RU2722704C2 - Method of laparoscopic transperitoneal removal of a polycystic kidney in low-pressure carboxyperitoneum using laparolift - Google Patents

Abstract

FIELD: medicine; surgery.SUBSTANCE: as working part of laparolift there used is sharpened needle at both ends with length of not less than 15 cm and diameter of not more than 3 mm. Under visual control of laparoscope, the pin is passed through punctures with skin and subcutaneous tissue capture in the lateral abdominal area in the longitudinal direction, selecting the most convenient traction position depending on the size and anatomical location of the polycystic kidney. Ends of the pin are fixed to ends of arc leg of the laparolift, through which, by means of a filament rod connected to an arc-shaped rigid bar with a wire attached to it, and by changing the filament length through the horizontal knee of the operating lamp, raising the abdominal wall upwards, creating a working space for nephrectomy. Working space cavity has triangular shape with highest point in projection of laparolift and maximum volume in area of renal pedicle, achieved by setting the laparolift pin in the most comfortable position. Further, the pressure of carbon dioxide in the abdominal cavity is reduced to a value of not more than 3 mm Hg and thereafter, a surgical aid is administered in low-pressure carboxyperitoneum conditions. Note here that Laparolift wire uses k-wire or Veresh wire.EFFECT: method enables to exclude the negative effects of the impact of the laparolift introduced into the abdominal cavity of the working part on the peritoneum and abdominal cavity associated with peritoneal injuries and infection, as well as improve visualization, provide ease of operation in low-pressure carboxyperitoneum conditions by creating a comfortable space for the surgeon in the abdominal cavity, taking into account the giant size and variability of the anatomy of the polycystic kidneys.1 cl, 2 ex, 2 dwg

Description

The invention relates to medicine, in particular to surgery, and relates to the question of performing laparoscopic nephrectomy of polycystic altered kidneys.

There is a method of gas-free laparoscopic nephrectomy, according to which a spiral laparolift inserted into the abdominal cavity through an incision is used to create a working space in the abdominal cavity. Laparolift is a curved metal rod with a diameter of 5 mm, the working part of which is made in the form of a single coil of a spiral with a radius of 6-9 cm, having a spherical thickening at the end, preventing injury to the anterior abdominal wall and internal organs when inserted into the abdominal cavity with fastening at the other end. When performing laparoscopic intervention after the formation of the "minimum" carboxyperitoneum (up to 8 mm Hg) under video control, the working part of the endolift is inserted into the abdominal cavity at a point at the navel along the midclavicular line with a gradually twisting movement. Laparolift is fixed on the lifting and holding device by fastening on the ceiling and carry out desufflation (Baido SV., Grigorenko V.M., Prundyuk S.I. Prevention of accelerated carboxyperitoneum during laparoscopic surgery in nirtsi // Men's Health. - 2015. - No. 2. - S. 39-42).

However, the introduction of a laparolift into the abdominal cavity and traction of the abdominal wall with it during the execution of the main stage of the operation is associated with the following negative phenomena:

- trauma to the peritoneum in the area of pressure of the working part of the laparolift;

- increased risk of infection of the abdominal cavity due to the introduction of an instrument - laparolift;

- a large amount of tissue damage, the need for additional incisions due to the large diameter of the rod and the working part of the laparolift;

- postoperative pain in the area where the laparolift was installed.

In addition, given the large size of the polycystic-altered kidneys and the limited narrow space in the abdominal cavity with its trapezoidal shape (in the prototype), it is not possible to obtain a sufficient volume of space and satisfactory access to the renal leg for its isolation under conditions of low gas pressure. Also, given the high variability of the anatomy of the arrangement of giant polycystic-altered kidneys, an undoubted inconvenience is the inability to displace the laparolift due to the large radius of its working part (6-9 cm) and the need in this case to make additional incisions in the abdominal wall to move it.

