RU2754499C1 - Method for laparoscopic treatment of liver and/or spleen cysts using electrothermal modified polydocanol - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely to abdominal surgery. Resection of the free part of the wall of the liver and/or spleen cyst with laparoscopic access is performed. The cyst walls are treated with a 3% polydocanol solution. The inner lining of the cyst, treated with polydocanol, is subjected to electrothermal action until a persistent and uniform change in the color of the epithelium for white.

EFFECT: increase the safety and radical treatment of cysts of parenchymal organs, reduce the number of complications of surgical intervention.

1 cl, 2 ex

Description

The invention relates to medicine, in particular to operative surgery, and can be used in clinical practice of practical health care.

Cysts of the liver and spleen are a fairly common pathology that requires surgical treatment. For this purpose, resection of cysts is most often used, which is feasible only in a limited area that is not in contact with the parenchyma of the organ, and an attempt to resect the visceral parts, as well as resection of the wall of intramural cysts, is complicated by severe bleeding.

There is a known method of sclerotherapy of cysts of parenchymal organs, when a cyst puncture is used under ultrasound control, complete aspiration of the contents and the introduction of 96% ethanol in a volume of 50-100% of the removed contents. The temporary exposure is 5-10 minutes, then the alcohol is completely evacuated [Lotov A.N. Minimally invasive ultrasound-guided interventions for surgical diseases of the hepatopancreatoduodenal zone. Doctoral dissertation, MMA them. THEM. Sechenov, 1998, 465 p .; Ignashin N.S. and coauthors. Ultrasound diapeutics of urological diseases, Stavropol 1991, 203 p .; Ignashin N.S., Demin A.I. "Ultrasonography and computed tomography in the diagnosis and treatment of urological diseases", Vidar, 1997, 260 pp.]. The disadvantages of this method include the possibility of damage to the vessels of the cyst wall with a needle installed in the cavity of the cyst, when the organ is displaced during the procedure (respiratory excursion) and a high risk of recurrence of cysts.

There is a known method for the treatment of nonparasitic liver cysts [RF patent No. 2485907, 06/27/2013] by puncture of the cavity, aspiration of the contents of the cyst, treatment of the cyst cavity, characterized in that the treatment of the cyst cavity is carried out using radiofrequency destruction using a high-frequency current generator in the minimum mode with heating the epithelial lining of the cyst cavity to 45 ° -55 ° C; the electrode is removed step by step, with a step length of up to 1.5 cm. The disadvantages of this method are: the use of the ablation technique for large and giant cysts is ineffective, incomplete treatment of the epithelial lining of the cyst occurs, followed by the formation of a relapse.

The use of such a technique as coagulation of the cyst wall, as a rule, is not radical, since its structure is uneven throughout and the release of heat and its distribution is unpredictable, and with significant thermal destruction, the sinuses are damaged with the development of bleeding in the early postoperative period. Even if it is possible to perform thermal destruction of all walls of the cyst, in the early postoperative period, there is a pronounced exudation into the cavity (due to the large burnt surface), inevitable stagnation of exudate and infection with inadequate sanitation - the development of a spleen abscess.

All known methods are not applicable to multicameral cysts and cysts with complex architectonics, massive cavitary bridges and intramural cysts. Moreover, it is a difficult technical task to carry out such an intervention using minimally invasive technologies and laparoscopic access. Non-radical excision of the splenic cyst leads in most cases to relapse and requires repeated surgical treatment.

For the purpose of radical surgical treatment of spleen cysts, splenectomy is most often used.

Also known is a method of surgical treatment of nonparasitic liver cysts, which involves excision of the part of the cyst protruding from the liver, removal of its contents, rubbing the residual liver cavity with alcohol or a weak solution of iodine, which is tamponed with an omentum. The omentum is hemmed to the edges of the liver, the entrance to the cavity is narrowed with sutures, but so as not to infringe on the part of the omentum introduced inside [V.S. Shapkin. Tumors and nonparasitic cysts and specific granulomas of the liver. Vladivostok, 1970, pp. 160-161]. The success of the operation is due to the great suction capacity of the omentum and its tendency to form adhesions. The disadvantage of this method lies in the increase in the duration of the postoperative period, due to the open access of the surgical intervention.

The prototype of this method is the previously registered patent [patent No. 2738044 dated 12/07/2020], which considers a method for the treatment of liver and spleen cysts, including resection of the free portion of the cyst wall by laparoscopic access, sanitation of the cyst cavity, intersection of adhesions, the use of a 3% polidocanol solution, tamponade cavity of the cyst. The use of polidocanol causes destruction of the epithelial lining of the cyst, which significantly reduces the risk of its re-formation.

EFFECT: increased safety and radicality of treatment of cysts of parenchymal organs, reduced number of complications of surgical intervention.

The advantage of the proposed method over the previously registered one is the use of the method of thermal destruction, which leads to signs of edema in the underlying layers, causing a delayed course of the resorptive effect, subsequently leading to a weakening of the intoxication syndrome.

Thus, the proposed method for treating cysts of parenchymal organs is safe and radical.

The purposes of the presented method of treating cysts are such parenchymal organs as the liver and spleen.

