RU2614107C1 - Method of minimally traumatic autopsy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to pathological anatomy. At the beginning of autopsy through semilunar access facing jugular notch neck organs are separated to upper opening of chest with successive application of device for separation of muscles of mouth diaphragm muscles, device for transection of neurovascular bundle of neck, device for gripping epiglottis, device for gripping soft tissues of neck and their extraction. After that, through upper-medial access with application of yard retractor or Segal retractor organ-complex, consisting of organs of digestive and genitourinary system, is separated as a single unit, if necessary complexes are separated one by one, for which purpose intestine and spleen are preliminarily mobilised and separated. After that, separation of neck and chest organs is completed, with successive application of device for lifting rib arch, device for transection of major neurovascular bundle of neck, device for separation of neck organs from cervical spine, device for gripping epiglottis, device for gripping soft tissues of neck and extraction of neck organs.

EFFECT: method makes it possible to optimise autopsy process due to facilitation of separation of organ-complexes, improvement of visualisation of body cavities at all stages of autopsy, facilitation of sampling material for histological and bacteriological analysis in case of inflammatory processes in thoracic cavity, reduction of autopsy duration, increase of preservation of anatomical integrity of skin and tissues of internal organs of corpse.

Description

The invention relates to medicine, in particular to pathological anatomy, and can be used in the pathological study of a corpse.

The closest analogue of the invention is a method of complete evisceration using low-traumatic technology [patent RU 2329765 from 07.27.08], in which the resection of the anterior part of the chest is excluded, and the organs of the neck, chest, abdominal cavity, retroperitoneal localization are removed in a single block through the upper median laparotomic access using a series of additional tools for the sectional set. At the same time, mobilization of the neck organs takes place using additional tools for the sectional set, and access to the neck organs itself is performed through a direct skin incision in the neck area 4-6 cm long.

At the same time, less traumatic autopsy remains laborious in conditions of complete evisceration of the organs of the neck, chest cavity, abdominal cavity and retroperitoneal organs in a single block, retractors are not used to visualize body cavities, damage to large vessels is sometimes allowed, with a number of nosologies there are contraindications, often the duration of pathological anatomical autopsy exceeds 1 hour or more.

The objective of the invention is to develop a method of less traumatic autopsy, which reduces the complexity and duration of postmortem autopsy, improves the visualization of body cavities at all stages of the organ section, the expansion of medical indications.

The technical result is the expansion of medical indications, reducing the complexity of evisceration by facilitating the allocation of organocomplexes, improving the visualization of body cavities at all stages of the organ section, facilitating the collection of material for histological and bacteriological studies in inflammatory processes in the chest cavity, reducing the duration of postmortem autopsy, increasing the integrity of the anatomical integrity skin and tissues of the internal organs of the corpse.

The proposed autopsy method is as follows. In the projection of the blades across the corpse lay a dense roller. During an external examination, the color and condition of the skin, the shape of the chest, abdomen, perineum are examined, the presence or absence of a catheter in the subclavian region, linear scars, drainage tubes, suprapubic fistula is clarified.

