RU2700676C1 - Method of forming a fenestration of a given diameter between an extracardiac conduit and a right atrium cavity in the patients with pulmonary arterial duct hypoplasia in the total right heart bypass operation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiosurgery. Extra-cardiac conduit is pre-formed; fenestration is performed on the side wall of the formed conduit. Hole is formed on the side surface of the RA. Xenopericardial patch is used to cut out a round flap with a hole formed in its center. Xenopericardial flap is sutured to the side wall of the extracardiac conduit so that the opening on the flap corresponds to the fenestration area. Synthetic conduit is used to create an anastomosis between the extracardiac conduit and RA; for this purpose, the synthetic conduit is sutured to the area of the opening on one end by one end, while the other end is immersed into the RA cavity through the formed hole on its side surface. Xenopericardial flap edges are anchored to the RA wall.

EFFECT: method enables simplifying the surgical technique of creating an anastomosis between a synthetic conduit which plays the role of fenestration, and an RA wall along with a total bypass of the right heart.

1 cl, 5 dwg, 1 ex

Description

The invention relates to cardiac surgery and can be used if it is necessary to create fenestration between extracardial conduit and the wall of the right atrium (PP) during the operation of total bypass of the right heart in children with congenital heart defects. Moreover, fenestration of a given diameter is created, this is due to the fact that the fenestration will be the right size (depending on the anatomical features and the clinical situation), since its role is played by a synthetic conduit of exactly the selected size, immersed in the cavity of the PP, and not the “formed” hole .

A known method of forming fenestration between the extracardial conduit and the right atrium, in which a synthetic conduit made of PTFE is used as fenestration, one end of which is sutured to the extracardial conduit and the other end to the wall of the PP so that some of it is immersed in the cavity of the PP [1, 2].

The main disadvantage of this method of forming fenestration is the technical inconvenience of creating an anastomosis between the synthetic conduit of PTFE, which plays the role of fenestration, and the wall of the PP in a contracting heart.

There is a method of forming fenestration between extracardiac conduit and the right atrium, in which a round flap with a hole in the center equal to the required diameter of fenestration sewn to the side wall of the extracardiac conduit is used as fenestration [3 - prototype]. The disadvantage of this method of creating fenestration is the hemming of the biological flap not to the edges of the formed opening on the right atrium, but around it, which leads to the fact that the size of the hole on the right atrium will change in accordance with the phases of the PP reduction.

The technical problem that the invention seeks to solve is the complexity of the surgical technique for applying an anastomosis between a synthetic conduit that plays the role of fenestration and the PP wall, taking into account the small diameter of the created anastomosis, as well as the need to apply purse-string and individual nodal sutures.

The technical result of the invention is to simplify the surgical technique of creating an anastomosis between a synthetic conduit, which plays the role of fenestration, and the PP wall, along with a total bypass of the right heart.

The specified "simplification" is due to the following. The anastomosis between the conduit and the PP wall is difficult to perform due to the technical inconvenience of taking the technique due to a contracting heart, bleeding from the hole on the PP wall, and also the small diameter of the fenestration. It was found that if a round xenopericardial flap is placed between the extra and extracardiac conduits and sewn to the PP wall, this technically simplifies the technology, since the flap is not sewn to the edges of the hole on the PP wall, but along the free wall around the hole, which increases the diameter of the anastomosis and simplifies the hemming technique. In addition, the opening in the wall of the PP allows you to place the end of an additional conduit in it, which in turn prevents the flow of blood, which complicates the visualization of the surgical field for the doctor, thereby optimally siding the xenopericardial flap with a circle.

The specified technical result is achieved due to the following set of essential features:

- pre-form extracardiac conduit, perform fenestration on the side wall of the formed conduit, form a hole on the side surface of the PP;

- a round flap is cut out from the xenopericardial patch, in the center of which a hole is formed, then the xenopericardial flap is sewn to the lateral wall of the extracardiac conduit so that the hole on the flap corresponds to the fenestration region;

- further, by means of a synthetic conduit, an anastomosis is created between the extracardial conduit and the PP, for which the synthetic conduit is sewn at one end to the region of the hole on the flap, and the other end is immersed in the PP cavity through the formed hole on its lateral surface, then the edges of the xenopericardial flap are sutured to the PP wall.

The method is as follows.

To carry out fenestration of a fixed diameter on the side wall of the extracardiac conduit, a hole of the required (specified) diameter is made under the control of a bougie of the appropriate size. Along with this, a xenopericardial flap is prepared, in the center of which a hole is formed corresponding to the diameter of the lateral opening on the extracardial conduit. After this, the holes on the xenopericardial flap and extracardial conduit are compared and in the area of the holes they are sutured to each other using an anastomosis of the side-to-side type. Next, a synthetic conduit pre-selected in size corresponding to the diameter of the common opening is sewn to the area of the common opening of the xenopericardial flap and extracardial conduit. The manufacture of a conduit of a similar design is carried out before the start of the main stage of the operation on a separate table by the second team of surgeons.

