RU2690914C1 - Set of instruments for vascular anastomosis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medical equipment, namely to surgical instruments used for small-diameter vessels (0.8 mm and less). A set of instruments for vessel anastomosing comprises three multipurpose tools – pointed curved forceps, short straight tweezers made of alloyed stainless steel, and a microgemistent hook. Pointed curved forceps comprise two spring-loaded tweezers with their working ends shaped as curved jaws. Sponges are flat with rough surface, having depth of recesses of not more than 5 mcm, gap of jaws at closing of working ends of tweezers is from 10 to 200 mcm and decreases with increased compression of branches. Short straight tweezers comprises two spring-loaded brushes with working ends in the form of straight jaws, with working edge thickness of 0.5 mm, which is beveled at angle of 30 degrees to the tweezers longitudinal axis, closing line of working edges of straight jaws makes 1.8 mm and does not change at strengthened branch. Microgemistent hook is made as resiliently elastic rod with cross-section dimensions 300×500 mcm. Rod is reinforced with wire with thickness of 100 mcm and contains sharpened working end and blunt end, free end of reinforcing wire is made in form of hook and comes out of blunt end. Use of the invention enables stabilization of elastic tissue capture, ultrathin needles and suture material, as well as atraumatic instrumentation of lumen of small vessels.EFFECT: disclosed is a set of instruments for vessel anastomosing.6 cl, 6 dwg

Description

Technical field

The technical solution relates to medical equipment, to surgical instruments used for operations on vessels of small diameter (0.8 mm or less).

The level of technology

It is known that with a small diameter of vessels the usual technique of a seam and toolkit is unsuitable. The technique of stitching vessels with an outer diameter of less than 0.8 mm, called "supermicrosurgery." For replantation surgery, reconstruction of the extremities and the facial area, grafts transplants on perforating vessels, the technical ability to stitch vessels with an outer diameter of 0.8 mm or less is critical. Anastomosing vessels of ultra small diameter (0.8 mm or less) requires a specialized tool, an ultrathin suture material (caliber 11-0-12-0) and special equipment (operations are performed under a microscope with high magnification and focal length).

In the catalogs (http://www.microsurgery.ch/index.php?id=5&L=) of the Swiss company S & T (S & T AG Tobelraastrasse 2 CH-8212 Neuhausen Switzerland, the website http://www.microsurgery.ch/) for Anastomosing vessels with a diameter of less than 2 mm offers a line of balanced steel forceps-needle holders, the use of which, compared with hinged microsurgical needle holders, allows for easier manipulation of the gripping, fixing and release from the needle, but the problem of needle deformation arises when using ultrathin suture material.

A set of microsurgical instruments for coronary and vascular surgery is known (source [1]: RU 12956. Published: 03/20/2000)., Which includes the following microsurgical instruments: DeBakey needles with diameters of 2.5; 3.0; 3.5 mm, Bulldog type clamps with sponges of 12 and 17 mm, tweezers for anastomosis with a length of 210 mm, atraumatic Akchurina tweezers with a length of 210 mm, tweezers for straight and curved threads with a length of 210 mm, microsurgical scissors, curved along the rib by 45o, on 60 °, 120 ° 200 mm long, microsurgical vascular scissors, curved, blunt 200 mm long, microsurgical needle holders: straight and curved with a lock of 180 and 200 mm long, vascular bougie with a diameter of 1.0; 1.5; 2.0; 2.5 mm, microsurgical dissectors direct and bayonet 220 mm long and box-laying, ensuring the quality and accuracy of the operation in coronary and vascular surgery. This kit [1] does not contain dilators (a tool for expanding the canal of a vessel) and counter-compressors (a tool for providing a counter-stop).

The prior art is known as the SuperMicro 9-0 + Instrument Set, for supermicro and microsurgery (source [2]: electronic product catalog of the company Mitaka USA, Inc., http://mitakausa.com/ section products, subsection “supermicro tools”, access mode (http://mitakausa.com/supermicro/). A set of tools [2] includes metal needle holders, microscissors, tweezers, stacked in a sterilization metal case. The two needle holders are hinged, without a lock, 15 cm long, the working ends are 0.1 and 0.3 mm thick. One microscissors with a length of 15 cm. Two micro-tweezers, with a working end thickness of 0.05 mm and one micro-tweezer with a working end thickness of 0.3 mm;

This analogue [2] has a high commercial value (US $ 5800), probably due to the manufacturing technology. At the same time, such an important operational characteristic of the instrument as the precision of the refined working ends is very quickly lost, often after a single use. The tool has a small resource and is not suitable for multiple long-term use. This set [2] does not contain dilators (a tool for expanding the canal of a vessel) and counter-compressors (a tool for providing an anti-stop), and it is assumed that tweezers are used to perform their working functions. The use of tweezers as dilators and counterpressors, traditionally when performing a vascular suture, however, when working with vessels of ultra small diameter (0.8 mm or less), this creates a high risk of mechanical damage to the vessels.

