RU2743969C1 - Model for developing the skill of performing laparoscopic resection ureteropyeloanastomosis and method of its formation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: model for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis contains a box with two holes for surgical instruments used to perform anastomosis, a video camera located inside the box with an illumination element connected to a monitor located outside the box, a model of a hydronephrotically dilated renal pelvis and a model of the ureter. The model of the hydronephrotically dilated renal pelvis and the model of the ureter are placed in a box on a polyethylene surface with the possibility of fixation on it and with the possibility of being connected with twisted sutures in the process of practicing the skill of laparoscopic resection ureteropyeloanastomosis. The model of the hydronephrotically dilated renal pelvis is made of chicken drumstick skin in the form of a truncated cone, and the ureter model is a tubularized rectangular flap of chicken skin. A method for practicing the skill of performing a laparoscopic resection ureteropyeloanastomosis is disclosed.

EFFECT: increased anatomical reliability.

6 cl, 10 dwg

Description

The group of inventions relates to medicine, namely urology, and can be used to master laparoscopic reconstructive plastic surgery. [A61B 17/00, A61B 17/11].

Pelvic-ureteric segment stricture is a common pathology. For the first time, laparoscopic plasty of the pelvic-ureteric segment was performed by W. Schuessler et al. In 1993. The method used combined the reduced morbidity of laparoscopy with reconstruction by direct imaging.

However, laparoscopic imaging implies working in a two-dimensional space with the transmission of tactile sensitivity through an instrument, the length of which is 35 cm.All stages and surgical techniques in the abdominal cavity are performed by the surgeon with laparoscopic instruments with a diameter of 5 to 10 mm with visualization and control of their actions on the monitor, and therefore , carrying out a laparoscopic reconstructive operation requires the development of a number of skills, in particular: delicate work with tissues, cutting in different directions, performing an intracorporeal suture (directly an anastomosis), correct tissue redistribution during the formation of a continuous wound suture.

At present, a significant difficulty is the possibility of training a surgeon who knows modern endoscopic operations without the use of special simulators or expensive courses of laparoscopic surgery performed on animals. Due to the fact that the cost of training in courses in laparoscopic surgery ranges from 70 to 400 thousand rubles, lasting from one to five days, a significant problem is the possibility of ensuring the development of the necessary skills on a systematic basis.

At the same time, R.G. Biktimirov and co-authors in their article "Our experience of laparoscopic plasty of the pelvic-ureteric segment" [Endoscopic surgery No. 1, 2012, pp. 9-11] indicate that when this operation is performed, the need for good knowledge of the skills of laparoscopic surgery with the technique of laparoscopic suture, and a progressive decrease in the duration of the intervention was noted only after the first 20 cases.

Despite the fact that the engineering community strives to create the most reliable imitation of tissue, there is still no “ideal” simulation simulator, due to the impossibility of creating a virtual “ideal” tactile sensitivity. The role of tactile sensitivity is currently of particular interest in surgery, as it is a critical factor in the recognition of normal and abnormal tissue (both in "open" and in laparoscopic surgery). Virtual simulators, while realistic, do not provide tactile sensitivity. Meanwhile, work on biomnequins provides tactile sensitivity, contributes to the formation of advanced laparoscopic skills in the surgeon, which are necessary for performing an intracorporeal suture in the formation of ureteropyeloanastomosis. The systematic consolidation of the skill on biomnequins allows the surgeon to prepare for the operation, which shortens the time of the actual operation, allows the surgeon to learn to delicately handle tissues, reduces the number of peri- and postoperative complications, relapses of the disease, and also increases the surgeon's confidence during the operation and significantly shortens learning curve ".

The model developed by us is available, easily reproducible, inexpensive, as close as possible to the real anatomical characteristics of the urinary tract, allows you to work out the stages and surgical techniques performed during laparoscopic plastic surgery, such as resection of the pelvis, spatulation of the ureter, and the formation of an anastomosis.

