RU2729431C1 - Method of laparoscopic treatment of varicocele - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely to urology, andrology and pediatric surgery. Simultaneously with laparoscopic clipping of the left testicular vein, pampiniform plexus vein sclerotherapy is performed. Scrotum skin is punctured on the left above the spermatic cord. Large branch of the pampiniform plexus of the testicular vein is removed through the puncture, ligatured by a ligature. That is followed by a venesection or venipuncture of the vein of the pampiniform plexus of the testis on the left with simultaneous introduction of two venous catheters in the distal and proximal direction from the ligation site of the pampiniform plexus vein.EFFECT: method provides a good cosmetic and functional result of the operation, is a low-traumatic, effective method of treating, enables reducing possible complications, including the effect of the operation on reproductive function.1 cl, 1 ex

Description

The invention relates to medicine, namely to urology, andrology and pediatric surgery, and is intended for the surgical correction of varicocele in patients of all age groups.

A known method of laparoscopic treatment of varicocele, which consists in endovideo-laparoscopy and occlusion of the testicular vein on the left using metal clips, or by ligation with ligatures; a number of authors use an ultrasonic scalpel to cross the testicular vein on the left (Stalmakhovich V.N. Laparoscopic method in the treatment of varicocele in children / V.N. Stalmakhovich, P.S. Yurkov, N.I. Mikhailov, V.M. Galchenko // Children's surgery. 1999. - No. 6. - pp. 17-20; Stepanov VN Atlas of laparoscopic operations in urology / VN Stepanov, ZA Kadyrov M .: "Miklos", 2001. - 125 p. ).

The operation of laparoscopic testicular vein occlusion includes several stages.

The first stage - in the supine position, the trocars are inserted and the pneumoperitoneum is applied. To apply pneumoperitoneum, open laparoscopy is performed, the first 5-mm blunt-pointed trocar is inserted along the upper edge of the umbilical ring. After the imposition of pneumoperitoneum (12-14 mm Hg) under the control of a laparoscope (5 mm with a 30 ° end cut), two additional 5 mm trocars are inserted, always at standard points: in the left iliac region and in the midline above the bosom. An abdominal revision is performed.

Second phase. The parietal peritoneum is opened over the vascular bundle of the left testicle at a distance of 3-4 cm from the deep inguinal ring using monopolar coagulation.

Stage three. After opening the peritoneum with the help of a dissector, blunt circular mobilization of the entire vascular bundle from the underlying tissues is performed for 1-1.5 cm, a holder thread is inserted under the mobilized bundle (non-absorbable material - silk, ethibond, thread length about 8 cm), which is not tied ...

The fourth stage is the isolation and preservation of the lymphatic ducts. Lymphatic vessels (at least 2 ducts) are carefully separated with a dissector from the vascular bundle, removed from under the thread-holder, previously applied to the entire bundle.

Fifth stage. After the isolation of the lymphatic ducts and the precision isolation of the arterial trunks, the entire remaining tissue array of the testicular vascular bundle is tied up with a holding thread.

Sixth stage. Control of hemostasis and discharge of the vascular bundle of the left testicle through the veins by compression on the left half of the scrotum. The peritoneal wound above the vascular bundle is not sutured. The gas is removed from the abdominal cavity. Trocars are removed under optical control. Layered sutures on wounds. Aseptic dressing. (Varicocele in children and adolescents. Clinical guidelines. Russian Association of Pediatric Surgeons. 2016. - p. 18)

This method of operation makes it possible to determine the structure of the spermatic vein, the presence of anastomoses - "satellites", through which the passage of blood flow is possible, in case of recurrence of the disease. It is important that in laparoscopy, optical magnification of 6-10 times makes it possible to detect the pulsation of the testicular artery, to identify the lymphatic ducts, avoiding their damage.

Despite the fact that the laparoscopic approach to the treatment of varicocele is technically difficult and not available to all medical institutions, it is invasive, requires the use of expensive equipment, its advantages in the form of low trauma and the absence of incisions are undeniable.