Multipurpose forceps Multipurpose Forceps with needle holder, dilator and high-precision forceps are known (source [3]: Principles, Techniques and Microsurgery TS Chang - 1986 - Chan Ti - Sheng. Access mode: https://sorensenclinic.com./about- dr-sorensen / instrument-design / multipurpose-forceps /). Multi-purpose microsurgical tweezers with straight and curved working jaws (working part) Multi-purpose tweezers combine the functionality of three microsurgical tweezers in one instrument with a round handle. The working jaws are configured so that they can be used as expanders, needle holders, clamping tongs. The tweezers are equipped with flat parallel working jaws, suitable for working with micro needles and stitches (8 / 0-12 / 0). The shape of the working part allows the use of tools as micro tweezers, ensures the seizure of the connective tissue surrounding the vessels and nerves, and allows using the tool as a dilator. The surfaces of the working jaws are mirror-polished and rounded, which makes them suitable for expansion of vessels (the standard size of the tip of the sponge is 0.3 mm, but can be changed to 0.2 mm or 0.1 mm). In addition, multi-purpose forceps are suitable for positioning the soft tissue of the vessel on the steel pins of microvascular anastomotic connecting devices.

However, plane-parallel jaws of tweezers [3] create the risk of deformation (bending) of an ultrathin needle. Despite the rounded ends and the polished surface, when instrumented with a long forceps lumen of a small vessel, it is difficult to avoid damage to its thin wall.

Known short "Jumbo" tweezers (source [4]: Principles, Techniques And Applications In Microsurgery. Chang Ts, Zhu Sx TS. Chang. Page 10. Access Mode: https://books.google.ru/books?isbn = 9814578266) providing the necessary grip force and ease of manipulation in the selection of vessels from adipose and connective tissue. The diameter of the working ends of the tweezers is 0.15-0.3 mm. However, the use of this tweezers [4] as a needle holder for ultrathin needles is problematic.

The use of Prolene 5/0 ligature thread as a stent for stitching arteries with a diameter of 0.5 mm is known (source [5]: A Novel Ex Vivo Training Model for Acquiring Supermicrosurgical Skills Using a Chicken Leg. J. Reconstr. Microsurg 2016; 32 (09 ): 699-705 PMID: 27542106 DOI: 10.1055 / s-0036-1586749). However, the rigidity of the ligature thread creates a risk of damage to the inner surface of the artery.

The use of a silicon microstate with pointed ends is known (source [5]: “Adaptation and microtool for carrying out sutures during anastomosing of small diameter arteries and their experimental approbation.” Journal “Advances of modern natural science.” - 2015. - №9 (part 2) - С . 260-263. Access mode: http://natural-sciences.ru/ru/article/view?id=35573).

However, poor visibility of silicone microstate for the naked eye creates inconvenience in the work. It is difficult to use this device to open separate stuck together inter-seams of a vascular microanastomosis.

Thus, analogs, tools and devices are known that are similar in purpose but not adapted to the conditions of the microvascular surgeons. Instrumentation of the lumen with refined tweezers or improvised means (ligature stents) creates the risk of damage to the intima and subsequent thrombosis of the anastomosis. There is a need for a set of tools, using which it is possible to ensure the release of a vessel of ultra-small diameter, sparing opening and dilatation of the vessel lumen, the walls of which stick together at the intersection, retaining the needle and stitching the vessel. Clinical practice needs a set of tools and devices for the anastomosis of ultralow diameter vessels, with a long resource, simple and convenient to use, this will facilitate the process of surgical intervention and improve the quality of treatment results.

The essence of the technical solution

The technical problem is to provide the surgeon with the tools facilitating the process of anastomosing of vessels of ultra small diameter and having the possibility of multiple use.

The technical result is to provide the ability to sew vessels of ultra-small diameter ultrathin needle with suture material. The set provides stabilization of the elastic capture of tissues, ultrathin needles and suture material, as well as atraumatic instrumentation of the lumen of small vessels.