A SIMPLE MODEL FOR LEARNING LAPAROSCOPY OF VASAL-URETHRAL ANASTOMOSIS [JOURNAL OF ENDOUROLOGY Volume 17, Number 7, September 2003. Mary Ann Liebert, Inc.] is known from the prior art. A model simulating laparoscopic running urethrovesical anastomosis was made using supermarket chicken skin placed in a laparoscopic training box. A circular continuous anastomosis was performed. The model contains chicken skin shaped like a 4 cm tube above a catheter to simulate the urethra, connected to another piece of skin that is folded towards itself to simulate the bladder. In this case, the "bladder neck" is made by cutting a hole 1 cm in diameter in the folded edge of the "bladder". The model is then secured with hairpins in the laparoscopic training box. A laparoscope with a camera and two holes for instruments is inserted into the box, which are located, as in surgery, with a camera in the midline, the right needle holder 5 cm lateral and distal and the left needle holder 8 cm lateral and distal. Sewing is done by Vikril 3-0 on a 5/8 needle. The assistant manipulates the Foley catheter in the “urethra” to facilitate the placement of urethral sutures.

The disadvantages of this analog are:

- in the analogue, chicken skin from an arbitrary part of the chicken is used, which reduces the quality of the formation of the skill of performing laparoscopic resection ureteropyeloanastomosis, due to the fact that anatomically reliable models of the pelvis and ureter can be formed only from specially selected areas of chicken skin;

- the analogue does not implement the preparation of the model for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis, namely washing the chicken skin, which also reduces the level of tactile sensitivity and leads to a decrease in the quality of skill formation.

Also known in the art is a TRAINING MODEL FOR OPEN OR LAPAROSCOPIC PYELOPLASTY [JOURNAL OF ENDOUROLOGY Volume 20, Number 2, February 2006 © Mary Ann Liebert, Inc.], which uses chicken legs; urinary catheter; a catheter for feeding babies; unstained absorbable suture material; marker pen and stapling tools. The procedure for creating a model is as follows: three incisions are made in the chicken skin, the first skin flap should form the pelvis and ureter, while the second and third flaps form the intersecting blood vessels. The first flap is folded back over the Foley catheter with an inflated balloon to form the renal pelvis and ureter, then it is sutured to the fold line with interrupted sutures. The second and third flaps are similarly sutured over the breastfeeding catheter.

The disadvantages of this analog are:

- due to the fact that the pelvis and ureter are formed from one element of chicken skin, the resulting model does not have a sufficient level of anatomical reliability, which significantly reduces the quality of practicing the skill of performing laparoscopic resection ureteropyeloanastomosis;

- the use of a virtual simulator in the form of a urinary catheter in the analogue reduces the tactile accuracy, as a result of which the quality of the surgical skill is reduced.

The closest in technical essence is the SURGICAL COMPETENCE ASSESSMENT MODEL (LAPAROSCOPIC URETHROVESICAL ANASTOMOSIS) [JOURNAL OF ENDOUROLOGY Volume 20, Number 9, September 2006 © Mary Ann Liebert, Inc.]. Tubes 4 cm long are made of chicken skin, the excess skin is cut off, and two ends of the skin are sewn using a thin black silk thread 2-0, imitating the urethral stump. A separate piece of chicken skin in the thigh area is folded over to simulate a bladder. The "bladder neck" is made by cutting a round hole 1 cm in diameter above the folded edge of the "bladder". The model is then secured with Ellis clamps in a laparoscopic training box. A laparoscope with a camera and two needle holders are used for modeling. Five 9 cm long incisions are made on the chicken skin with C-15 cutting needles. The camera is positioned next to the middle line with two needle drivers approximately 5 cm on either side of the needle. At the beginning of the skill training, the participant is not allowed to perform any manual actions. The assistant is allowed to provide assistance, namely to push or withdraw the urethral catheter into the "bladder" at the request of the participant to facilitate suturing at the appropriate time.

The main technical problem of the prototype is that the model is formed without taking into account the anatomical features of the pelvis, namely: its shape, size and tactile qualities, which reduces the reliability of the model. A decrease in reliability, in turn, leads to an increase in the time spent preparing a surgeon for a real operation, increases the time for a real operation on a person, and increases the risk of the patient developing postoperative complications and relapses of the disease.

The objective of the invention is to eliminate the disadvantages of the prototype.

The technical result of the invention is to improve the reliability of the model for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis.

The specified technical result is achieved due to the fact that a model for practicing the skill of performing a laparoscopic resection ureteropyeloanastomosis, containing a model of hydronephrotically dilated renal pelvis made of chicken shin skin in the form of a truncated cone and a model of the ureter in the form of a tubularized rectangular flap of chicken skin, which are connected by continuous twisted sutures.