A known method for the surgical treatment of varicocele using X-ray endovascular intervention. The method is as follows. This treatment technique is carried out in an X-ray operating room. A Seldinger puncture of the right femoral vein is performed, an angiographic catheter is passed through the inferior vena cava and catheterization of the left renal vein is performed. Selectively, a catheter is inserted into the left testicular vein and phlebography is performed to assess the structure of its basin and visualize a retrograde discharge to the groin-like plexus. After assessing the angioarchitectonics of collaterals and overflows, a sclerosing drug (3% foamed sodium tetradecyl sulfate solution) is injected through the catheter, preliminarily clamping the spermatic cord at its exit from the inguinal canal. A control diagnostic phlebography is performed 15 minutes after sclerosis. The lack of contrasting of the distal parts of the left testicular vein and its branches indicates the effectiveness of treatment. The catheter is removed. A hemostatic pressure bandage is applied at the puncture site (Varicocele in children and adolescents. Clinical guidelines. Russian Association of Pediatric Surgeons. 2016. - p. 20).

The positive aspect of the intervention is that this X-ray endovascular technique can be performed both in the main and in the loose type of testicular vein structure. The method can be performed under local anesthesia or superficial anesthesia, including on an outpatient basis.

The disadvantages of the above method of endovascular sclerotherapy include the following. An anatomical anomaly of the confluence of the testicular vein and the impossibility of selective catheterization of the testicular vein, as well as malformations and thrombosis of the inferior vena cava and iliac veins can become a technical obstacle to the performance of endovascular sclerosis. The use of significant amounts of a radiopaque substance creates the possibility of an allergic reaction, creates a prolonged radiation load on the body. According to different authors, an allergic reaction to a contrast agent was 3.5% of cases; temporary pain in the left iliac region (29%); thrombophlebitis of the veins of the groin-like plexus in 4% of patients, as well as perforation of the vessel walls and thrombosis of the renal venous system.

Also known is a method of retroperitoneal surgery for varicocele, which is as follows. Patients who have been diagnosed with a renotesticular hemodynamic type of varicocele undergo video-retroperitoneoscopic surgery, which is performed under general anesthesia, with tracheal intubation and the use of muscle relaxants. An access is created in the lumbar region about 1.5 cm long, the fascia is perforated, its edges are sutured to the skin incision. After the formation of the optical space and the imposition of carboxyrethroperitoneum, a trocar with a telescope is inserted and the left kidney and its vascular pedicle are revised. Then, under video control, two working trocars are installed. After isolating the entire vascular bundle, the testicular vein is differentiated and clipped with metal clips. The duration of the operation is on average about 60 minutes. (Nasyrov AR Video-retroperitoneoscopic treatment for relapses of varicocele in children. Medical Bulletin of Bashkortostan. Volume 9, No. 1, 2014, pp. 69-72.).

The method allows for clipping the testicular vein outside the abdominal cavity; however, it also requires intubation anesthesia, like the laparoscopic method, but its duration is longer, due to the more complex technique of creating a cavity in the peri-renal space. In addition, with this method, the volume of the manipulation cavity is very small, which creates technical difficulties and lengthens the time of the surgical intervention. After the operation, a noticeable postoperative scar remains in the lumbar region. There is no impact on the veins distal to the level of the lower pole of the kidney; the method is applicable only in the case of the renotesticular hemodynamic type of varicocele.

Closest to the claimed invention is a method of antegrade sclerotherapy by the method of Tauber R., Johnsen N. (1993), taken as a prototype. The known method is carried out in the following stages.

Производят инфильтрационную анестезию семенного канатика на уровне основания полового члена 10 мл 1% локального анестетика. Кожу мошонки в области разреза дополнительно инфильтрируют 1-2 мл анестетика.

Infiltration anesthesia of the spermatic cord is performed at the level of the base of the penis with 10 ml of 1% local anesthetic. The skin of the scrotum in the area of the incision is additionally infiltrated with 1-2 ml of anesthetic.

