RU2614218C1 - Method for rear retroperitoneal adrenalectomy perfomance - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: rear retroperitoneoscopic adrenalectomy is performed through an incision to 30 mm under the 12th rib end. The workspace is created using an endoscope tube. Along the wound edges two punctures for the endoscope and working tool are made. Detection of adrenal gland tumours is performed. First, the lower part of the adrenal gland, then the side surfaces are subjected to mobilization, then the adrenal gland central vein is suppressed, and the rear surface is mobilized. The upper part is the last to be suppressed.

EFFECT: method eliminates the costly special equipment, reduces pain in the postoperative period and provides a good cosmetic effect due to operation according to a specially developed algorithm of adrenal gland selection from the surrounding tissues.

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Description

The invention relates to medicine, namely to surgery, and can be used in operations associated with the need to remove adrenal neoplasms by adrenalectomy.

Until 1992, an adrenalectomy was performed only from traditional laparotomy, lumbotomic or thoracophrenolumbotomic accesses, which involve dissection of a large array of tissues, which are often accompanied by complications in the postoperative period, but the introduction of endosurgical operations into practice allowed adrenalectomy to be performed using a relatively minimally invasive technique (RU 2245105, 2005; Saveliev BC Endoscopic Surgery, Geotar, Medicine, 1998, 289-295). The well-known advantages of endoscopic surgery over traditional. They are expressed primarily in reducing the morbidity of the operation. A significant reduction in the volume of dissected tissues, the amount of blood loss contributes to the rapid development of endosurgery techniques in recent years, a change in the principles of surgical treatment of many diseases.

The anatomical location of the adrenal glands allows you to maximize the benefits of endosurgery to remove them, since most tumors of this location are small. However, the location of the adrenal glands in the retroperitoneal space in close proximity to vital organs, large vessels requires special development of original techniques that allow reliable visualization and isolation of the adrenal gland and its vessels.

A known method of operations on the adrenal glands (RU 2165740, 2003), in which a soft tissue incision is preliminarily performed from the posterior axillary line to the vagina of the rectus abdominis muscle along the XI rib with a subperiostal resection of 5-7 cm of its distal part. The abdominal cavity is opened in layers. Access provides an angle of operational action along the length of 70-90 ° and along the width of 42-60 ° to the adrenal gland. However, it does not provide optimal parameters for the approach to the adrenal glands and especially their central veins. In addition, the resection of the distal portion of the XI rib 5-7 cm long is carried out without taking into account the individual anatomical features of the body, and the bed of the resected rib is not directly used in the approach to the operation objects.

The modern development of endoscopic operations allows you to perform a number of operations from one skin incision 2-3 cm long, in which endoports of various modifications are installed. The main feature of these ports is the presence of several channels, allowing you to install along with the laparoscope tube and working tools. The result is a reduction in surgical trauma caused by surgical intervention on the muscular skeleton, which provides a significant reduction in the rehabilitation period, a decrease in pain, and a cosmetic effect (Inoue S., Ikeda K., Kajiwara M. Laparoendoscopic single-site adrenalectomy sans transumbilical approach : initial experience in Japan. Urol J. 2014 Sep 6; 11 (4): 1772-6.) Thus, a laparoscopic adrenalectomy is known by right-side and / or left-side access, including the installation of trocars for holding instruments in the abdominal cavity, an overview of the abdominal th cavity, finding the right and / or left central vein of the right or left adrenal gland, its hemostasis and intersection, hemostasis of large and small blood vessels at all stages of the operation, and performing right and / or left adrenalectomy, in which trocars are introduced along the edge of the costal arch with so that the working angle between them is 70-90 °, and the line of introduction of the laparoscope forms a bisector of this angle, dissection, hemostasis and vessel ligation during the operation are carried out using an electrosurgical instrument, eriruyuschego high frequency alternating current pulse packets, creating a seal when haemostasis collagen, the dissection of the inferior vena cava to the right or left renal vein to the central carried adrenal veins tissue mobilization along them further mobilization and subsequent removal of the adrenal performed en bloc with the surrounding fiber.

Known (RU 2181987, 2002) is a method of endosurgical adrenalectomy, including transperitoneal access, isolation and clipping of the central adrenal vein, isolation and removal of a macro product of a pathologically altered adrenal gland, in which selective phlebography is performed and its length is determined by catheter into the lumen before the central adrenal gland is extracted. the fiber is inserted, the end of the fiber is placed at the mouth of the vein, then the fiber is connected to the light source, the laparoscope illuminator is turned off and the central the adrenal vein in transmitted light, using the effect of transillumination.