In particular, the rectangular skin flap is made from chilled chicken thigh skin.

In particular, the longitudinal edges of the rectangular chilled chicken thigh skin flap are joined by a suture.

In particular, the distance from the edges of the incision of the ureter model to the continuous winding suture is 2 mm, the spacing between the sutures of the continuous winding suture is 3 mm.

In particular, for the models, chicken skin is used, which has not previously been subject to freezing.

The specified technical result is achieved due to the fact that a model for practicing the skill of performing a laparoscopic resection ureteropyeloanastomosis, containing a box with two holes for surgical instruments used to perform anastomosis, a video camera located inside the box with a lighting element connected to a monitor located outside the box, the model is hydronephrotic dilated renal pelvis and a model of the ureter, while the model of the hydronephrotically dilated renal pelvis and the model of the ureter are placed in a box on a polyethylene surface with the possibility of fixation on it and with the possibility of being connected with twisted sutures in the process of practicing the skill of laparoscopic resection of ureteropyeloanastomosis, the model is made of hydronephrotically dilated skin of the lochial dilated chicken drumstick in the form of a truncated cone, and the ureter model is a tubularized rectangular flap of chicken skin.

In particular, the rectangular skin flap is a chilled chicken thigh skin.

In particular, the longitudinal edges of the rectangular chilled chicken thigh skin flap are joined by a suture.

In particular, for the model of the pelvis and the model of the ureter, chicken skin was used, which had not previously been subject to freezing.

The specified technical result is achieved due to the fact that the method of practicing the skill of performing laparoscopic resection ureteropyeloanastomosis, characterized by the fact that the model according to paragraph 1 is used, the model of the hydronephrotically dilated renal pelvis is resected in an oblique direction from itself up to the upper angle, then the dissection of the ureter model is performed, along the edge opposite to the suture with a length of at least 2 cm, connect the models with the first continuous twisted suture from the lower edge of the ureter model and the hydronephrotically dilated renal pelvis model, forming the posterior wall of the anastomosis, then connect the upper edges of the skin flaps of the ureter model and the upper edge of the model with the second continuous twisted suture hydronephrotically dilated renal pelvis, forming the anterior wall of the anastomosis.

In particular, the first continuous twisting suture is applied from the inner most protruding corner outside the incision of the pelvis model inward, the injection is made from the inside outward, while four seams are formed, the first seam is made double.

Brief Description of Drawings

FIG. 1 shows a front view of the skin of a chilled chicken thigh prepared for the formation of a model of the ureter.

FIG. 2 shows a general front view of the skin of a chilled chicken thigh with two incisions to form a ureteral tube.

FIG. 3 shows a front view of the skin of a chilled chicken thigh with tubularization of the resulting internal flap by suturing the edges.

FIG. 4 shows a front view of the skin of a cooled chicken drumstick prepared for the formation of a pelvis model, taking into account the performed resection

FIG. 5 shows a front view of the installation for the ureter and pelvis for plastic surgery.

FIG. 6 shows a general view of the model of the ureter and a diagram of the imposition of the first suture.

FIG. 7 shows a general view of the models of the ureter and pelvis, taking into account the direction of imposition of the first continuous winding suture.

FIG. 8 shows a general view of the models of the ureter and pelvis, taking into account the imposition of the first continuous winding suture.

FIG. 9 shows a general view of the models of the ureter and pelvis, taking into account the imposition of the second continuous suture.

FIG. 10 shows a general view of the models of the ureter and pelvis, taking into account the imposition of the first and second continuous winding sutures.

The drawings indicate: 1 - chilled chicken thigh skin, 2 - clamps, 3 - tube, 4 - section of the ureter model, 5 - chilled chicken drumstick skin, 6 - section of the pelvis model, 7 - polyethylene surface, 8 - box, 9 - hole for surgical instruments, 10 - video camera, 11 - lighting element, 12 - monitor, 13 - first continuous wrap-around stitch, 14 - second continuous wrap-around stitch.

