RU2630356C2 - Set of surgical instruments for liver echinococcosis treatment and method for liver echinococcosis surgical treatment - Google Patents

Set of surgical instruments for liver echinococcosis treatment and method for liver echinococcosis surgical treatment Download PDF

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RU2630356C2
RU2630356C2 RU2015134874A RU2015134874A RU2630356C2 RU 2630356 C2 RU2630356 C2 RU 2630356C2 RU 2015134874 A RU2015134874 A RU 2015134874A RU 2015134874 A RU2015134874 A RU 2015134874A RU 2630356 C2 RU2630356 C2 RU 2630356C2
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cyst
cysts
liver
echinococcosis
echinococcal
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RU2015134874A
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Russian (ru)
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RU2015134874A (en
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Михаил Иосифович Прудков
Шухрат Шодиевич Амонов
Тошпулат Гульмурадович Гульмурадов
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Михаил Иосифович Прудков
Шухрат Шодиевич Амонов
Тошпулат Гульмурадович Гульмурадов
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Priority to RU2015134874A priority Critical patent/RU2630356C2/en
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    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00Surgical instruments, devices or methods, e.g. tourniquets
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B17/00Surgical instruments, devices or methods, e.g. tourniquets
    • A61B17/28Surgical forceps
    • A61B17/29Forceps for use in minimally invasive surgery
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B10/00Other methods or instruments for diagnosis, e.g. instruments for taking a cell sample, for biopsy, for vaccination diagnosis; Sex determination; Ovulation-period determination; Throat striking implements
    • AHUMAN NECESSITIES
    • A61MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61BDIAGNOSIS; SURGERY; IDENTIFICATION
    • A61B10/00Other methods or instruments for diagnosis, e.g. instruments for taking a cell sample, for biopsy, for vaccination diagnosis; Sex determination; Ovulation-period determination; Throat striking implements
    • A61B10/02Instruments for taking cell samples or for biopsy
    • A61B10/0233Pointed or sharp biopsy instruments

Abstract

FIELD: medicine.
SUBSTANCE: for liver echinococcosis surgical treatment, a set of surgical instruments is used. The set comprises a cannula aspirator and tweezers with a working part in the form of sponges, with end grippers in the form of tight trays. The cannula aspirator is configured to bend along the axis in the working part, with the lumen diameter of 4 mm, and comprises a sealing sphere. Tweezers for chitinous sheath, daughter and granddaughter cysts removal grasps them with tightly closed trays. The method for hepatic echinococcosis treatment includes laparotomy, cysts puncture, hydatid liquid evacuation. After puncture, the cyst is exposed, and chitinous sheath, daughter and granddaughter cysts are removed through the open cyst wall defect by capturing and reliable retantion of cyst content with the instrument from the set.
EFFECT: use of an instrument set allows to improve the results of surgical treatment of hepatic echinococcosis, reduce the frequency of relapses due to hydatid cysts content evacuation without contact with the surrounding tissues and abdomen surface when removed from the cavity.
2 cl, 3 ex, 1 dwg