The technical result is achieved by the fact that the set of tools for anastomosing vessels includes three multi-purpose tools - pointed curved tweezers, short straight tweezers, microhistor-hook. This pointed curved tweezers contains two spring-loaded jaws with working ends in the shape of curved jaws, flat sponges with a rough surface with hollows not more than 5 micrometers, the jaw gap when closing the working ends of tweezers is from 10 to 200 microns and decreases with enhanced compression of the branches. Short straight tweezers contains two spring-loaded branches with working ends in the form of straight jaws, with a working edge thickness of 0.5 mm, which is beveled at an angle of 30 degrees to the longitudinal axis of the tweezers, the clamping line of the working edges of straight jaws is 1.8 mm and does not change with enhanced compression of the branches. The microhousing hook is designed as an elastic elastic rod with a cross section of 300 × 500 micrometers, the core is reinforced with a wire 100 micrometers thick and contains a pointed working end and a blunt end, the free end of the reinforcing wire is made in the form of a hook and leaves the blunt end.

The above essence ensures the achievement of the technical result, other features of the set are defined in the following description.

The technical solution is illustrated by the drawings:

FIG. 1 - the first tweezers, photography;

FIG. 2 - the second tweezers, photograph;

FIG. 3 - microhousing hook, laid near the scale grid, photo;

FIG. 4 - working end of the first tweezers when closing the ends of the sponges, photo;

FIG. 5 - the working end of the second tweezers when closing the ends of the sponges, photo;

FIG. 6 - fixing the needle 11/0 (diameter 50 μm) with suture material with sponges of pointed curved tweezers, photograph.

Implementation of the technical solution

A set of tools for anastomosing vessels includes three multi-purpose tools - pointed curved tweezers (Fig. 1), made with sharp-pointed curved, short straight tweezers (Fig. 2), made short straight, and micro-hook (Fig. 3). Pointed curved tweezers are made of chrome-plated stainless steel, resistant to sterilization and repeated cleaning, contains two spring-loaded branches with working ends in the form of curved jaws (the bend angle is from 30 to 45 degrees to the longitudinal axis of the tweezers), sponges are flat with a rough surface having a hollow depth no more than 5 micrometers, the gap of the jaws when the working ends are closed (fig. 4) of the tweezers is from 10 to 200 μm and decreases with enhanced compression of the branches. When the jaws are closed, the sponge of the pointed curved tweezers fit snugly together. The hardness of the branches of pointed bent tweezers after heat treatment is in the range from 41.5 to 49.5 HRC. Full installed resource not less than 500 cycles. For the cycle take a full closure and the opening of the tweezers. Short straight tweezers made of chromic stainless steel contains two spring-loaded jaws with working ends in the form of straight jaws, with a working edge thickness of 0.5 mm, which is beveled at an angle of 30 degrees to the longitudinal axis of the tweezers, the closing line of the working edges of straight jaws is 1, 8 mm and does not change with enhanced compression of the branch. When closing (Fig. 5), the branches of the sponge of the short straight tweezers fit snugly together. The hardness of the branches of short straight tweezers after heat treatment is in the range from 41.5 to 49.5 HRC. Branches tweezers elastic. The roughness Ra (arithmetic average of the absolute values of profile deviations within the base length) of the outer surfaces of the tweezers is in the range from 0.16 to 0.32 micrometers. Full installed resource not less than 500 cycles. The microhousing hook is designed as an elastic-elastic rod made of polymer (for example, silicone, fluoroplastic, polypropylene), with a cross-section of 300 × 500 micrometers, the elastic-elastic rod is reinforced with 100 micrometers thick metal wire and contains a pointed working end and a blunt end, the free end of the reinforcing wire made in the form of a hook and out of the blunt end.