Большим и указательным пальцами захватывают семенной канатик вместе с кожей мошонки и натянутую кожу рассекают продольно на 1 см. на один палец латеральнее и ниже основания полового члена

The spermatic cord together with the skin of the scrotum is grasped with the thumb and forefinger, and the stretched skin is dissected longitudinally by 1 cm.on one finger lateral and below the base of the penis

Семенной канатик препарируют и мобилизуют. Под семенной канатик подводят резиновую сосудистую петлю-держалку и оттягивают его

The spermatic cord is dissected and mobilized. A rubber vascular loop-holder is brought under the spermatic cord and pulled back

Рассекают фасцию семенного канатика, препарируют одну из вен гроздьевидного сплетения и дистально перевязывают ее

The fascia of the spermatic cord is dissected, one of the veins of the aciniform plexus is dissected, and it is tied distally

Вену рассекают проксимальнее лигатуры, в ее просвет вводят тонкостенную канюлю 24 G, которую фиксируют простой лигатурой. Препарирование вены облегчается, если ноги больного опустить книзу и попросить его потужиться

The vein is dissected proximal to the ligature, and a thin-walled 24 G cannula is inserted into its lumen, which is fixed with a simple ligature. Dissection of the vein is facilitated if the patient's legs are lowered down and asked to push

Approximately 3 ml of non-ionized contrast medium is injected into the cannula, and its outflow is checked by X-ray. After injecting 1 ml of air into the vein (airlock), with the simultaneous Valsalva maneuver (straining), 3-4 ml of ethoxysclerol are injected into the vein. At the same time, the reverse flow of the mixture of air with a sclerosing substance in the aciniform plexus is clearly visible.

Sclerotherapy is completed, the cannula is removed, the vein is ligated proximally, the fascia of the spermatic cord is sutured with two sutures and the spermatic cord is released. The skin is sutured with catgut 3/0. The spermatic cord is compressed by hand for 3-5 minutes and a sterile bandage and suspensory are applied (Quoted from "Operative urology. Classics and innovations: A guide for doctors / T. G. Managadze, N. A. Lopatkin, O. B. Laurent , D.Yu. Pushkar, S.P. Darenkov, N.L. Turmanidze, R. Hohenfellner. - M .: Medicine, 2003. S. 334. ")

The method allows the operation to be performed on an outpatient basis, under local anesthesia, does not require a large operative access and does not leave a noticeable scar, however, it gives a significant number of relapses due to the lack of ligation of the main trunk of the testicular vein, is less radical, in comparison with analogues, has limited use in children and adolescence, due to the performance under local anesthesia, is not applicable in the renospermatic hemodynamic type of varicocele due to ineffectiveness. The use of sclerosing the lumen of the veins of the groin-shaped plexus without ligation of the main trunk can contribute to recanalization of the lumen of the venous vessel.

There is a significant variety of surgical approaches to the treatment of varicocele in children and adolescents, however, no optimal laparoscopic treatment has been found.

The objective of the claimed method of surgical treatment of varicocele is to develop an objective, easily reproducible method for laparoscopic treatment of varicocele, as well as prevention of its recurrence, reducing the number of "typical" local complications after "open" operations in the form of indurative testicular edema, its hypotrophy.

The technical result of the invention is to reduce the percentage of recurrence of varicocele, to reduce the number of "typical" local complications after "open" operations in the form of indurative testicular edema, its hypotrophy.

The essence of the proposed method is that in the method of laparoscopic treatment of varicocele, including diagnostic laparoscopy, clipping of the testicular vein along with metal clips, with excision of a fragment of the vein, puncture the skin of the scrotum on the border with the skin of the abdomen, above the spermatic cord, and conduct sclerotherapy of the veins of the aciniform plexus both antegrade and retrograde.

The novelty of the proposed method is that, firstly, they combine two different surgical approaches in two places at the same time, namely, in a place typical for laparoscopic access by introducing 3 trocars, as well as in the place of localization of varicocele (projection of the spermatic cord on the left) ; secondly, the introduction of the sclerosant is carried out both in the antegrade and retrograde directions, which, in combination with retroperitoneal ligation of the veins, ensures complete occlusion of the testicular vein throughout.

