RU2629039C1 - Method for creation of end-to-side vascular microanastomosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: before sutured together, vascular walls are coloured with sterile 1% aqueous of gentianviolet. The walls of the anastomosed vessels are stitched together by successive single nodal sutures. At that, the first suture is applied and the needle is inserted into the walls of the sutured vessels to make the second suture. The needle is left in this position, and knots are tied using the thread end and the suture loop, after which the thread of the suture loop is cut off. Similarly, the following single nodal sutures are imposed.

EFFECT: method allows to reduce labour intensity, improve anastomosis formation quality, simplify and accelerate the formation process.

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Description

The invention relates to medicine, namely to vascular surgery and microsurgery, and can be used in the formation of microvascular anastomoses.

A known method of applying a venous anastomosis of the type "end to side", including a section of the recipient vein and suturing into this section of the vein graft. In this case, an oblique incision of the vein graft is performed, and an arched incision is made on the recipient vein with a length equal to the diameter of the sutured vein graft. Then, nodal sutures are applied to the posterior lip of the anastomosis. Next, the anterior wall of the vein is excised along the arc and nodal sutures are applied to the anastomosis anterior lip (Method of imposing an end-to-side anastomosis: RF patent 2292850, А61В 17/11 / Zabirov E.M., Nuzov B.G., Kagan I. I., Laikov A.V., Kim V.I .; publ. 10.02.2007).

The disadvantages of this method include the impossibility of matching homogeneous layers of the walls of the stitched vessels, as well as the high likelihood of thrombosis due to the complexity of visualization of residual elements (adventitia, media) of the recipient vessel in the lumen of the transplant vessel after the opening of the opening in it.

The disadvantages also include the difficulty of excision of the anterior wall of the vessel after suturing the posterior lip of the anastomosis, because with a small diameter of the stitched vessels, the vessel wall may be damaged or the stitches severed. In addition, this step takes extra time.

The closest in technical essence to the proposed is a method of applying a vascular microanastomosis of the type "end to side", in which before stitching the walls of the vessels are tinted with a sterile 1% aqueous solution of methylene blue. Then the end of the donor vessel is fixed to the recipient vessel with two single seams located along the axis of the recipient vessel opposite each other. Then, from one single seam to another, a continuous seam is imposed with loosened loops. After that, the loops are cut, and the ends of each loop are connected in pairs. Similarly, sutures are placed on the opposite side of the anastomosis (RF Patent 2533030, IPC АВВ 17/00, А61В 17/11. Method for applying a vascular microanastomosis of the type "end to side" / Byvaltsev VA, Belykh EG, Damdinov B .B., Sorokovikov V.A .; publ. Applicant and patent holder of FSBI "NTSRVH" SB RAMS. - No. 2013121518; application. 07.05.2013; publ. 20.11.2014, Bull. No. 32).

The disadvantages of this method include the short duration of the effect of tinting the walls of blood vessels with a solution of methylene blue, which lasts no more than 5 minutes, and the application of the anastomosis takes from 10 to 40 minutes. At the same time, such tinting is easily washed off with liquor and / or solution irrigating the surgical field.

Also, the disadvantages of this method include the reception of the simultaneous formation of a number of loops in an amount up to 5-7, which can become confused and thereby complicate the visualization of the overlay area of the next seam, which will require additional time to correct their position.

In addition, when suturing, it is necessary to constantly fix the needle in the field of view of the microscope, which, under the action of the elasticity of the thread, can leave the field of view. The search for the needle is associated with additional movements of the microscope along the surgical field, which is a distraction, which also takes some time.

All these disadvantages impede the visualization and the process of applying a microvascular anastomosis.

The objective of the proposed technical solution is to develop a method of forming a vascular microanastomosis of the type "end to side", which allows to reduce the complexity and simplify the process of suturing.

The technical result of the proposed method is to reduce the complexity of the formation of the anastomosis due to the persistent staining of the walls of the stitched vessels, as well as by eliminating the displacement of the needle beyond the boundaries of the field of view of the operating microscope.

The technical result is achieved by the fact that the method of applying a vascular microanastomosis of the type "end to side" includes forming the end of the donor vessel and the hole in the wall of the recipient vessel, tinting the walls of the stitched vessels with a sterile dye solution, fixing the end of the donor vessel to the recipient vessel with single sutures .