The use of technical solutions

A set of tools (pointed curved tweezers, short straight tweezers, a microhistor hook) are used to anastomose vessels of supersmall diameter (ie, 0.8 mm or less). The surgeon, using this toolkit, can sew ultralow-diameter vessels with an ultrathin needle with a suture (thread gauge 10 / 0-12 / 0). The seams are performed on round atraumatic needles with a diameter of 50 and 75 microns. They work with a set of tools observing the operative field under a microscope, for example, they use a MBS-10 binocular stereo microscope with a magnification of 8, 16 and 32. Pointed curved tweezers are taken into the dominant hand, short straight tweezers into the other hand. They separate the vessel from the surrounding adipose and connective tissues, use both tweezers, while acting (squeezing, releasing) on the branches of the tweezers capture the tissues with working ends (sponges). Sponges flat, pointed bent tweezers with a rough surface of not more than 5 micrometers and a gap when closing from 10 to 200 microns provide a stable elastic capture of tissues. Straight sponges of short straight tweezers, with a working edge thickness of 0.5 mm, which is beveled at an angle of 30 degrees to the longitudinal axis of the tweezers, also provide a stable elastic grip of tissues. Working tweezers straighten the vessel and carry out the dilatation of the vessel lumen, for this purpose, a microhistor hook is used. To do this, a micro-sugar hook is taken by the blunt end with pointed curved forceps and while holding the vessel with short straight tweezers, gently insert the pointed working end of the micro-hook hook into the vessel lumen. At the same time, the end of the vessel is held with short straight tweezers, shifting its adventitia (the outer shell of the vessel) from the lumen. For visualization and dilatation of the collapsed arterial lumen, its ends are irrigated with warm saline solution, carefully moving the adventitia away from the vessel ends. The vessel is not mechanically damaged as the microhistorical core of the hook is elastic and this provides atraumatic instrumentation of the lumen. Next, perform the seam. Carry out the convergence and stitching of the ends of the vessel "end to end" with the subsequent restoration of integrity. First, two installation seams are placed at a distance of about 120 degrees from each other, which are tied with instrumental double and single knots. Then, using adjusting seams for tensioning the vessel wall and turning the anastomosis, impose from 4 to 7 additional separate nodal joints, each of which was tied with two single knots. When conducting seams using an increase in the microscope 16x and 32x, which allows you to visually monitor the passage of the ultra-thin needle through the translucent wall of the vessel. Pointed bent tweezers are used as a needle holder. An ultrathin corner with a suture material is captured (FIG. 6) with pointed curved forceps and the vessel is punctured. The ultrathin needle is captured and held by the jaws of the pointed curved tweezers, the jaw gap when the working ends of the tweezers are closed is 10 to 200 μm and decreases with enhanced compression of the branches. At the same time, a microhousing hook is used as a counterpressor; to do this, create a counter-back pressure with an ultrathin needle, holding the blunt end of a microhousing hook with short straight tweezers. For tying ligatures use both the first pointed curved tweezers (with the dominant hand) and short straight tweezers (with the non-dominant hand). If, after tightening the installation seams, the vessel lumen is re-collapsed, the free end of the reinforcing wire, made in the form of a hook, is used to open it. Short straight tweezers can also be used as a needle holder. The tweezers grip the ultrathin needle in a similar way, using sponges from the sharp corners of their working edges.

The kit provides the ability to sew ultralow-diameter vessels with an ultrathin needle with suture material, while ensuring atraumatic instrumentation of the lumen of small vessels, providing a full resource of at least 500 cycles.

Claims (6)

1. A set of tools for anastomosing vessels, characterized by the fact that it includes three multi-purpose tools - pointed curved tweezers, short straight tweezers, made of alloyed stainless steel, and microharacter hook, while the pointed curved tweezers contain two spring-loaded branches with working ends in the form curved jaws, flat jaws with a rough surface having a depression depth of not more than 5 microns; the jaw gap when the working ends of the tweezers are closed is from 10 to 200 microns and decreases with usi flax compression branches, short straight tweezers contains two spring-loaded jaws with working ends in the form of straight jaws, with a working edge thickness of 0.5 mm, which is beveled at an angle of 30 degrees to the longitudinal axis of the tweezers, the closing line of the working edges of straight jaws is 1.8 mm and does not change with enhanced compression of the branch, the microhousing hook is designed as an elastic elastic rod with a cross section of 300 × 500 μm, the rod is reinforced with a wire 100 μm thick and contains a pointed working end and a blunt end, the free end of the reinforcing The wire is made in the form of a hook and comes out of the blunt end. 2. A set of tools under item 1, characterized in that the tweezers are made of corrosion-resistant alloyed chromium steel. 3. A set of tools under item 1, characterized in that the roughness Ra of the outer surfaces of the tweezers is in the range from 0.16 to 0.32 microns. 4. A set of tools under item 1, characterized in that the pointed curved tweezers with working ends in the form of curved jaws, where the bend angle is from 30 to 45 degrees to the longitudinal axis of the tweezers. 5. A set of tools under item 1, characterized in that the hardness of the branches of tweezers is in the range from 41.5 to 49.5 HRC. 6. A set of tools under item 1, characterized in that the microhistor-hook is made of fluoroplastic.

Images