At the first stage, the organs of the neck are isolated. When isolating the organs of the neck, a semilunar incision of the skin is used, with a bulge facing the jugular notch about 4-5 cm long. A sectional knife creates a skin-subcutaneous tunnel from the jugular notch to the muscles of the diaphragm of the mouth along the front-upper and lateral surfaces of the neck. At the next stage, the muscles of the diaphragm of the mouth are crossed around the perimeter using the device for isolating the muscles of the diaphragm of the mouth according to the patent of the Russian Federation for utility model No. 39,065, 2004. The used device for isolating the muscles of the diaphragm of the mouth contains an ellipsoid-shaped blade, a shaft, and a handle. The rod has a different length depending on the anthropometric features of the chest and neck of the corpse. For example, with a normosthenic physique of a corpse, the length of the rod is 190 mm, asthenic - 230 mm, hypersthenic - 150 mm. The rod and blade are connected in a horizontal direction or at right angles. The perimeter blade is sharpened on the mustache, and this is important for observing the sequence of allocation of the muscles of the diaphragm of the mouth and neck organs. First, the muscles of the diaphragm of the mouth are crossed around the perimeter using a device in which the blade is horizontally connected to the shaft. This device is removed and replaced by another, in which an elliptical blade is soldered to the rod at a right angle. This allows you to complete the dissection of the remaining tissues of the bottom of the mouth and select the organs of the neck in a single block. After that, the device is removed through cervical access. In the neck, the neurovascular bundles on the right and left are crossed using the device according to the patent of the Russian Federation for utility model No. 40166, 2004. This device is designed to intersect the neurovascular bundle of the neck. It can be used for acute separation of soft tissue residues in the area of the upper opening of the chest. He is led into the wound through cervical access. The device contains a blade of a pike shape, which is sharpened on a mustache, a rod and a handle. The rod has an obtuse angle (175 °) of inclination in the sagittal plane and a different length, allowing to take into account the anthropometric features of the corpse. The device has the shape of a “cobra” due to the obtuse angle (175 °) of the inclination of the rod in the sagittal plane and the peak-like configuration of the blade. The rod has a different length, taking into account the anthropometric features of the chest and neck of the corpse. For example, with a normosthenic physique of a corpse, the length of the rod is 190 mm, asthenic - 230 mm, hypersthenic - 150 mm. These features of the knife and the presence of a skin-subcutaneous tunnel in the neck provide free manipulation and anatomical isolation of the organs of the neck. The blade is connected to the shaft symmetrically or asymmetrically, which allows you to take into account the anatomical features of the location of the neurovascular bundle of the neck. Consistently applying device modifications, neurovascular bundles cross in the transverse direction to the right and left with the help of a spiked blade. Then the soft tissues of the neck organs are captured by the device according to the patent of the Russian Federation for utility model No. 39063, 2004. The device contains a right clip with a hinge, a clip in one step, a ring at the end; left clamp with hinge, one-time clamp, ring on the end. Using the screw and nut, the right-hinge joint and the left-hinge joint are connected and fixed in a predetermined mode. The clips are of sufficient length, taking into account the anthropometric features of the chest and neck of the corpse. For example, with a normosthenic physique of a corpse, the length of the clamps is 320 mm, asthenic - 360 mm, hypersthenic - 280 mm. The necessary clamping force is achieved by bringing the hinge closer to the center of the ring by a distance of not more than 70 mm, by increasing the grip area with the fenestrated nature of the end part of this device. It is also possible to use the device for capturing the epiglottis according to the patent of the Russian Federation for utility model No. 39264, 2004, which contains a handle, a rod and a hook. Reliability of tissue capture is achieved by the design features of the hook, which gradually increases in the perimeter, forms a semicircle and goes into the rod and handle. At the same time, a rounded and gradual transition of the end section of the hook into the rod ensures reliable grip and eliminates additional tissue damage. The length of the rod takes into account the anthropometric data of the chest and neck of the corpse. For example, with a normosthenic physique of a corpse, the length of the rod is 190 mm, asthenic - 230 mm, hypersthenic - 150 mm. These devices are carried to the place of surgical action through cervical access. And after the capture of soft tissues, they are transferred to the left hand and smooth traction of the soft tissues of the neck is carried out downward and anteriorly. To separate the organs of the neck from the cervical spine, the device according to the RF patent for utility model No. 39,064, 2004 is used. The device contains a figured blade in the form of an ellipse, a rod, a handle and two nuts connected by means of a stud. The blade and the shaft are rigidly connected by solder, the shaft and the handle are pivotally connected. The blade is sharpened on a mustache, has an ellipse configuration and is located perpendicular to the rod in the frontal and sagittal planes. On average, the length of the rod is 190 mm, which corresponds to the normosthenic physique of the corpse. On the inside of the handle there is a groove and eight semicircular steps designed to change the length of the rod by shifting the handle after loosening the fastening of two nuts and studs. With asthenic and hypersthenic physique of the corpse, the length of the rod changes by 230 mm and 150 mm, respectively. Moreover, at each of the eight levels of semicircular steps, it is possible to change the angle of inclination of the handle in the frontal plane with respect to the axis of the device from 0 ° (180 °) to 45 °. On the back wall of the sternum and costal arch of the chest cavity, the device is smoothly advanced up to the neck organs. Free manipulation of the device is achieved by the presence of a subcutaneous tunnel in the neck, the ability to change the length and angle of the handle in the frontal plane due to the existing hinge. The blade of the device is transferred beyond the neck at the level of the diaphragm of the mouth. With a smooth traction from top to bottom, the blades of the device quite easily separate the organs of the neck from the bodies of the cervical vertebrae. The organs of the neck and tongue are moved to the upper opening of the chest cavity. Thus, the mobilization of the organs of the neck is carried out to the upper opening of the chest, bounded by the first pair of ribs, I thoracic vertebra and jugular notch of the sternum. Used instruments are removed through cervical access, then the results of a study of the organs of the neck are entered into the autopsy protocol.