Description

The group of inventions relates to medicine, namely to surgery, and can be used for the surgical treatment of liver echinococcosis.
Echinococcosis of the liver is endemic. In recent years, its epidemiology has been studied by numerous researchers. According to many researchers, among lesions of various organs and tissues, liver echinococcosis occurs from 44.2 to 84.2%.
The clinical picture and the development of the parasite are explained by the relatively late diagnosis and development of various complications, the frequency of which is 22-53%. The increase in severe, complicated forms of liver damage by echinococcus due to lack of awareness of the population about the transmission of this disease.
The development of a parasite in the human body often causes a variety of complications, leading to disability of patients, often to the death of the patient.
In recent years, in the CIS countries, where there is considerable experience in the treatment of echinococcosis, serious positive changes have occurred, due to both the development of hepatology and the introduction of new technologies. The leading modern methods for diagnosing liver echinococcosis are ultrasound (ultrasound) and computed tomography - CT. The diagnosis of echinococcosis is an indication for surgical treatment. The choice of the method of operation and the volume depend on the size and location of the cysts, the presence of complications, taking into account the general condition of the patient and related diseases.
At present, epidemiology, diagnostics and surgical treatment of liver echinococcosis have been well studied. However, the frequency of postoperative complications, relapses of echinococcosis, and unsatisfactory results of surgical treatment does not tend to decrease. Unfortunately, the achievement of complete aparasitism in all patients with various localizations of echinococcus is impossible. Compliance with the principle of parasitism in all interventions in patients would significantly reduce the risk of dissemination of the germinal elements of the echinococcal cyst, reduce the frequency of relapses and improve the results of surgical treatment of echinococcosis. The cause of dissemination and implantation during echinococcectomy is the embryonic elements of the maternal cyst, therefore, in accordance with the principle of aparasitism during manipulations with the parasitic cyst, it is necessary to evacuate the contents of the cyst without contact with surrounding tissues and the surface of the abdominal cavity.
Among others, along with diagnostic difficulties contributing to the occurrence of postoperative complications and unsatisfactory results of surgical treatment of liver echinococcosis, traditional tactical approaches and the imperfection of surgical technique are provided.
A known method of treating echinococcosis of the liver, in which a trocar with a direct distal section is used, equipped at the distal end with a transparent silicone casing protruding 10 mm beyond the section, and vacuum suction; an endoscopic needle with a cut-off angle of the working part of 45 ° and external centimeter marking is placed inside the trocar to control the depth of penetration of the needle into the cyst cavity [Goremykin I.V. Video laparoscopy in the treatment of liver echinococcosis. Abstract. dis ... dr. honey. sciences. - Saratov, 1999. - 42 p.]. When an endoscopic needle is inserted into the cavity of the trocar, negative pressure is created in it, which ensures a dense attraction of the slice to the surface of the fibrous capsule. A transparent casing allows you to remove echinococcal fluid from the lumen, which entered the trocar by leaking in addition to the needle. The extraction of the contents of the cyst, including the chitin membrane, is carried out through an endoscopic needle using a vacuum suction.
However, after a puncture of the cyst, the contents of the cyst are likely to enter the abdominal cavity during manipulations or respiratory movements of the patient. Another disadvantage is the difficulty of placing the device in the surgical wound and the impossibility of its use in cysts of the diaphragmatic surface of the liver (posterior segments of the liver) and complicated and dead cysts due to the fact that the needle is clogged with solid elements of the cyst; lack of visualization when removing the chitinous membrane, daughter and grandchild cysts. Another disadvantage is the large diameter of the puncture, during the execution of which there is a likelihood of damage to liver tissue.
The closest analogue adopted for the prototype is a method of surgical treatment of echinococcosis of the liver, including laparotomy, access to the echinococcal cyst of the liver, cyst puncture, evacuation of echinococcal fluid, opening the fibrous membrane of the echinococcal cyst, removal of the chitinous membrane, daughter, grandchild cysts. Puncture and aspiration is carried out with a puncture needle. To remove the chitinous shell, daughter and grandchild cysts, use anatomical forceps and a Luer terminal clip (http://iziru.ru/index/ehkhinokokkoz_diagnoz/0-1071)…
The disadvantage is the great threat of desimenation of germ elements. When removing the chitinous shell with these instruments, often