The inventive method has the following advantages over the prototype:

эффективным, доступным способом перекрывается кровоток по практически всей протяженности яичковой вены, начиная от гроздевидного сплетения и заканчивая верхней третью вены перед впадением в левую почечную вену;

in an effective, affordable way, blood flow is blocked along almost the entire length of the testicular vein, starting from the groin-like plexus and ending with the upper third of the vein before flowing into the left renal vein;

при этом все оперативное вмешательство осуществляется из проколов, малоинвазивным закрытым способом,

at the same time, all surgical intervention is carried out from punctures, in a minimally invasive closed way,

отсутствует лучевая нагрузка на организм

there is no radiation load on the body

The claimed method is carried out as follows.

Laparoscopy is performed by placing three trocars. Find the left testicular vein, open the peritoneum above it, stepping back 1.5-2.5 cm from the inner inguinal ring, isolate the venous trunk of the testicular vein (1 or 2-3, if there is a loose type of structure). Isolation is carried out in the direction of the left kidney, while separating the lymphatic ducts and artery, coagulating small venous tributaries in the "chain" type of vessel structure. The level of discharge in the proximal direction extends to the intersection with the ureter. After isolation, the testicular vein trunk is clipped in the proximal and distal directions, applying 2 clips each; the middle part of the vein is removed for histological examination. Control for hemostasis and desufflation of carboxyperitoneum is carried out, trocars are removed from the abdominal cavity. Make a puncture of the skin on the left scrotum up to 0.8 cm long in the projection of the spermatic cord. A large branch of the groin-like plexus of the testicular vein is removed through a puncture, tied up with a ligature. Distal and proximal to the ligature, departing from it by 0.5-0.7 cm, the vein is punctured with 2 venous catheters of the "angiocache" type with a pavilion, and temporary ligatures are applied distal and proximal to the puncture sites. Into the lumen of the vein through the catheters, 2.0 ml of 1% solution of ethoxysclerol are injected alternately, or 1 ml. 3% solution of ethoxysclerol in the form of "foamed" form. After the introduction of the sclerosant, the vein walls are tightly pressed by pressure on the scrotum.

Examples of the implementation of the proposed method.

Example 1.

Patient Z-ny Alexander, 17 years old, operated on for varicocele on the left, III degree. During the operation for varicocele under intubation anesthesia, after treatment of the operating field with solution of betadine twice, from the level of the nipples on the anterior abdominal wall to the scrotum inclusively and the upper anterior surface of the thighs, puncture of the abdominal cavity with a Veress needle in the umbilical ring was performed, carboxyperitoneum was imposed , the abdominal cavity is punctured 5 mm. a trocar through the umbilical ring, laparoscopy was performed, two additional ports were installed: one 5-mm trocar was installed in the left iliac region, the second - 10-mm in the midline between the navel and the bosom. After examining the abdominal cavity, the left testicular vein was identified, the peritoneum was opened above it, 2 cm away from the inner inguinal ring, 1 venous trunk of the testicular vein was isolated with its mobilization towards the left kidney, while separating the lymphatic ducts and artery, to the point of intersection with the ureter ... After isolation, the testicular vein trunk was clipped in the proximal and distal directions, applying 2 clips each; the middle part of the vein was excised for histological examination. Control for hemostasis and desufflation of carboxyperitoneum; lapoports were removed from the abdominal cavity under visual control. Performed a skin puncture on the left scrotum up to 0.8 cm long in the projection of the spermatic cord. The spermatic cord was captured through the skin of the scrotum and brought to the puncture site, with the help of a vascular clamp, a branch of the aciniform plexus of the testicular vein with a diameter of up to 0.5 cm was removed through the puncture, tied with a ligature (polysorb No.-00). Distal and proximal to the ligature, departing from it by 0.5 cm, punctured the vein with 2 venous catheters of the "angiocash" type No. 2, and imposed temporary ligatures (polysorb No.-00) distal and proximal to the puncture sites, without tying knots. Into the lumens of the vein through the catheters, 2.0 ml of 3% solution of ethoxysclerol was injected in turn in the form of "foam". After the introduction, the spermatic cord was tightly pressed by pressing on the scrotum for 2 minutes. Then the catheters were removed, the ligatures were tied, previously applied distal and proximal to the punctures, thus achieving complete hemostasis. The vein was crossed between two ligatures, the stumps were sunk under the membranes of the spermatic cord; the edges of the membranes were not sutured. One catgut suture was placed on the skin of the scrotum. The abdominal wall punctures were sutured with 1-2 sutures. Aseptic stickers. The duration of the operation was 54 minutes. The patient's postoperative period was uneventful. After observation for 3 hours in the intensive care unit, the patient was transferred to the unit, discharged home under the supervision of a surgeon the next day. Examined on call after 6 months. No complaints. No relapse.