Then, a mid-median laparotomy is performed with a ventral scalpel or a sharp rib knife from the sectional set. The midline incision of the skin with underlying tissues can be continued downward. To increase the visibility zone and facilitate manipulation in the abdominal cavity, a rack retractor from a large surgical set is brought to the upper middle access and, with the help of a screw, the edges of the wound are bred to the required distance, or Seagal booms are fixed to the section table. In this case, the mirrors of this device are fixed to the edges of the laparotomic access in the upper third of the abdomen. With the help of a screw on the rods of the device, the laparotomy access is expanded with mirrors of 15 cm or more. In the abdominal cavity, a macroscopic examination of the organs begins with the right iliac fossa. Then, the entire abdominal cavity is examined clockwise. In this case, pay attention to the state of the organs of the right lateral canal, subhepatic region, splenic angle, left lateral canal and pelvis. In the presence of adhesions, the latter are separated by an acute or blunt method. In the protocol of postmortem autopsy, the location of the drainage tubes is recorded. They describe the state of organs and tissues, note the presence of tumor-like formations, pustules abscesses, intestinal fistulas, foci of hemorrhage and other changes detected by the naked eye.

At the corpse, the diaphragm is high, the surface of the liver adjacent to it occupies the highest position. The diaphragm starts from the sternum, ribs and lumbar vertebrae; a liver mirror is used to identify the aorta, esophagus in the lumbar part and the inferior vena cava in the tendon center. In this case, a hepatic mirror is installed between the diaphragm and the anteroposterior surface of the liver. By smoothly tracing this tool in the caudal direction, the liver is moved downward by a certain distance. Using a Deschan needle, two ligatures (silk No. 6) are brought into the abdominal esophagus and aorta from a large surgical instrument set, the latter are ligated at a distance of 2-3 cm from each other and the organs cross between these sutures. In the tendon center of the diaphragm, the inferior vena cava is similarly ligated and intersected between two ligatures. This technique eliminates leakage of gastric contents and blood into the abdominal cavity. Next, the hepatic mirror is removed from the abdominal cavity.

The device according to the patent of the Russian Federation for utility model No. 39264, 2004, or the device for capturing the epiglottis according to the patent of the Russian Federation for useful model No. 39063, 2004 capture accessible areas of the 2nd complex of organs and carry out their smooth traction downward in the caudal direction. Holding the 2nd complex of organs with the left hand for ligatures previously placed on the esophagus, aorta and inferior vena cava, contributes to the anatomical allocation of the underlying tissues from the spinal column. Then, with the right hand, they begin the acute separation of the 2nd and 3rd complex of organs from the lower thoracic, lumbar and sacral spinal column. It is possible to use a device for isolating the organs of the neck from the cervical spine, suitable for this stage of evisceration. For the same purpose, they use a sectional knife, which finally separates the pelvic organs and genitals from the underlying tissues.

In cases where the extraction of the 2nd and 3rd complex of organs as a single unit is difficult, the initial section of the jejunum is isolated from the Treitz ligament, the organ is ligated with two silk threads No. 6 at a distance of 5-6 cm from each other. The rectosigmoid colon is also mobilized and between the two ligatures cross the organ. Subsequently, the intestines are mobilized in an acute or blunt way, and the spleen is included in the preparation. Less commonly, the spleen is removed separately. This frees up free space in the abdominal cavity to optimize further manipulation of the prosector. Under these conditions, intestinal contents are also excluded from entering the abdominal cavity.

The extracted organ complexes are placed on the preparation table and proceed to their study in a clear link with each other. Initially, preparations of the 2nd complex are studied at a macroscopic level, and morphometric indicators are taken, which are recorded in the protocol. Macroscopic examination of the kidneys, ureters and pelvic organs fix pathological changes. Particular attention is paid to the condition of the bladder and prostate gland. At the same time, suspicious areas detected in the genitourinary system should be excised for subsequent microscopic examination. The abdominal cavity is drained with gauze napkins and the abdominal part of the diaphragm is examined. As additional lighting, a laryngoscope is used.