Implementation of the invention

To form a model of the ureter, the skin of a cooled chicken thigh 1 is used, washed under cold water and not dried, having a size of at least 6x6 cm. The upper part of the skin flap of a cooled chicken thigh 1 is fixed in both corners with clamps 2, for example, needles from syringes. In this case, the lower part of the skin of the cooled chicken thigh 1 is formed in such a way that tubularization forms a tube 3, which is a model of the ureter, in the lower part of which there is an incision of the model of the ureter 4 with a length of at least 2 cm. The model also contains the skin of the cooled chicken drumstick 5, washed under cold water and dry, having the shape of a truncated cone, or a funnel that completely imitates the hydronephrotically expanded renal pelvis in shape and size, which is fixed with fixators 2 from the outer edges and has a pelvis model section 6 from the upper to the lower corner of the skin of a cooled chicken drumstick 5 The tube 3 and the skin of the chilled chicken drumstick 5 are located on the polyethylene surface 7, inside the box 8. Along the perimeter of the box 8 there are two openings for surgical instruments 9, as well as a video camera 10 equipped with lighting elements 11. In this case, the camera 10 is connected to the monitor 12. Edge of tube 3 formed by the skin of chilled chicken troubles pa 1, and the lower edge of the skin of the cooled chicken drumstick 4 are connected by a first continuous twisting suture 13, which forms the posterior wall of the anastomosis. The upper edges of the skin flaps of the tube 3 and the upper edge of the skin of the cooled chicken drumstick 4 are interconnected by means of a second continuous twisting suture 14, thus forming the front wall of the anastomosis. In this case, the indents from the edges of the incision of the model of the ureter 4 to the second continuous winding suture 14 is 2 mm, the step between the seams of the second continuous winding suture 14 is 3 mm.

The formation of a model of the ureter and pelvis for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis is carried out as follows.

Initially, parts of chicken are used to form the model, namely, chicken thigh and chicken drumstick, chilled, previously not subject to freezing. The preparation of materials is carried out as follows: they take a chilled chicken thigh, wash it with cold water, do not dry it, then remove the skin from the thigh by dissecting the delicate adhesions connecting the skin and muscle tissue to form a chilled chicken thigh skin flap 1, for the subsequent formation of a model of the ureter. Next, they take a chilled chicken drumstick, washed with cold water, do not dry it, and separate the skin from muscle tissue by dissecting delicate adhesions. Next, a bordering skin incision is made at the level of the narrowest point of the lower leg, and the skin is removed from the lower leg and turned inside out. After removing the skin from the lower leg, it is turned back with an uneven surface outward, while forming the skin of a cooled chicken drumstick 5, to form a model of a hydronephrotically dilated renal pelvis.

Next, a model of the ureter is formed by tubularization of a chilled chicken thigh skin flap 1. To do this, take the skin of a chilled chicken thigh 1 is placed on a surface covered with polyethylene, placed inside the box 8. Inside box 8, a video camera 10 is mounted, the data from which is displayed on the monitor 12 outside the box ... Lighting in box 8 is provided due to the functioning of the lighting element 11.

The upper part of the flap in both corners is fixed with clamps 2. From the bottom up, scissors make two even cuts 5 cm long at a distance of 1.5-2 cm from each other with the formation of an internal flap. Then tubularization of the resulting internal flap is performed by suturing the edges with a twisted suture with 5-0 thread, needle size 13-17 mm, with the formation of tube 3. Then tube 3 is separated from the main large flap by cutting with scissors. The resulting tube is a model of the ureter.

Further, in box 8, on the polyethylene surface, the obtained models of the ureter and pelvis formed by the skin of the cooled chicken drumstick 5 and the tube 3 for performing plastic surgery are laid.

On the polyethylene surface 7, the skin of the chilled chicken drumstick 5 (pelvis model) is placed, formed by the wide part of the flap on the outside, narrow - on the inside. Then the tube 3 (model of the ureter) formed from the skin of the cooled chicken thigh 1 is placed next to the narrow part of the skin of the cooled chicken drumstick 5. The tube 3 is fixed from the outer edge with a retainer 2, for example, with a needle from a syringe, and the skin of the cooled chicken drumstick 5 is fixed from the outer edge with two fixators 2, for example, syringe needles.

Next, resection of the pelvis model formed by the skin of the cooled chicken drumstick 5 is performed in an oblique direction "from oneself upward" to the upper corner.

Next, scissors perform a dissection of the model of the ureter formed by tube 3, along the edge opposite to the seam with a length of at least 2 cm.At the same time, traction of tube 3 is performed towards oneself, the branches of the scissors are inserted into the lumen of tube 3 and the wall is dissected in the direction from yourself. This technique is intraoperatively called "spatulation of the ureter" and is mandatory when performing the operation.