12 patients with varicocele of varying severity, starting with the second degree (5) and ending with the third (7 patients), were operated on by the claimed method of laparoscopic treatment, with recurrent varicocele - not operated. The grade of varicocele was preliminarily established on the basis of clinical classifications, as well as by ultrasound. In addition, the control group included patients (105 people) with varicocele, operated laparoscopically. Among them, relapses were detected in 6 patients; no relapses were found among the group of subjects.

The data obtained made it possible to recommend a new method of laparoscopic varicocelectomy for use in pediatric surgical departments.

Thus, the main differences of the proposed method are:

1. The use of an additional puncture of the skin of the scrotum at the border with the skin of the abdomen, above the spermatic cord, and sclerotherapy of the veins of the aciniform plexus both antegrade and retrograde.

2. For the first time for varicocele, a combination of two different surgical approaches is used in two places at the same time, namely, in a place typical for laparoscopic access by the introduction of 3 trocars, as well as in the place of localization of varicocele (projection of the spermatic cord on the left).

3. In case of varicocele, the sclerosant is administered in both antegrade and retrograde directions, which, in combination with retroperitoneal ligation of the veins, ensures complete occlusion of the testicular vein throughout.

The above set of distinctive features has not been described in the literature.

Thus, the claimed invention meets the "novelty" criterion.

Comparison of the proposed solution not only with the prototype, but also with other solutions in this field of science has shown that the optimal surgical method for laparoscopic treatment of varicocele is the claimed method of simultaneous laparoscopy and sclerotherapy, which allows radically operating patients with varicocele without prejudice to testicular trophism and the danger of its atrophy ...

The method does not provide for radiation exposure, and does not require a wide invasive access, it is easily reproducible in a hospital setting, the discharge of patients from the department is carried out 1-2 days after the operation.

Sources of information:

1. Stalmakhovich V.N. Laparoscopic method in the treatment of varicocele in children / V.N. Stalmakhovich, P.S. Yurkov, N.I. Mikhailov, V.M. Galchenko // Pediatric surgery. 1999. - No. 6. - S. 17-20.

2. Stepanov V.N. Atlas of laparoscopic operations in urology / V.N. Stepanov, Z.A. Kadyrov M .: "Miklos", 2001. - 125 p.

3. Varicocele in children and adolescents. Clinical guidelines. Russian Association of Pediatric Surgeons. 2016 .-- p. 18, 20.

4. Nasyrov A.R. Video-retroperitoneoscopic treatment for recurrent varicocele in children. Medical Bulletin of Bashkortostan. Volume 9, No. 1, 2014, p. 69-72.

5. Kadyrov Z.A. Video endoscopic surgery in patients with varicocele (literature review) / Z.A. Kadyrov, S.M. Dudiev, Kh.S. Ishonakov et al. // Andrology and genital surgery. 2007. - No. 4. - S. 29-35.

6. Operative urology. Classics and innovations: A guide for doctors / T.G. Managadze, N.A. Lopatkin, O.B. Laurent, D.Yu. Pushkar, S.P. Darenkov, N.L. Turmanidze, R. Hohenfellner. - M .: Medicine, 2003 .-- 740 p.: P. 334.

Claims (1)

A method of laparoscopic treatment of varicocele, including laparoscopic occlusion of the testicular vein on the left, characterized in that, simultaneously with laparoscopic clipping of the left testicular vein, sclerotherapy of the uviform plexus veins is carried out, while the skin of the scrotum is punctured on the left above the spermatic cord, a large branch of the gravicular vein is removed through the puncture, ligate it with a ligature, perform venesection or venipuncture of the vein of the groin plexus of the testicle on the left with the simultaneous introduction of two venous catheters in the distal and proximal direction from the site of ligation of the trunk of the vein of the groin plexus.