For patients with concomitant cardiovascular pathology, laparoscopic operations in conditions of intense carboxyperitoneum are contraindicated. This is especially true for patients with autosomal dominant polycystic kidney disease, among which the frequency of concomitant cardiovascular pathology in the population reaches 50%.

The objective of the proposed invention is to eliminate the negative effects of the introduced into the abdominal cavity of the working part of the laparolift on the peritoneum and abdominal cavity associated with trauma to the peritoneum and infection, as well as improving visualization, ensuring the convenience of operating in low-pressure carboxyperitoneum by creating a surgeon-friendly working space cavities, taking into account the gigantic size and variability of the anatomy of polycystic-altered kidneys.

To do this, in the known method of laparoscopic nephrectomy under low pressure carboxyperitoneum using a laparolift, according to the invention, a needle pointed at both ends with a length of at least 15 cm and a diameter of no more than 3 mm is used as the working part of the laparolift. Under visual control of the laparoscope, the needle is passed through punctures with the capture of skin and subcutaneous tissue in the lateral abdomen in the longitudinal direction, choosing the most convenient position for traction depending on the size and anatomical location of the polycystic-altered kidney. The ends of the knitting needles are fixed to the ends of the arcuate rod of the laparolift, through which the abdominal wall is lifted up by creating a working space for performing nephrectomy using a thrust rod connected to an arched rigid rod with a knitting needle attached to it, and by changing the length of the thread rod through the horizontal knee of the operating lamp. . As a result, a working space is formed having a triangular cavity with the highest point in the projection of the laparolift and the maximum volume in the region of the renal leg, achieved by installing the laparolift needle in the most convenient position. Next, reduce the pressure of carbon dioxide in the abdominal cavity to a value of not more than 3 mm. Hg, and then carry out further surgical benefit in low pressure carboxyperitoneum.

In this case, the Kirschner or Veress needle is used as a laparolift needle.

The use of a sufficiently thin knitting needle, which is carried out under visual control of a laparoscope through punctures with grasping of the skin and subcutaneous tissue in the longitudinal direction, can significantly reduce trauma to the peritoneum in the pressure area of the working part of the laparolift, as well as the amount of tissue damage. This reduces the patient’s postoperative pain in the area where the prototype laparolift was installed.

Holding the needle under visual control of the laparoscope ensures the exclusion of damage to the peritoneum and the choice of the most convenient position.

Due to the installation of the laparolift needle in the most convenient position, it is possible to obtain a triangular shape in the abdominal cavity of the working space with the highest point in the projection of the laparolift and with a maximum volume in the region of the renal leg, which ensures sufficient visualization and freedom of displacement of the instruments during the operation.

The proposed method for laparoscopic transperitoneal removal of a polycystic altered kidney under low pressure carboxyperitoneum is carried out using a laparolift shown in the figures, where in FIG. 1 shows a view of a laparolift along and in FIG. 2 - across the patient’s body.

Laparolift includes a needle 1, pointed at both ends and held through punctures with a grip of the skin and subcutaneous tissue 2 in the lateral region of the abdomen in the longitudinal direction, the ends of which are attached to the legs of the arched rigid rod 3 (Fig. 1, 2). The rigid rod 3 is connected to a thread rod 4 tied up in its middle part, thrown over the horizontal knee 5 of the operating lamp and configured to adjust its length (Fig. 1,2).

The proposed method is as follows.