there is a fragmentation of the membranes and leakage of fluid, as well as daughter and grandchild cysts into the surrounding tissue, which lengthens the time of the operation. When using a puncture needle, complete sealing of the puncture site at the time of aspiration of the contents is not ensured. In addition, daughter cysts “stick” to the hole in the needle and fluid enters the abdominal cavity along with the germinal elements. Effective capture by anatomical forceps and Luer clamp of fragments of the chitinous shell of the parasite, daughter and grandchild cysts is not possible due to slipping with dissemination of the germinal elements of the echinococcal cyst in the tissue of the surgical wound.
The problem to which the invention is directed, is to improve the results of surgical treatment of liver echinococcosis, reduce the frequency of relapses.
The technical result is to ensure the evacuation of the contents of the echinococcal cyst without contact with surrounding tissues and the surface of the abdominal cavity.
To solve the problem in a set of surgical instruments for treating echinococcosis of the liver, containing a tool for evacuating echinococcal fluid and a tool for removing chitinous shell, daughter and grandchild cysts, according to the invention, the tool for evacuating echinococcal fluid is an aspirator cannula with a lumen diameter of 4 mm, made with a bend along the axis in the working part, containing a sealing sphere, turning into a tip with a sharp cutting tip and additional holes in the side walls On the opposite side of the cutting tip, a thread was made for connection with a suction and a handle, and the tool for removing the chitinous shell, daughter and grandchild cysts is a curved jaw having a pivotally connected working part in the form of sponges with grips at the ends in the form of tightly closing spoons .
To solve the problem in a method for the surgical treatment of echinococcosis of the liver, including laparotomy, access to the echinococcal cyst of the liver, puncture of the cyst, evacuation of echinococcal fluid, opening the fibrous membrane of the echinococcal cyst, removal of the chitinous membrane, daughter and grandchild cysts, according to the invention, use the tools from the kit according to claim .1, the puncture is performed with an aspirator cannula using a sharp cutting tip, the tip is placed in the cyst cavity to the sealing sphere, tightly pressing the sphere to the prok ol to ensure complete tightness of the puncture site at the time of aspiration of the contents, which is carried out through the end and side holes; after which an autopsy of the cyst is performed, and through the open defect of the cyst wall, the chitinous membrane, daughter and grandchild cysts are removed with the help of curved jaws by hermetically seizing and fixing the contents of the cyst between the spoons and removing from the cavity.
The use of a cannula-aspirator equipped with a sphere allows to ensure complete tightness of the puncture site at the time of aspiration of the contents.
The use of a cannula equipped with additional lateral openings allows you to effectively remove the contents of the cyst when child cysts block the end opening of the cannula.
The presence of the holder provides control of the position of the cannula in the surgeon's hand in one position, including the necessary position of the sealing sphere.
The presence of a thread allows you to reliably connect the cannula to the suction.
The implementation of the cannula with a lumen of 4 mm allows for effective, fast aspiration, even if there are complicated cysts (dead, suppurating, with increased viscosity). With aspiration of the maternal cyst, a puncture of the wall of the daughter and grandchild cysts sometimes occurs. The execution of the cannula with a lumen of 4 mm allows you to aspirate the solid elements of the damaged cyst. In addition, with rapid aspiration of the contents of the cyst, fatigue of the surgeon’s hand holding the aspirator cannula does not occur, which reduces the degree of infection of surrounding tissues, since the surgeon’s tired hand weakens the sphere’s holding in the long-fixed position during aspiration.
The presence of a cutting edge allows you to perform an incision with tight fixation of the aspirator cannula without slipping into the wound of the chitinous membrane.
The execution of the cannula with a bend allows you to remove the surgeon's hands from the area of the operative action and provide a free view of the surgical field in difficult anatomical conditions and in the surgical space shifted to the side of the wound, which ensures control of the fixation of the cannula position.
The use of curved branches with grippers at the ends in the form of tightly closing spoons allows for careful grip, extraction, reliable fixation of echinococcal bubbles and their fragments and transportation over the wound without the risk of slipping and tearing.
The use of curved branches allows the surgeon's hands to be pulled out of the operative area and to provide a free view of the surgical field in difficult anatomical conditions and in the surgical space that is shifted away from the wound, which allows you to effectively capture the contents of the cyst.
The invention is illustrated by drawings.
In FIG. 1 shows a set of surgical instruments for the treatment of liver echinococcosis:
a) cannula-aspirator;