In all cases, pleural cavities are examined. Sometimes the diaphragm hangs due to the accumulation of pleural fluid. After focal cauterization of the diaphragm at the place of its attachment to the edge of the costal arch, linear sections are made in an organ about 2 cm long. When liquid is detected, its volume and nature are determined, and the contents are collected in sterile tubes for bacteriological and bacterioscopic studies. Using the middle sectional knife, the diaphragm is separated from the sternum, ribs, up to the vertebrae. The anterior mediastinum is separated from the chest using a sectional knife, or using a device for isolating the muscles of the diaphragm of the mouth according to the patent of the Russian Federation for utility model No. 39,065, 2004. A manual examination of the right and left pleural cavities is carried out for adhesions and other obstructions for gentle allocation organs of the neck and chest cavity. In the presence of adhesions, the latter are separated by a blunt or acute method. Additional lighting is achieved through the use of a laryngoscope with backlight.

To provide wider access to the organs of the neck and thoracic cavity through the upper middle laparotomy incision, a device raising the costal arch according to the RF patent for utility model No. 39265, 2004 is brought into the lower chest opening. This device contains an arch with a strip, rib, spikes and support with a strip, rib, spikes connected by two screws on four hinges. The screw has nuts for free rotation of the screws in the support and the arc. By rotating clockwise two screws with nuts from the minimum position (158 mm), the costal arc is raised to the maximum (260 mm) possible level. This provides a large area of accessibility, an increase in the angle of operational action and freedom of manipulation with complete evisceration. The device is installed in an upright position with the help of spikes in the support to the thoracic vertebra and spikes of the arch to the costal arch. In this case, the screws with nuts are rotated counterclockwise and with four hinges to a minimum to ensure rational placement of the device in the abdominal cavity. When the screws rotate clockwise, the arc of the device raises the costal arch of the front surface of the chest up to a predetermined angle of 15-30 ° of the operational action. This significantly increases the viewing area of the cavity of the chest and neck organs. When you rotate clockwise the screws with nuts, the arc with four hinges freely raises the front surface of the chest up to a predetermined angle of operational action. In this case, the support spikes and the arc spikes penetrate deep into the bone tissue and tightly fix this device in the abdominal cavity. From the laparotomic access through the upper hole in the chest to the neck organs, a clamp device according to the patent of the Russian Federation for utility model No. 39264, 2004, or a device for gripping the epiglottis according to the patent of the Russian Federation for utility model No. 39,063, 2004 are brought to them. They capture soft tissues of organs the neck and epiglottis, which move into the chest cavity. At the next stage, the tools are transferred to the left hand, and without weakening the smooth traction of organs in the caudal direction, the right hand is used to separate the soft ones with the help of a sectional knife or a device for isolating the neck organs from the cervical spine according to the RF patent for 2004 model 200490 tissue from the upper thoracic spine. Finally, the organs of the neck, tongue, lungs with a tracheobronchial tree, large vessels located in the chest cavity are removed through the upper median laparotomic access. From the abdominal cavity, instruments from the sectional set and devices from the additional list are removed.

For a clearer description of the pathological process in the lungs, a paired organ is examined on a preparation table according to a certain plan. With pneumonia, autopsy of the lungs has some features. At the same time, the lungs are carefully examined, including by palpation of the organ. In case of detection of pathological formations, their location and size, its relation to the tracheobronchial tree are specified. Isolation of lung tissue at the segment level allows you to more accurately establish a causal relationship between the inflammatory process in the bronchus and the adjacent lung parenchyma. The research protocol includes the collection of biological material for bacteriological and bacterioscopic studies. All segments of the lungs are weighed, and the data is recorded in a special card. Usually, four pieces of biological material are taken from the lung tissue, two from the side of the visceral pleura, two from the area of the roots of the organ. In some cases, the number of pieces can reach 10-12 or more.

Autopsy is completed by laying the internal organs in the corresponding cavity of the corpse. The accesses on the skin of the neck and the anterior abdominal wall are fastened with nylon seams and sealed with a wide adhesive plaster.

A full autopsy method using the proposed low-traumatic autopsy technology was used in 14 cases. In all cases, the specified technical result was achieved.