However, such techniques for performing operations on the adrenal glands have a significant number of limitations, in particular the impossibility or a significant increase in the risk of intraoperative complications in the presence of a patient with adhesive disease; a restriction in the laying of the patient (in the position on the side) in which, in the presence of severe pathology of the spinal column, there is a risk of a fracture of the spine; the risk of circulatory failure with intense carboxyperitonenum in patients with severe heart failure; the need to mobilize the abdominal organs to perform an adrenalectomy.

Closest to the claimed method is posterior retroperitoneoscopic adrenalectomy (Borisov A.E., Levin L.A., Zemlyanoy V.P. and other Video endoscopic interventions on the organs of the abdomen, chest and retroperitoneal space. - St. Petersburg: Enterprise EFA, "Janus ”, 2002, p. 360). The operation is performed in the retroperitoneal tissue without penetration into the abdominal cavity. Therefore, the presence of adhesive disease does not pose technical difficulties for the operation, and there is no need to mobilize the abdominal organs. As a result, gas insufflation in the retroperitoneal fiber does not exert pathological pressure on the cardiovascular system. At the same time, laying the patient directly and on the abdomen eliminates the load on the spine. Posterior retroperitoneoscopic adrenalectomy is performed through three incisions to install endoports (under the ends of 11, 12 ribs and 5 cm from the spine at the same level). After performing an adrenalectomy, the tumor is removed through the middle endoport by expanding the incision of the latter to 3-4 cm. The need for three incisions is due to the fact that the created working space in the retroperitoneal tissue is much smaller than the space of the abdominal cavity, therefore laparoscopic curved instruments used in single-port surgery with transabdominal access , is not suitable for the operation, and when using conventional direct laparoscopic instruments, the problem of "scratch swords ”, when the instruments crossed each other because of the extremely small angle of attack of the instrument, this problem was especially acute when installing the instrument through a special endoport (ENDOCONE (Karl Storz, Tuttlingen, Germany) and SILS port (Covidien, Switzerland) for several instruments, in addition, the large size of their outer part limits the angle of operational action, which prevents the laparoscope from lowering as horizontally as possible.

The technical problem solved by the authors is the development of a method that allows you to abandon special expensive equipment that provides maximum safety exposure with improved cosmetic.

This problem was solved by applying modified single-port surgery by modifying the skin incision and performing the operation with only one working tool according to a specially developed algorithm for isolating the adrenal gland from surrounding tissues.

The technical result was achieved due to the fact that in the method of performing posterior retroperitoneoscopic adrenalectomy, which includes laying the patient directly on the abdomen, performing three incisions to install endoports, creating a working space, dissection, coagulation and cutting of tissues and blood vessels, detecting adrenal neoplasm, its sequential mobilization, removal of the working tool and suturing of the skin incision; instead of three incisions, one incision is made 25-30 mm long, under the end of the 12th rib with dissection The surface layer of the dermis and along the edges of the wound perform two punctures under the endoscope and a working tool along the edges of the incision. In this case, the lower part of the adrenal gland is mobilized first, then the lateral surfaces, after which the central vein of the adrenal gland is nipped and the back surface is mobilized, during the whole operation the adrenal gland with neoplasm is fixed by the upper part, which is stopped last, and after removing the working instrument, a larger trocar is installed the diameter through which the tumor is removed.

Punctures are performed with a diameter of 3 and 8 mm under a 5 mm working trocar and a 10 mm trocar for a laparoscope. In the event of technical difficulties, due to which it is impossible to perform the intervention with one instrument, it is advisable to perform additional punctures at the end of 11 ribs and 5-6 centimeters from the spine so that they are in line with each other and additional trocars are inserted through them .

