoscopic cholecystectomy from single transumbilical access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, specifically to abdominal surgery. To perform laparoscopic cholecystectomy from a single transumbilical access, method comprises determining dimensions of anterior abdominal wall. Point A is found on anterior abdominal wall in a frontal plane as middle of distance between point, defining right lower edge X of rib, and a point of middle line of body at level of line which connects lower points X of ribs. Point C is found in a sagittal plane in centre of distance, defining height of anterior abdominal wall at level of boundary of epigastric and mesogastric region. Point D is defined as point of intersection of middle line of human body and line, connecting lower edges X-x of ribs. Navel is marked with point B. Distance BC is calculated by formula: BC= $$\sqrt{A{C}^2+A{D}^2+D{B}^2}$$

, If BC is more than 30 cm, performing laparoscopic cholecystectomy from a single transumbilical access is not possible.

EFFECT: method increases accuracy of determining possibility of performing laparoscopic cholecystectomy through a single transumbilical access by determining laparometric parameters.

1 cl, 4 dwg, 2 ex

Description

The invention relates to surgery, namely to abdominal surgery, and can be used to perform laparoscopic cholecystectomy from a single transumbilical access.

Closest to the proposed is a method for determining the parameters of surgical access to the gallbladder for laparoscopic cholecystectomy (RF Patent No. 2205599, A61B 17/00, Bull No. 16, 06/10/2003). The known method consists in the fact that when performing laparoscopic cholecystectomy, after creating the necessary pneumoperitoneum and raising the head end of the operating table by 20-25 °, a laparoscope is inserted into the patient’s paraumbilical region, surgical trocars for instruments are placed in the right hypochondrium and epigastrium. After examining the abdominal cavity, the bottom of the gallbladder is captured by the grasper, and it is moved as far as possible in the cephalic direction. In this position, the projection points on the anterior abdominal wall of the neck and bottom of the bubble are determined by constructing lines perpendicular to the plane of the operating table. At these points, a long needle is then alternately inserted and the distance to the neck and bottom of the bubble is measured, characterizing the depth of the working space and the operating position of the organ in the vertical plane of intervention.

The main disadvantages of the method is the need to perform intraoperative measurements, which in its own does not determine the diagnostic value of the method.

The objective of the proposed method is to determine the possibility of performing laparoscopic cholecystectomy using a single transumbilical access.

The task is achieved due to the fact that in the preoperative period determine the size of the anterior abdominal wall: for the conditional point of projection of the gallbladder on the anterior abdominal wall in the frontal plane, take the middle of the distance between the point defining the lower right edge of the X-rib and the middle of the trunk line at the level the line connecting the lower points of the X-rib - point A; the conditional location of the gallbladder in the sagittal plane will be the middle of the distance that determines the height of the anterior abdominal wall at the level of the border of the epigastric and mesogastric regions - point C, the AS line is measured with a ruler; the intersection of the midline of the human torso and the line connecting the lower edges of the X-th ribs is point D, the navel is point B; in the sagittal plane, the lines connecting points C, A, B form a triangle ABC, the hypotenuse of which is the distance from B to C - and there will be the length of the surgical channel, which is calculated as BC = √AC ² + AD ² + DB ² , and the length the surgical channel should not be more than 30 cm, otherwise it is not possible to perform laparoscopic cholecystectomy from a single transumbilical access.

In total, three main planes are distinguished in human anatomy (Fig. 1):

- The sagittal plane (a) separates the right and left halves of the body. A special case of the sagittal plane is the median plane, it passes exactly in the middle of the body, dividing it into two symmetrical halves.

- The frontal plane (b) or coronal - is located vertically, perpendicular to the sagittal, it separates the front (ventral) part of the body from the back (dorsal) part.

- Horizontal (s), axial or transverse plane - perpendicular to the first two and parallel to the surface of the earth, it separates the overlying parts of the body from the underlying.

These three planes can be drawn through any point on the human body; the number of planes can be arbitrary.

The method is carried out: for the conditional point of projection of the gallbladder on the anterior abdominal wall in the frontal plane, take the middle of the distance between the point defining the right lower edge of the Xth rib and the midline of the body at the line level connecting the lower points of the Xth ribs (Point A) . The conditional location of the gallbladder in the sagittal plane will be the middle of the distance that determines the height of the anterior abdominal wall at the level of the border of the epigastric and mesogastric region (Point C). The AC line is measured with a ruler.

The intersection of the midline of the human torso and the line connecting the lower edges of the X-th ribs is indicated by point D, the navel - point B. The distance AB is the hypotenuse in the right triangle ABD formed by the points described above. Thus, the square of the distance from point B to the conditional location of the gallbladder (Point A) is the sum of the squares of the distances that define the legs of the resulting rectangle.