Claims (1)

The method of postmortem autopsy, including a direct midline incision of the anterior abdominal wall with subsequent isolation of the abdominal and thoracic cavity organs, a midline neck incision with the allocation of neck organs using tools for conducting a minor traumatic autopsy, without dissecting the anterior chest, characterized in that the organs of the neck are secreted, for which makes a half-moon incision, convex facing the jugular notch, 4-5 cm long, then create a skin-subcutaneous tunnel from the jugular notch to the muscles of the diaphragm of the mouth along the anterior th and lateral surfaces of the neck, using a device for isolating the muscles of the diaphragm of the mouth, containing an ellipsoidal shape of the blade, the shaft and the handle, the shaft and blade being connected in a horizontal position or at right angles, and the blade is sharpened around the perimeter with a mustache, the muscles of the diaphragm are first crossed around the perimeter using a device in which the blade is horizontally connected to the rod, then the device is removed and replaced by another, in which the elliptical blade is soldered to the rod at a right angle, with which dissection of the remaining tissues of the bottom of the mouth, after which the device is removed through the cervical access, the neurovascular bundles in the neck area are intersected on both sides with the device for their intersection, which contains a figured blade, a shaft having an obtuse angle (175 °) of inclination in the sagittal plane , and the handle, the blade sharpened on a mustache, has a peak-like configuration, symmetrically or asymmetrically connected to the shaft, soft tissue of the organs of the neck is captured by a device for capturing soft tissue of the neck, having a left and right clip from the hinge and with clamps in one step, with rings at the end, connected with a screw to a nut or device for gripping the epiglottis, having a handle with a rod and a hook on the end, and carried out to the jugular notch, the soft tissues of the neck are separated with a device to isolate the organs of the neck from the cervical region the spine, which contains a curly blade, a rod, a handle and two nuts connected by a hairpin, the blade sharpened on a mustache, has an ellipse configuration and is located perpendicular to the rod in the frontal and sagittal planes, and on the inside the groove of the handle are a groove and eight semicircular steps designed to change the length of the shaft by shifting the handle after loosening the two nuts and studs to the upper chest opening (aperture), the device is removed through the cervical access, and then the upper mid laparotomic incision of the anterior abdominal wall is performed , a rack-mounted retractor or a retractor of Seagal is installed in it, then a hepatic mirror is placed between the diaphragm and the front-upper surface of the liver and produced two ligatures, which are ligated at a distance of 2-3 cm from each other and cross the organs between these sutures, similarly, in the tendon center of the diaphragm, ligature and cut the inferior vena cava, liver mirror they are removed, then using a device to isolate the organs of the neck or hook (hook), they grab the soft tissues and the ends of the ligatures superimposed on the esophagus, aorta and inferior vena cava near the lower thoracic vertebrae, and produce a smooth traction soft tissues and abdominal organs from the lower thoracic, lumbar and sacral spinal column are separated from the abdominal canals downward, with a sectional knife or a device for isolating the neck organs from the cervical spine, the initial jejunum at the Treitz ligament is isolated, the organ is ligated with two silk threads No. 6 at a distance of 5-6 cm from each other, between which the organ crosses, the rectosigmoid part of the colon is also mobilized and the organ is crossed between the two ligatures, then by a sharp or blunt path the intestines and spleen are licked, after cauterization of the hanging sections of the diaphragm, linear cuts are made 2 cm long at the place of its attachment to the edge of the costal arch, with the middle section knife, the diaphragm is separated from the sternum, ribs and lumbar vertebrae, with a long section knife or a curved device for isolating the muscles of the diaphragm of the mouth, the anterior mediastinum is separated from the chest, a manual examination of the right and left pleural cavities is performed, adhesions are separated by a blunt or sharp path, larin is used for additional illumination a backlit hoscope, a device that lifts the costal arch is inserted through the upper mid laparotomic access, fragments of unseparated soft tissues are also crossed in the region of the upper thoracic cavity, neck organs, including the tongue, are moved to the upper thoracic cavity, and a device for isolation is inserted through the upper middle access organs of the neck or device for capturing the epiglottis, holding the tool in the left hand, with the help of the device for separating the organs of the neck from the spine, help the smooth movement of the organ and new soft tissue down, neck and chest cavity bodies recovered through verhnesredinny access, then extracted previously used devices, light is divided into segments and weighed separately.