b) curved branches, general view;
c) curved branches, side view.
The inventive method and tool kit is used for echinococcectomy from small accesses, as well as in traditional surgery.
A set of surgical instruments for treating liver echinococcosis contains a cannula-aspirator 1, curved branches 2. The cannula-aspirator 1 is made with a bend 3 along the axis in the working part. The suction cannula 1 contains a sealing sphere 4 with a diameter of 35 mm, passing into a tip 5 with a length of 150 mm with a sharp cutting tip 6 along the edge of the end hole 7 and additional holes 8 in the side walls. The diameter of the cannula-aspirator is 1-6 mm, the diameter of the inner lumen is 4 mm. On the opposite side from the cutting tip, a thread 9 is made for connection to a suction (not shown in the drawing) and a handle 10. Curved branches 2 contain a pivotally connected working part in the form of jaws 11 with grips at the ends in the form of tightly closing spoons 12. The size of the spoons can be different. In a specific embodiment, the size of the spoon: length 50 mm, width 35 mm, depth 2 mm.
The operation is as follows.
Produce laparotomy (15-18 cm) or mini-access (5-6 cm). After detecting a cyst, it is limited to sterile wipes from surrounding tissues. An aspirator cannula 1 using a cutting tip 6 puncture an echinococcal cyst. The suction cannula 1 is inserted into the cyst to the sealing sphere 4, creating a sealing of the puncture site so that the parasitic fluid does not spill into the abdominal cavity. The threaded part 9 of the cannula-aspirator 1 is hermetically connected to the suction, through which the contents of the cyst are aspirated. Thanks to the handle 10, the surgeon controls the installation of the cannula of the aspirator 1 in one position. Produce aspiration of the contents of the cyst. In addition to puncture and aspiration, the cannula aspirator 1 can also be used to administer antiparasitic drugs into the echinococcal cyst cavity. After aspiration, the maternal cyst is degelmented with glycerol or NaCl solution. Next, the fibrous capsule is opened with a coagulator of 3-4 cm, after which the chitinous membrane, daughter, grandchild cysts are removed using curved branches 2 by gripping, reliably fixing the contents of the cyst between the spoons 12 and carefully removing it from the cavity. The bend of the cannula-aspirator 1 and brush 2 along the axis in the working part allows the surgeon’s brush to be removed from the manipulation zone and to provide a free view of the surgical field in difficult anatomical conditions and in the operating space that is offset from the wound, while increasing the safety and efficiency of using the tool, convenience of operation increases. After removal of the chitinous membrane, daughter, grandchild cysts from the cavity of the cyst, free areas of the fibrous membrane are excised by electrocoagulation. In order to destroy the inner surface of the fibrous capsule, a 33% hydrogen peroxide solution (perhydrol) is used, which has a pronounced local cauterizing effect, decomposes into active oxygen and water upon contact with tissues, and does not have a toxic effect. When exposed to gauze turunda, slightly moistened with perhydrol, within 7-10 minutes there is a complete destruction of the inner fibrous cyst membrane to a depth of 1.2 ± 0.07 mm without damage to the underlying portal tracts. When this method is performed, conditions are created to reduce the size of the residual cavity, achieved by destruction of the fibrous capsule by perhydrol, the rigidity is removed, and the compliance of the walls of the fibrous capsule is increased. Due to the removal of the "skeleton factor", the liver tissue is freed from the fibrous capsule, and conditions are created for relatively early filling and healing of the eliminated residual cavity due to granulation-regenerative processes in it. At the same time, the radicalization of the operation, which in echinococcosis depends on the actual removal of the fibrous membrane, also increases. Then, a mini-assistant retractor is installed in the cyst cavity, the lumen is straightened, and all its departments are carefully examined. In this case, optimal conditions arise for the use of revision and endosurgical surgery techniques from an expanding stable mini-access. In all cases, it is possible to achieve the same high-quality visual revision as with wide accesses, which made it possible to examine all the walls of the cyst, large tubular structures that deform its lumen, all available pockets and their contents. Remove remaining parasitic elements. After treatment, inspect the inner surface of the fibrous capsule. The effectiveness criterion is the bright white color of the entire inner surface of the cyst. Against the white background of the entire inner surface of the fibrous capsule, the detection of small bile ducts is not difficult. In those places where there are bile ducts, not only staining with bile of the gauze napkin is noted, but also the flow of bile into the cavity of the fibrous capsule. The boundaries of the color change of the fibrous capsule, as well as with wide accesses, clearly visualized the treatment zones and its quality. Swabs moistened with perhydrol are again applied to insufficiently treated areas, achieving uniform destruction and visualization of bile ducts. For suturing the internal bile fistulas, standard instruments of the “mini-assistant” series are used for operations on the bile ducts. The discoloration of the inner surface of the cyst contributed to the identification of bile fistulas that are hermetically sutured during surgery. The mouth of the bile fistula is sutured with atraumatic absorbable sutures 4.0-5.0. The residual cavity, depending on the volume of the cyst, is drained with one or two silicone tubes with low vacuum aspiration. Layered stitches on the wound.