Then the anastomosis is performed through the holes for surgical instruments 9. The first suture is applied from the inner most protruding corner of the skin of the cooled chicken drumstick 5 outside the incision of the pelvis model 6 inward, then the injection is made from the inside to the outside of the tube 3, thereby connecting the tube 3 and the skin of the cooled chicken drumstick 5 , while forming four sutures, while the first suture is double, using a 13 mm needle, a 5/0 thread and leaving a part of the thread at least 15 mm long for subsequent tying after the anastomosis is completely formed. Then the needle with the thread is passed under both flaps of the tube 3, formed by the incisions of the ureter model 4, transferring the needle and the thread down under the tissue of the tube 3 and with the first continuous twisting suture 13 in the direction "downward towards you" connect the lower edge of the ureter model formed by the tube 3, and models of the pelvis formed by the skin of the chilled chicken drumstick 5, thereby form the back wall of the anastomosis, while monitoring the sufficient tension of the thread and the strength of the seams and prevent them from unraveling. Further, continuing with a continuous twisted seam, they move to the upper edges. And in the direction "from oneself up" with the second continuous-twisted suture 14, the upper edges of the flaps of the tube 3 are connected, thereby forming the front wall of the anastomosis. In this case, a continuous twisted suture is performed, retreating from the edges of the models of the ureter and pelvis by 2 mm, the "step" between the sutures is 3 mm.

The technical result of the invention, increasing the anatomical reliability of the model for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis is achieved due to the fact that:

- the execution of the model of the hydronephrotically dilated renal pelvis is made from the skin of a chilled chicken drumstick 5, washed under cold water, not dried, having the shape of a truncated cone, or a funnel, which completely imitates the hydronephrotically dilated renal pelvis in shape, size and tactile qualities, which makes it possible to get as close as possible model to the conditions of a real operation.

- the skin of the chilled chicken drumstick 5, washed under cold water, is not dried, and is dissected by the incision of the pelvis model 6 from the upper to the lower corner. Thus, a model of a hydronephrotically dilated renal pelvis is formed, which in shape, size and tactile qualities corresponds to the real one.

The applicant has repeatedly formed the claimed model, which makes it possible to practice the skill of performing a laparoscopic resection ureteropyeloanastomosis and to reduce the time of subsequent operations by 55-65% to 20-25 minutes.

Claims (6)

1. A model for practicing the skill of performing laparoscopic resection ureteropyeloanastomosis, containing a box with two holes for surgical instruments used to perform anastomosis, a video camera located inside the box with a lighting element connected to a monitor located outside the box, a model of a hydronephrotically dilated renal pelvis and a model of the ureter, at the same time, the model of the hydronephrotically dilated renal pelvis and the model of the ureter are placed in a box on a polyethylene surface with the possibility of fixing on it and with the possibility of being connected with twisted sutures in the process of practicing the skill of laparoscopic resection ureteropyeloanastomosis, the model of the hydronephrotically dilated renal pelvis is made of the skin of a chicken tibia in the form of and the ureteral model is a tubularized rectangular chicken skin flap. 2. The model of claim. 1, characterized in that the rectangular skin flap is the skin of a chilled chicken thigh. 3. The model of claim. 1, characterized in that the longitudinal edges of the rectangular skin flap of the cooled chicken thigh are connected by a seam. 4. The model of claim. 1, characterized in that for the model of the pelvis and the model of the ureter used chicken skin, previously not subject to freezing. 5. A method of practicing the skill of performing a laparoscopic resection ureteropyeloanastomosis, characterized by the fact that the model according to claim 1 is used, the model of the hydronephrotically dilated renal pelvis is resected in an oblique direction from itself upward to the upper corner, then the dissection of the ureter model is performed along the edge opposite to the suture length not less than 2 cm, connect the models with the first continuous twisted suture from the lower edge of the ureter model and the hydronephrotically dilated renal pelvis model, forming the posterior wall of the anastomosis, then connect the upper edges of the skin flaps of the ureter model and the upper edge of the hydronephrotically dilated renal pelvis with the second continuous twisted suture the anterior wall of the anastomosis. 6. The method according to claim 5, characterized in that the first continuous wrap-around suture is applied from the inner most protruding corner outside the incision of the pelvis model inward, the injection is made from the inside out, while four seams are formed, the first seam is made double.

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