Execution technique:

Under intubation anesthesia through the supra-umbilical access, a CO2-pneumoperitoneum is applied according to the standard technique. In the epigastrium and in the left mesogastrium, 5 mm trocars are inserted to introduce working instruments into the abdominal cavity. After that, the head end of the operating table rises and turns to the right side (Fowler's position on the right side), thereby displacing the abdominal organs from the left subphrenic space. An audit is carried out, the formation of a free operating field. With the help of electric scissors with monopolar coagulation, bipolar instruments, including the LigaSure apparatus, the free section of the cyst wall of the parenchymal organ is resected. The resected section of the cyst wall, its contents are sent for histological and cytological examination. The cyst cavity is sanitized, the adhesions are intersected. The walls of the cyst are treated with a 3% polidocanol solution. The drug does not penetrate deeper than the basement membrane, thereby not affecting the parenchyma of the organ, eliminating the risk of bleeding. The use of the method of thermal destruction leads to signs of edema in the underlying layers, which causes a delayed course of the resorptive effect, leading to a weakening of the intoxication syndrome.

The duration of the electrothermal effect on the inner lining of the cyst treated with polidocanol was determined according to the "Frost" criterion, that is, a persistent and uniform change in the color of the epithelium to white. The use of the method of thermal destruction leads to signs of edema in the underlying layers, which causes a delayed course of the resorptive effect, leading to a weakening of the intoxication syndrome.

Then, in the cavity treated with electrothermally modified polidocanol, a strand of the greater omentum is placed, which is fixed along the periphery to the remains of the cyst wall using a surgical stapler and a manual endosurgical suture. An insurance drain is placed in the left subphrenic space for 1 day. Desufflation is performed, sutures are applied to the insertion sites of trocars. The laparoscopic approach proposed by us assumes less tissue trauma. Tamponing of the cyst cavity provides natural sanitation and restriction from the free abdominal cavity, thereby preventing purulent complications and adhesions.

The claimed method indicates the use of a combined effect at the local level of electrothermally modified polidocanol (Ethoxysclerol) on the epithelial lining of the liver cyst and / or spleen.

Polidocanol is a venosclerosing drug (detergent). The use of polidocanol in a hypotonic environment causes destruction of the epithelial lining of the cyst, which significantly reduces the risk of its re-formation. The duration of the electrothermal effect on the inner lining of the cyst treated with polidocanol was determined according to the "Frost" criterion, that is, a persistent and uniform change in the color of the epithelium to white. The use of the method of thermal destruction leads to signs of edema in the underlying layers, which causes a delayed course of the resorptive effect, leading to a weakening of the intoxication syndrome.

In addition, in combination with subsequent omentopexy, these methods show their high safety and effectiveness.

Clinical example:

Patient K., 29 years old, was admitted to the ORPH with a diagnosis of spleen cyst.

Clinically distressing pulling pain in the left hypochondrium and left mesogastrium. On ultrasound examination, a 9 x 5 cm fluid mass located on the posterior surface of the spleen extending to the inferior pole. On other organs of the abdominal cavity without pathology. The level of antibodies to echinococcus by ELISA-nondiagnostic titer. In 6-month dynamics, ultrasound showed an increase in the size of the cyst to 10 x 7 cm. The diagnosis of the cyst of the lower pole and posterior wall of the spleen was confirmed by MRI. After a standard preoperative examination, the patient was operated on with a laparoscopic approach. Resection of the cyst wall in the area of the lower pole was performed, the cyst walls were treated with 3% polidocanol using electrothermal action on the inner lining treated with polidocanol until a persistent and uniform change in the color of the epithelium to white, followed by omentopexy. The postoperative period was unremarkable. Discharged on the 3rd day. Control ultrasound after 1 and 2 years of cyst recurrence was not detected.

Patient M., 42 years old, was admitted to the ORPH with a diagnosis of liver cyst.

Clinically distressing pulling pain in the epigastrium and right hypochondrium. On ultrasound examination, a 6 x 5 cm fluid mass located on the inferior surface of the liver extending to the hepatic hilum and adjacent to the portal vein. On other organs of the abdominal cavity without pathology. The level of antibodies to echinococcus by ELISA-nondiagnostic titer. In 6-month dynamics, ultrasound showed an increase in the size of the cyst to 12 x 7 cm. The diagnosis of liver cyst was confirmed by MRI. After a standard preoperative examination, the patient was operated on with a laparoscopic approach. Resection of the cyst wall in the area of the lower pole was performed, the cyst walls were treated with 3% polidocanol using electrothermal action on the inner lining treated with polidocanol until a persistent and uniform change in the color of the epithelium to white, followed by omentopexy. The postoperative period was unremarkable. Discharged on the 5th day. Control ultrasound after 1 and 2 years of cyst recurrence was not detected.

Claims (1)

A method of treating liver and / or spleen cysts, including resection of the free section of the cyst wall by laparoscopic access, sanitation of the cyst cavity, intersection of adhesions, treatment of the cyst walls with 3% polidocanol solution, tamponade of the cyst cavity with a strand of the greater omentum, characterized in that the inner lining of the cyst treated with polidocanol , subjected to electrothermal action until a persistent and uniform change in the color of the epithelium to white.