1. Patient A, 41 years old.
Diagnosis: Echinococcal disease, hydatid cyst of the right lobe of the liver.
The patient underwent an operation with a minithoracophrenotomy echinococcectomy from the right lobe of the liver (segment 7) according to the claimed method. A minithoracophrenotomy was performed with a length of 6 cm, with a resection of 9 ribs, after which a mini-assistant expander was installed in the wound. An audit revealed an echinococcal cyst measuring 8 × 8 cm in 7 segments of the liver. After restriction around the cyst, the cyst is punctured by an aspirator cannula. The cannula is inserted into the cavity of the echinococcal cyst to the sealing sphere. 150 ml of clear liquid, odorless and impurity of bile, were evacuated from the cavity of the echinococcal cyst. After aspiration of the contents of the cyst, the fibrous capsule was opened by a 3-4 cm coagulator, after which the chitinous membrane 8 × 7 cm in size was removed using curved branches. The residual cavity was treated with napkins moistened with a perhydrol solution for 7 minutes. The drainage tube is installed in the residual cavity. Layered seams on the wound. In the postoperative period, she experienced a moderate pain syndrome, which required a double intramuscular injection of a narcotic analgesic (tramadol). The postoperative period was uneventful. The patient was discharged from the hospital on the 10th day after the operation in satisfactory condition. During dynamic observation for 12-24 months, the disease recurrence was not detected.
2. Patient B, 26 years old.
Diagnosis: Echinococcal disease, hydatid cyst of the right lobe of the liver.
The patient underwent surgery minilaparotomic echinococcectomy from the right lobe of the liver (segments 5.6) by the present method. Subcostal minilaparotomy was performed with a length of 6 cm, after which a mini-assistant expander was installed in the wound. During the audit, an echinococcal cyst 11 × 9 cm in size was found in 5, 6 segments of the liver. After limiting around the cyst, the cyst is punctured with an aspirator cannula. The cannula is inserted into the cavity of the echinococcal cyst to the sealing sphere. 350-400 ml of yellow liquid, odorless and impurity of bile, were evacuated from the cavity of the echinococcal cyst. After aspiration of the contents of the cyst, the fibrous capsule was opened by the coagulator 3-4 cm, after which the chitin sheath 10 × 9 cm and daughter cysts 2 × 1 cm in size were removed using curved branches. Thanks to the closing spoons, the chitinous membrane and daughter cysts were sealed and evacuated from cavity of the cyst. The residual cavity was treated with napkins moistened with a perhydrol solution for 7 minutes. The drainage tube is installed in the residual cavity. Layered seams on the wound. In the postoperative period, he experienced a moderate pain syndrome that did not require the use of narcotic analgesics. The postoperative period was uneventful. The patient was discharged from the hospital on the 8th day after surgery in a satisfactory condition. During dynamic observation for 12 months, no relapse of the disease was detected.
3. Patient B, 57 years old.
Diagnosis: Echinococcal disease, hydatid cyst of the right lobe of the liver.
The patient underwent an operation with a minithoracophrenotomy echinococcectomy from the right lobe of the liver (segments 7, 8) according to the claimed method. A mini-thoracophrenotomy was performed with a length of 6 cm, with a resection of 8 ribs, after which a mini-assistant expander was installed in the wound. An audit revealed an echinococcal cyst measuring 7 × 8 cm in 7, 8 segments of the liver. After restriction around the cyst, the cyst is punctured by a cannula. The cannula is inserted into the cavity of the echinococcal cyst to the sealing sphere, which creates a sealing of the puncture site so that the parasitic fluid does not spill into the abdominal cavity. 250-300 ml of clear liquid, odorless and bile admixture, were evacuated from the cavity of the echinococcal cyst. After aspiration of the contents of the cyst, the fibrous capsule was opened by a 3-4 cm coagulator, after which the chitinous membrane 7 × 7 cm in size, daughter and grandchild cysts were removed using curved branches. The residual cavity was treated with a perhydrol solution for 7 minutes. The drainage tube is installed in the residual cavity. Layered seams on the wound. In the postoperative period, she experienced a moderate pain syndrome, which required a double intramuscular injection of a narcotic analgesic (tramadol). The postoperative period was uneventful. The patient was discharged from the hospital on the 9th day after the operation in satisfactory condition. During dynamic observation for 12-24 months, the disease recurrence was not detected.