In the sagittal plane, the lines connecting points C, A, B form a triangle ABC, the hypotenuse (distance from B to C) of which will be the length of the surgical channel, which directly determines the possibility of laparoscopic cholecystectomy through a single transumbilical access. In order to find out this distance, it is enough to determine the length from point B to point C, which will be the length of the working channel, and should not be more than 30 cm, otherwise it is not possible to perform laparoscopic cholecystectomy from a single transumbilical access, since the length the working part of the tools used to perform the operation is 42 cm. Fig. 2, 3, 4.

Thus, we calculate the formula:

Novelty

- for the first time, laparometric parameters have been developed that determine the performance of laparoscopic cholecystectomy through a single transumbilical access;

Clinical example 1.

Patient R., 45 years old, admitted diagnosis: gallstone disease; chronic calculous cholecystitis.

In the preoperative period, the parameters of the anterior abdominal wall were determined by the proposed method: we draw a midline, a line connecting the lower edges of the X ribs. The intersection point of these lines will be D. Find the middle of the distance from the bottom edge X of the edge to the right to point D, which will be point A. We also determine the length of the distance from point D to the navel (point B). Next, we determine the height of the anterior abdominal wall at the level of the lower edges of the X rib on the right. The middle of the standing height of the anterior abdominal wall will be a conditional point of location of the gallbladder in the sagittal plane (point C). As a result, the desired distance of the working channel for the instruments, when performing cholecystectomy from transumbilical access, will be the length of the distance from point C to point B. As a result, we use the formula:

AC = 7 cm, AD = 17 cm, DB = 20 cm

BC = 27 cm (<30 cm), which satisfies the conditions for performing cholecystectomy using transumbilical access.

Operation: a skin incision is performed, bordering the navel, 2 cm away from its central part, with its mobilization in the form of a funnel, then an aponeurosis is cut along the white line, above the navel 3 cm with the transition to the umbilical ring, a flexible port with three working channels is introduced: one with a diameter of 10 mm for a laparoscope, two with a diameter of 5 mm for manipulators. After revision of the subhepatic space, the gallbladder is fixed with a soft laparoscopic clamp, its traction is performed for further clipping and intersection of the elements of the neck of the gallbladder. The gall bladder is removed from the abdominal cavity. Next, reorganization of the subhepatic space is performed. From the bed of the gallbladder moderate bleeding was noted, which was stopped by thermocoagulation. Drainage of the subhepatic space is performed by a tubular graduate, which is discharged through the navel. Conduct a desfusion. Aponeurosis is sutured. Stitches on the skin around the umbilical ring. Aseptic dressing.

When performing the operation, there were no technical difficulties, the duration of the operation was 45 minutes.

Clinical example 2.

Patient Z., 49 years old, admitted diagnosis: gallstone disease; chronic calculous cholecystitis.

In the preoperative period, the parameters of the anterior abdominal wall were determined by the proposed method. Points A, B, C, D on the anterior abdominal wall are identified. As a result, the desired parameters are: AC = 9 cm, AD = 20 cm, DB = 25 cm.

Calculated by the formula:

We obtain the desired distance of 33.26 cm (> 30 cm), which does not allow laparoscopic cholecystectomy from a single transumbilical access. The patient underwent a laparoscopic cholecystectomy of four trocar approaches.

The use of the proposed method in clinical practice allows in the preoperative period to determine the possibility of performing laparoscopic cholecystectomy through a single transumbilical access, which is a priority in high-tech surgery.

Claims (1)

A method for determining the ability to perform laparoscopic cholecystectomy through a single transumbilical access, including determining the coordinates of the gallbladder in the frontal and sagittal planes, characterized in that in the preoperative period determine the size of the anterior abdominal wall: for the conditional point of projection of the gallbladder on the anterior abdominal wall in the frontal plane the middle of the distance between the point defining the lower right edge of the X-rib and the middle of the trunk line at the line level, connecting the lower points of the X-rib - point A; the conditional location of the gallbladder in the sagittal plane will be the middle of the distance that determines the height of the anterior abdominal wall at the border of the epigastric and mesogastric regions - point C, line AC is measured with a ruler; the intersection of the midline of the human trunk and the line connecting the lower edges of the X-th ribs is point D, the navel is point B; in the sagittal plane, the lines connecting the points C, A, B form a triangle ABC, the hypotenuse of which is the distance from B to C - and there will be the length of the surgical channel, which is calculated as BC = $$\sqrt{A{C}^2+A{D}^2+D{B}^2}$$

, while the length of the surgical channel should not be more than 30 cm, otherwise performing a laparoscopic cholecystectomy from a single transumbilical access is not possible.

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