The position of the patient on the left or right side in 3/4 turn. The abdominal wall is lifted with a clamp (not shown in the figure), carbon dioxide is injected using a Veress needle or Kirchner under pressure up to 6 mmHg. Art. Such pressure, in combination with the lifting of the abdominal wall by means of a clamp, is sufficient for satisfactory visualization of the peritoneum 6 in the region of the spokes 1 (Fig. 1, 2). An endoport 7 is installed with a diameter of 10 mm (Fig. 2) for a laparoscope along the line connecting the middle of the costal arch 8 and the navel 9 8-10 cm below the costal arch 8 (Fig. 1). For visualization, a 10 mm, 30 ° laparoscope is used. A giant polycystic-altered kidney is visualized 10. Under the visual control of a laparoscope (not shown in the figure), a spoke 1 is carried out in the longitudinal direction in the lateral region in the most convenient position, taking into account the anatomical location of the polycystic altered kidney 10 (as a rule, the needle is pierced in the iliac region by 2 -3 cm medial to the anterior axillary line and 2 cm above the anterior superior iliac spine, is carried out longitudinally parallel to the anterior axillary line and punctures 4-5 cm below the costal arch 8 (Fig. 1). Further, the spoke 1 is fixed to an arched rigid rod 3 and using thread traction 4 through the knee 5 of the operating lamp, traction of the abdominal wall is performed and a working space 11 is created. Then, desufflation is performed to a pressure value of less than 3 mm Hg, and the subsequent stages of the operation are carried out under low pressure carboxyperitoneum. 3 mmHg) carbon dioxide injection is indicated to prevent the formation of vacuum in the abdominal cavity. Next, the necessary endoports for nephrectomy are established and the operation is performed. The triangular shape of the working space 11 with the highest point in the projection of the laparolift and the maximum volume in the region of the renal pedicle 12 allows you to create sufficient visualization and freedom of movement of the instruments. The ability to install the laparolift in the most convenient position, taking into account the anatomical location of the giant polycystic-altered kidney, simplifies the operating technique and improves visualization. The absence of contact of the laparolift with the peritoneum 6 and the abdominal cavity protects it from additional damage and prevents infection of the abdominal cavity. In the postoperative period, there is practically no pain in the area of the laparolift.

The proposed method makes it possible to perform laparoscopic nephrectomy under conditions of low pressure carboxyperitoneum in patients with autosomal dominant polycystic kidney disease and concomitant cardiovascular pathology.

The possibility of using the proposed method is confirmed by clinical examples.

Patient S. 62 years old, autosomal dominant polycystic kidney disease was detected in 1987, was registered with a nephrologist. In 2013, amid decreased urine output, critical azotemia was diagnosed and renal replacement therapy with hemodialysis started. In the first year of efferent therapy, coronary heart disease debuted: it suffered myocardial infarction in the region of the lower wall of the left ventricle. In connection with the development of early post-infarction angina pectoris, angioplasty and agency of the right coronary artery were performed in 2013. In 2016, the patient developed a clinic of increasing heart failure. 07/27/2017 Aortic coronary artery bypass grafting was performed.

On September 11, 2017, the patient underwent laparoscopic nephrectomy on the right under reduced pressure carboxyperitoneum using a laparolift under endo-tracheal anesthesia. Postoperative course without features. The patient was transferred from the intensive care unit and intensive care on the first day, activated on the 2nd day. In satisfactory condition he was discharged for outpatient treatment on September 15, 2017.

November 14, 2017, the patient underwent laparoscopic nephrectomy on the right under low pressure carboxyperitoneum using a laparolift under endo-tracheal anesthesia. Postoperative course without features. The patient was transferred from the intensive care unit and intensive care on the first day, activated on the 2nd day. In satisfactory condition he was discharged for outpatient treatment on November 20, 2017. After stabilization, the patient was included in the kidney transplant waiting list.

A 66-year-old patient M. was admitted to the hospital with a diagnosis of Autosomal - dominant polycystic kidney disease, chronic pyelonephritis, latent phase. Chronic hemodialysis since 2010. In 2011, he suffered an acute myocardial infarction (the reason was a traumatic situation). At this stage, a typical clinic of acute coronary syndrome was noted. He was treated inpatiently, medical treatment was timely. The course of the pathology is not complicated. In 2013 - repeated myocardial infarction. The course of the disease was the same. In connection with the preservation of angina pain 02/06/2015 performed bimammar and autoarterial coronary artery bypass grafting on a working heart. The postoperative period was calm.