Claims (2)

1. A set of surgical instruments for treating echinococcosis of the liver, comprising a tool for evacuating echinococcal fluid and a tool for removing chitinous membranes, daughter and grandchild cysts, characterized in that the tool for evacuating echinococcal fluid is an aspirator cannula with a lumen diameter of 4 mm, made with a bend along the axis in the working part, containing a sealing sphere that passes into the tip with a sharp cutting tip and additional holes in the side walls, opposite to the cutting onchika portions are threaded for connection with suction and the handle, and a tool for removing a chitinous sheath child and grandchild cysts is curved jaws having a working part is pivotally connected in the form of grippers with jaws at the ends to form a tightly interlocking spoons.
2. A method of surgical treatment of echinococcosis of the liver, including laparotomy, access to the echinococcal liver cyst, puncture of the cyst, evacuation of echinococcal fluid, opening the fibrous membrane of the echinococcal cyst, removal of the chitinous membrane, daughter and grandchild cysts, characterized in that they use the tools from the kit according to p. 1, the puncture is performed with an aspirator cannula using a sharp cutting tip, the tip is placed in the cyst cavity to the sealing sphere, tightly pressing the sphere to the puncture site to ensure a complete seal the identity of the puncture site at the time of aspiration of the contents, which is carried out through the end and side openings; after which an autopsy of the cyst is performed, and through the open defect of the cyst wall, the chitinous membrane, daughter and grandchild cysts are removed with the help of curved jaws by hermetically seizing and fixing the contents of the cyst between the spoons and removing from the cavity.
RU2015134874A 2015-08-18 2015-08-18 Set of surgical instruments for liver echinococcosis treatment and method for liver echinococcosis surgical treatment RU2630356C2 (en)

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Cited By (1)

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RU2695007C1 (en) * 2018-12-27 2019-07-18 федеральное государственное бюджетное образовательное учреждение высшего образования "Первый Санкт-Петербургский государственный медицинский университет имени академика И.П. Павлова" Министерства здравоохранения Российской Федерации Method of treating echinococcal hepatic cyst of the type ce2b, ce3b

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* Cited by examiner, † Cited by third party
Publication number Priority date Publication date Assignee Title
RU2695007C1 (en) * 2018-12-27 2019-07-18 федеральное государственное бюджетное образовательное учреждение высшего образования "Первый Санкт-Петербургский государственный медицинский университет имени академика И.П. Павлова" Министерства здравоохранения Российской Федерации Method of treating echinococcal hepatic cyst of the type ce2b, ce3b

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