The method is illustrated by drawings:

Figure 1 shows an extracardiac conduit 1 made of PTFE with a hole formed of the required diameter (usually 5 mm) on one of its walls, as well as a round xenopericardial flap 2 (diameter 15 mm) with a hole in the center (5 mm) corresponding to the diameter of the hole on the wall conduit.

Figure 2 and figure 3 (side view relative to figure 2), shows a xenopericardial flap sewn to a hole in the wall of the extracardial conduit.

Figure 4 shows a shortened PTFE conduit partially immersed in PP.

Figure 5, shows a xenopericardial flap stitched to the wall of the PP, a shortened conduit made of PTFE, stitched to the xenopericardial flap and a hole in the wall of the extracardial conduit and partially immersed in the PP.

In figures 1-5, the following elements are indicated by positions:

1 - extracardial conduit from PTFE;

2 - xenopericardial flap;

3 - conduit from PTFE;

4 - the right atrium.

Clinical example

Patient E., 6 years old, was admitted to a specialized surgical hospital for planned surgical treatment of congenital heart disease. Diagnosed with a single ventricle of the heart, the full form of the atrioventricular canal, the state after the operation of a bidirectional cavopulmonary anastomosis.

It was decided to perform Fontaine’s operation (total bypass of the right heart) in conditions of cardiopulmonary bypass and hypothermia.

During access to the heart, the surgeon created a fenestration of a given diameter on a separate table according to the following procedure. A hole of 5 mm diameter was created on the side wall of the extracardiac conduit from PTFE No. 18 under the control of a bougie of the appropriate size, while the place of the hole was formed in the planned zone of hemming to the side wall of the PP. After that, a round flap with a diameter of 15 mm was cut out from the xenopericardial patch, in the center of which a hole with a diameter of 5 mm was formed. A xenopericardial flap was sutured in the region of the opening to the region of the lateral opening on the extracardiac conduit using a continuous GW-Tex 6.0 continuous thread sewing. Then, synthetic conduit made of PTFE with a diameter of 5 mm and a length of 10 mm was additionally sutured to the created anastomosis. At this stage, the conduit cut was completed.

Then, using the extracardial conduit, the inferior vena cava was connected to the lower aspect of the right pulmonary artery (previously imposed cavopulmonary anastomosis), while the fenestration region was positioned opposite the part of the lateral wall of the PC with which the anastomosis was planned. After that, an incision was made on the very side wall of the PP, through which a 10 mm long synthetic conduit was sewn into the PC cavity, sewn together with a xenopericardial flap to the extracardial conduit.

The sealing of the anastomosis was performed by suturing the edges of the xenopericardial flap to the free wall of the PP. Thus, the end of a synthetic conduit made of PTFE with a diameter of 5 mm was freely (not detected) in the cavity of the PP.

The early postoperative period was uneventful. Cardiotonic support: adrenaline - 0.06 mcg / kg / min. The total time of mechanical ventilation is 12 hours. The total time spent in the intensive care unit is 24 hours.

Due to the positive dynamics, the patient was discharged from the hospital on the tenth day after the operation. According to the control echocardiography before discharge: discharge on fenestration with a diameter of 5 mm.

Bibliography

1. Turkoz R., Celik M., Palaoglu E., Baysa A., Cindik N., Kocak G. Easy fenestration technique for extracardiac Fontan operation. World Journal for Pediatric and Congenital Heart Surgery. 2015; 6 (4): 551-2.

2. Bradley S.M. Extracardiac conduit Fontan procedure. Operative Technique in Thoracic and Cardiovascular Surgery. 2006; 11 (2): 123-40.

3. Kwak J.G., Lee J.R., Jang W.S., Bae E.J. Extracardiac Fontan with T-shape conduit in non-confluent pulmonary arteries. Journal of Cardiothoracic Surgery. 2008; 3: 7.

Claims (1)

A method of creating fenestration of a given diameter between extracardial conduit and the cavity of the PP (PP) during hypoplasia of the pulmonary arterial bed during a total bypass of the right heart, including the preliminary formation of extracardial conduit, fenestration on the side wall of the formed conduit, the formation of an opening on the lateral surface of the PP, creating anastomosis between extracardial conduit and PP, characterized in that a round shape flap is cut from the xenopericardial patch s, in the center of which a hole is formed, then a xenopericardial flap is sewn to the lateral wall of the extracardial conduit so that the hole on the flap corresponds to the fenestration region, then anastomosis is created between the extracardial conduit and the PP using a synthetic conduit, for which a synthetic conduit is sewn at one end to the hole area on the flap, and the other end is immersed in the PP cavity through the formed hole on its lateral surface, then the edges of the xenopericardial are sutured flap to the wall of the PP.

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