After patient rehabilitation, 06/29/2015, a laparoscopic nephrectomy was performed on the right under low-pressure carboxyperitoneum using a laparolift under endo-tracheal anesthesia. Postoperative course without features. The patient was transferred from the intensive care unit and intensive care on the first day, activated on the 2nd day. In satisfactory condition, was discharged for outpatient treatment on 07/03/2015. After stabilization, the patient was included in the kidney transplant waiting list.

As a result of the implementation of the described method creates a working cavity. Due to its shape, as well as the ability to displace the laparolift, visualization during the main stage of the operation is significantly improved.

The advantages of the proposed method:

1. The working part of the laparolift does not start in the abdominal cavity

2. The risk of infection of the abdominal cavity is reduced.

3. Due to the small diameter of the knitting needles, it is carried out through punctures.

4. Due to the absence of damage to the peritoneum and additional incisions of pain in the standing area of the laparolift after surgery, there is practically no.

5. A more convenient triangular-shaped workspace is created with better visualization and the highest point in the projection of the renal leg.

6. There is the possibility of installing the laparolift in the most convenient position, depending on the anatomy of the location of the polycystic-altered kidney, as well as the possibility of its displacement if necessary during the main stage of the operation.

7. The possibility of continuous operation with a vacuum aspirator without reducing the volume of the working cavity, more thorough hemostasis due to rapid coagulation due to the constantly working vacuum aspirator.

8. Laparoscopic nephrectomy in conditions of low-pressure carboxyperitoneum can be performed in patients with autosomal dominant polycystic kidney disease and concomitant cardiovascular pathology.

Using the proposed method in the clinic of urology PSPb GMU im.akad. I.P. Pavlova performed a series of laparoscopic nephrectomy of polycystic altered kidneys under conditions of low pressure carboxyperitoneum using an extraperitoneal laparolift. In this method, the abdominal wall is held by a laparolift held outside the abdominal cavity. This allows you to get a larger volume of the working operating space with the highest point in the projection of the laparolift and the maximum volume of the cavity in the region of the renal leg, makes it possible to correct the location of the laparolift depending on the variable anatomy of polycystic-altered kidneys.

The proposed method eliminates the negative effects caused by intraperitoneal laparolift, as well as the formation of an adequate working space in the abdominal cavity for convenience and ease of manipulation of the surgeon during laparoscopic surgery and improved visualization of giant polycystic-altered kidneys, which distinguishes it from the prototype.

Claims (2)

1. A method for laparoscopic nephrectomy of polycystic altered kidneys under low pressure carboxyperitoneum using a laparolift, including lifting with a clamp of the anterior abdominal wall, supplying carbon dioxide to the abdominal cavity to install a laparolift and introducing an endoport to conduct a laparoscope used to visually monitor the laparolph installation , with the help of the working part of which form the operative working space in the abdominal cavity by traction upward of the anterior abdominal wall, and performing the indicated operation, characterized in that a needle pointed at both ends with a length of at least 15 cm and a diameter of no more than 3 is used as the working part of the laparolift mm, which is carried out under visual control of a laparoscope through punctures with capture of the skin and subcutaneous tissue in the lateral region of the abdomen in the longitudinal direction, choosing the most convenient position for traction depending on the size and anatomical location of polycystic of the kidney, the ends of the knitting needles are fixed to the ends of the arcuate rod of the laparolift, through which the abdominal wall is lifted upward with the help of a thread rod connected to an arcuate rigid rod with a spoke attached to it and by changing the length of the thread rod through the horizontal knee of the operating lamp, creating a working space for performing a nephrectomy, the cavity of which has a triangular shape with the highest point in the projection of the laparolift and the maximum volume in the region of the renal leg, achieved by installing the laparolift needle in the most convenient position, further reduce the pressure of carbon dioxide in the abdominal cavity to a value of no more than 3 mm Hg . and then carry out further surgical benefit in low pressure carboxyperitoneum. 2. The method of carrying out a laparoscopic nephrectomy of polycystic altered kidneys according to claim 1, characterized in that the Kirschner or Veress needle is used as a laparolift needle.

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