The method is as follows. A 25 mm cut is made under the end of the 12th rib. Only the surface layer of the dermis is dissected. Two punctures of 8 mm and 3 mm under a 10 mm endoscope and 5 mm working tool are made along the edges of the wound. Thus, the wound edges create a sealing effect of the endoport, and the absence of protruding parts above the skin surface allows you to lower the angle of the laparoscope and working tool to the level of the back, significantly expanding the angle of the surgical action. Using the tube of the endoscope after perforating the fascia of Gerot, a working space is created, then using the electrosurgical tool “Liga-Sure”, which allows dissection, coagulation and cutting of tissues and blood vessels, a further operation is performed. Using only one tool allows you to avoid crossing them in the workspace. After mobilization of the upper pole of the kidney and detection of neoplasm of the adrenal gland, it is sequentially mobilized. The sizes of adrenal gland neoplasms recommended by the authors for removal by this method are up to 45 mm. It is important to adhere to the adrenal gland isolation algorithm. First, the lower part of the adrenal gland is mobilized, then the lateral surfaces, the central adrenal vein is suppressed, the posterior surface is mobilized. The entire period of operation of the adrenal gland with a neoplasm is fixed by the upper part, which is stopped last. When suppressing the upper part of the adrenal gland at earlier stages, the adrenal gland sinks to the bottom of the working cavity and it is impossible to complete the operation with one tool. In this case, additional working tools are installed through separate punctures under the end of the 11th rib and 5-6 centimeters from the spine so that they are in line with each other. After performing an adrenalectomy, a 5 mm trocar of the working instrument is removed, a 10 mm trocar is inserted in its place, through which the tumor is removed with the help of a landing net. The skin incision is sutured cosmetically.

The essence and advantages of the method are illustrated by the following examples.

Example 1

Patient K., 48 years old. Diagnosis: pheochromocytoma of the right adrenal gland.

The size of the neoplasm was 40 × 36 mm. After preliminary preparation of the patient in the conditions of the endocrine department of the patient, a rear single-port adrenalectomy was performed. The duration of the operation was 56 minutes. The level of hypercapnia was within acceptable values up to 50 mm Hg. The cut size was 27 mm. The patient was discharged from the hospital on the second day of the postoperative period in satisfactory condition. The patient noted an extremely low level of postoperative pain, which allowed the patient to independently refuse to prescribe painkillers.

Example 2. The described method was applied in 120 operations. Patients with both hormone-active and hormone-inactive neoplasms were operated on. In 5 cases (4.1%), there was a need to install additional trocars.

When determining the level of postoperative pain, a numerical pain scale from 0 to 10 was used in all patients 3 hours after waking up, 10 hours, on the first and second days after surgery at 9 am. When assessing pain above 7 points, the patient was prescribed narcotic analgesics, from 3 to 7 non-narcotic analgesics, and from 1-2 the patient did not need the introduction of analgesic drugs.

In 12 patients (10%), the level of postoperative pain was more than 2.

Carrying out an adrenalectomy using the inventive modified single-port posterior retroperitoneoscopic access has the following advantages over other methods:

- preservation of all the advantages of posterior retroperitoneoscopic adrenalectomy compared with laparoscopic adrenalectomy;

- the abandonment of the special endoport and tools necessary to work with it, reduces the level of material costs for the operation;

- a significant decrease in the level of postoperative pain;

- cosmetic effect - there is only one scar, its size does not exceed 3 cm, and the scars on the back are less cosmetically significant than on the stomach.

Claims (4)

1. A method of performing posterior retroperitoneoscopic adrenalectomy, which includes laying the patient directly on the abdomen, performing an incision, installing endoports, creating a working space using an endoscope tube, dissection, coagulation and cutting of tissues and blood vessels, detecting adrenal neoplasm, its sequential mobilization, removing the worker tool and suturing of the skin incision, characterized in that the incision is made up to 30 mm long under the end of the 12th rib with dissection of the surface layer of the dermis and along the edges of the wound two punctures under the endoscope and the working instrument are filled, first the lower part of the adrenal gland is mobilized, then the lateral surfaces, then the central vein of the adrenal gland is nipped and the back surface is mobilized, and during the whole operation the adrenal gland with the neoplasm is fixed by the upper part, which is stopped last, and after removal of the working instrument, a larger diameter trocar is installed, through which the tumor is removed. 2. The method according to p. 1, characterized in that the punctures are made with a diameter of 3 and 8 mm 3 The method according to p. 1, characterized in that, after removing the working tool, a trocar with a diameter of 10 mm is installed. 4. The method according to p. 1, characterized in that in the case when the adrenal gland sinks to the bottom of the working cavity, additional working tools are installed through separate punctures under the end of the 11th rib and 5-6 centimeters from the spine so that they are in line with each other with a friend.