Distinctive techniques of the proposed method are that the walls of stitched vessels are tinted with a sterile 1% aqueous solution of gentian violet.

A distinctive method of the proposed method also consists in the fact that the donor vessel with the recipient vessel is sewn together in successive single interrupted sutures. In this case, a first seam is applied and a needle is inserted into the walls of the stitched vessels for the second seam. In this position, the needle is left and knots tied, using the end of the thread and the loop from the first seam, after which the thread is cut. Further, in a similar manner, the following single nodal joints are imposed.

A comparative analysis of the proposed technical solution with the prototype allows us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

From the analysis of patent and specialized literature it was established that the proposed method has features that distinguish it not only from the prototype, but also from other technical solutions in this field and related fields of medicine. The authors have not found a way to impose a vascular microanastomosis of the type "end to side" containing the distinctive techniques of the proposed method.

The use of a sterile 1% aqueous solution of gentian violet as a dye allows one to obtain stable staining of the walls of stitched vessels, which is held on the vessel until the final stage of microvascular anastomosis formation, i.e. more than 40 minutes

Fixing the end of the donor vessel to the recipient vessel with two single seams located opposite each other allows you to compare and fix the holes of the anastomosed vessels in a given position.

The proposed sequential overlapping of single nodal sutures allows you to constantly control the distance between them, since the subsequent injection of the needle is carried out without tensioning the vessel wall with the previous suture. At the same time, the needle left in the walls of the stitched vessels (in the state of their puncture) supports these walls, preventing their adhesion.

Fixing the needle in the walls of the stitched vessels also facilitates its search and capture for the next suture, thereby saving the time of formation of the anastomosis.

With further advancement of the needle, the formed loop supports the walls of the vessels, preventing them from falling off and turning up, as a result of which the hemming of the opposite stitched vessel wall is excluded, which also facilitates and accelerates the suturing process.

Subsequent cutting of the loop of the thread and the binding of its ends to each other make it possible to obtain a series of consecutive single nodal sutures uniformly located on the side of the anastomosis, which ensures matching of the walls of the anastomosed vessels with the same layers. A similar stitching on the opposite side of the anastomosis allows you to finish its formation.

The above methods of the proposed method reduce the complexity while ensuring uniform suturing, which is achieved by providing a long visualization of the color of the layers of the walls of the stitched vessels, as well as by eliminating the displacement of the needle beyond the field of view of the operating microscope.

From the foregoing, it follows that the proposed method of applying a vascular microanastomosis of the type "end to side" meets the criterion of "inventive step".

The method comprising the invention is intended for use in healthcare. This method can be used in microsurgery when applying a vascular microanastomosis of the type "end to side". The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The essence of the proposed method of applying a vascular microanastomosis of the type "end to side" is illustrated in FIG. 1, where 1 is the artery of the donor, 2 is the artery of the recipient, 3 and 4 are single seams located opposite each other, 5 is the end of the thread, 6 is the needle.

The proposed method is carried out using optical zoom in 12-30x and microsurgical instruments.

A comparable sized end of the artery of the donor 1 and a hole in the side of the artery of the recipient are formed. To visualize the walls of arteries 1 and 2, they are tinted with the tip of a micro-forceps moistened in a sterile 1% aqueous solution of gentian violet. The end of the vessel of the donor 1 is fixed to the vessel of the recipient 2 with two single seams 3 and 4 located at 0 and 180 °, i.e. opposite each other along the axis of the recipient vessel.

Next, the anastomosed vessels 1 and 2 are sutured in successive single nodal sutures. In this case, the first seam is applied and the needle 6 is inserted into the walls of the stitched vessels 1 and 2 for the second seam. In this position, the needle 6 is left. Using the end of thread 5 and the loop from the first seam, knot knotted. After that, the thread of the loop of the first seam is cut off. Further, in a similar manner, the following single nodal joints are imposed.

The essence of the proposed method is illustrated by an example of a specific implementation.

Patient G., 63 years old, was hospitalized at the Center for Neurosurgery of the NIH “Road Clinical Hospital at st. Irkutsk-Passenger ”in a planned manner with a diagnosis of“ Partially thrombosed saccular aneurysm of segment M1 of the middle cerebral artery (SMA) on the left. The consequences of subarachnoid hemorrhage. "

The patient underwent surgery in the amount of: Left-sided osteoplastic craniotomy, clipping of saccular aneurysm of the left middle cerebral artery, formation of extra-intracranial double microanastomosis on the left, between the superficial temporal arteries (PVA) and SMA.

During the operation, two vascular microanastomoses of PVA-CMA were applied to ensure distal blood flow during clipping of an aneurysm of SMA.

The distal section of the prepared frontal branch of the PVA is isolated, freed from the adventitial membrane and is cut like a fish mouth. A temporary clip is superimposed. The cortical branch of the SMA is isolated from arachnoidal fusions, and a silicone “substrate” is placed under it. Temporary clipping of the supra-force branch of the SMA over the course was carried out. According to the proposed method, anodomosis of the end-to-side type between the frontal branch of the PVA and the suprasilvic branch of the SMA was performed by separate interrupted sutures (Prolen 10/0). Temporary clipping time - 20 minutes.

Visual consistency check: the anastomosis pulsates, the blood flow is preserved, there are no signs of stenosis. Bleeding from the injection sites is stopped by Surgicel strips.

Checking the viability of the anastomosis using intraoperative video angiography with indocinous green - we pass the anastomosis, there is no stenosis.

Similarly, a microvascular anastomosis was placed between PVA and the suprasilia branch of SMA. Checking the consistency of the anastomosis using intraoperative video angiography with indocinous green - we pass the anastomosis, there are no signs of stenosis.

Next, the Silvian gap was divided, the branches M2 and M3 of the SMA are tightly spliced with the dome of the aneurysm. It was not possible to isolate the neck of the aneurysm, the discharge and bringing vessels, therefore, a direct permanent clip was placed on the M1 segment of the left SMA and two direct permanent clips on both segments M2 of the left SMA. The blood flow in the distal branches is maintained due to the double microanastamosis.

Aneurysm puncture was performed: adequate clipping, aneurysm is turned off from the bloodstream. Ripple is satisfactory, there are no signs of edema.

The dura mater is sutured with single sutures with a clearance for the PVA branches. Leak test. A hole was made in the bone flap and temporal muscle for PVA branches. The bone flap is fixed by two craniofixes. The wound is sutured in layers. An aseptic dressing is applied.

Postoperative course. During postoperative CT monitoring, elements of arterial aneurysm and hemorrhagic foci were not detected.

6 days after surgery during an MRI scan of the brain, no new foci of hemorrhage were detected, an increase in cerebral blood flow in the left hemisphere was noted.

The patient was discharged on the 10th day without the progression of neurological deficit.

In the next 6 months, patient G. did not notice any new symptoms of neurological deficit.

According to the proposed method, 5 patients were treated. 10 anastomoses were performed between the superficial temporal artery and the cortical branches of the middle cerebral artery. In all cases of thrombosis or insolvency of the anastomosis and deterioration of the neurological condition was not noted. It should be noted that during the application of microanastomoses, it was never necessary to remove the microscope from the area of its application.

Thus, the proposed method due to persistent staining of the walls of the stitched vessels to the final stage of the formation of microanastomosis, can improve its quality, as well as simplify and speed up the process of applying a microvascular anastomosis by eliminating the need to move the needle beyond the field of view of the operating microscope. When performing microanastomosis, the proposed method simplifies the choice of the injection site of the needle, which contributes to the uniformity of suturing. In this case, the vessel wall is less injured in the process of performing the anastomosis, because the walls of the anastomosed vessels during suturing are in close contact with each other, do not fall off, are not rigidly fixed, which allows manipulation with them.

Claims (1)

The method of applying a vascular microanastomosis of the type "end to side", including forming the end of the donor vessel and the hole in the wall of the recipient vessel, tinting the walls of the stitched vessels with a sterile dye solution and fixing the end of the donor vessel to the recipient vessel with two single interrupted sutures, characterized in that the walls of the stitched vessels are tinted with a sterile 1% aqueous solution of a gentian violet and stitched with successive single interrupted sutures, while the first stitch is inserted and a needle is inserted into the stitched walls vessels for the subsequent seam, in such a position and the needle is left tied nodes using the end of the thread and a loop of the suture, after which more suture thread is cut similarly applied following single nodal joints.

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