RU2757251C1 - Method for endovideosurgical determination of intestinal viability intracted in inguinal hernia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to hernia surgery, and can be used in the surgical treatment of strangulated inguinal hernias. Trocars are placed. The restrained bowel loop is removed from the restraining ring into the abdominal cavity. The trocar is removed from the abdominal cavity and an intestinal laparoscopic clamp with a ratchet is passed through it. With the help of a laparoscopic clamp rack, the pulse oximeter is fixed in an open form and an entry into the abdominal cavity is performed with a trocar with a pulse oximeter fixed in it. A pulse oximeter is put on the strangulated bowel loop. The level of blood saturation of the strangulated organ with oxygen is determined, and when the blood is saturated with oxygen of 80% and above, the intestine is determined as viable.

EFFECT: method allows reducing the risk of removing a viable organ; reduce the risk of developing necrosis of the intestinal area that has been in a strangulated hernia in the early postoperative period and, as a result, reduce the risk of developing peritonitis in the postoperative period.

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Description

The invention relates to medicine, namely herniosurgery, and can be used for endovideosurgical treatment of strangulated inguinal hernias, where the strangulated organ is a part of the intestine.

Currently, when performing diagnostic laparoscopy, in case of infringement of the intestinal loop in the inguinal hernia, only visual methods are used to assess its viability, such as the condition of the hernial sac and the nature of the “hernial water”, changes in the color of the intestine, the reflective properties of its peritoneum, the pulsation of the marginal vessels, and intestinal peristaltic activity. [Akimov V.P. Guidelines for endovideosurgery / ed. V.P. Akimova / Akimov V.P. Levin L.A. Khurtsilava O.G. and others // SPb .: "Publishing house" Levsha. " St. Petersburg ", 2016. - 412 s: ill.].

As a prototype for the closest technical essence, we have chosen a method of diagnostic laparoscopy for strangulated inguinal hernias with infringement of the bowel loop in the hernial sac. [Levin, L.A. Endovideosurgical interventions for acute diseases and injuries of the abdomen: author. dis. ... Dr. med. sciences / L.A. Levin. - SPb., 2009. - 46 p.]. The method is carried out as follows - an incision of the skin and subcutaneous adipose tissue is performed to the aponeurosis, then either a carboxyperitoneum is created using a Verisha needle and laparocentesis is performed, or an entry into the abdominal cavity is performed using a Hassen minilaparotomy. Diagnostic laparoscopy is performed under combined endotracheal anesthesia. Determination of the viability of the intestine is carried out by visual assessment of the condition of the hernial sac and the nature of the “hernial water”, changes in the color of the intestine, the reflective properties of its peritoneum, the pulsation of the marginal vessels and peristaltic activity of the intestine. Resection of the restrained organ, when indicated, is possible both laparoscopically and in a video-assisted version.

Positive aspects: minimally invasive operative access will allow a person to return to their usual way of life in the shortest possible time, the use of narcotic analgesics is required in smaller quantities.

The disadvantages of the prototype include the lack of objectivity of data in assessing the viability of the intestine, which, with poor color rendering through the laparoscope, or due to insufficient experience of the operating surgeon, can lead to resection (removal) of a healthy organ, as well as to the performance of an unjustified laparotomy for a more adequate assessment of the viability of the intestine in help palpation of vascular pulsation in the zone of infringement. An inadequate assessment of the intestinal viability can lead to the abandonment of a non-viable organ in the abdominal cavity with its subsequent necrosis and the development of peritonitis.

The objective of the invention is:

• reducing the risk of removing a viable organ;

• reducing the risk of developing necrosis that has been in a strangulated hernia of the intestine in the early postoperative period and, as a consequence, reducing the risk of developing peritonitis in the postoperative period.

The technical result of the invention is an objective determination of the viability of the strangulated bowel loop.

The technical result of the invention is achieved by the fact that the method of endovideosurgical determination of the viability of the intestine strangulated in the inguinal hernia consists in performing laparocentesis, creating carboxyperitoneum and installing two additional trocars. The restrained bowel loop is removed from the restraining ring into the abdominal cavity using two intestinal laparoscopic clamps inserted into two additional trocars. After removing the restrained bowel loop from the restraining ring into the abdominal cavity, the carboxyperetoneum is removed, and the trocar is removed from the abdominal cavity in the umbilical region. Then, through the extracted trocar, outside the abdominal cavity, an intestinal laparoscopic clamp with a ratchet is carried out, its branches are bred and a portable pulse oximeter is fixed in them with a ratchet of a laparoscopic clamp, and a trocar is entered into the abdominal cavity, with a pulse oximeter fixed in it with the re-creation of carboxyperitoneum. After that, the laparoscope is brought into the next trocar and, under video control, a pulse oximeter is put on the restrained loop of the intestine by placing it with an intestinal laparoscopic clamp between the divorced branches of the pulse oximeter. Then the intestinal clamp is opened, and the level of saturation of the blood of the restrained organ with oxygen is determined. At saturation of blood with oxygen of 80% and above, the intestine is determined as viable.

The method is carried out as follows:

To perform the proposed method of endovideosurgical determination of the viability of the intestine strangulated in the inguinal hernia, diagnostic laparoscopy is used. In this case, after entering the abdominal cavity according to Hassen, creating a carboxyperitoneum, viewing the abdominal cavity, setting two additional trocars and removing the restrained bowel loop from the hernial sac, the carboxyperitoneum is eliminated. The trocar is removed from the abdominal cavity in the umbilical region. Then, through the extracted trocar outside the abdominal cavity, an intestinal laparoscopic clamp with a ratchet is carried out, its branches are bred and a sterile portable pulse oximeter is fixed in them in an open form using the ratchet of an intestinal laparoscopic clamp. After that, the entrance into the abdominal cavity according to Hassen is performed again with a trocar with a pulse oximeter fixed in it. Carboxyperitoneum is re-created, the laparoscope is inserted into an additional trocar and, under video control, the pulse oximeter is put on the strangulated bowel loop by placing it between the open branches of the pulse oximeter. Then the intestinal laparoscopic clamp is opened and the button of the pulse oximeter is pressed to determine the level of oxygen saturation of the blood of the strangulated organ. If the blood oxygen saturation is 80% or more, the intestine is always viable; if the oxygen saturation is less than 80%, the intestinal viability is doubtful and should be resected. Further surgical treatment is carried out depending on the intraoperative situation, with a non-viable intestine, its resection and hernia repair are performed in an open way, with a viable intestine, the surgical intervention can be completed both by laparoscopic hernioplasty and open with the use of mesh endoprostheses.

Essential distinguishing features of the invention and the cause-and-effect relationship between them and the achieved technical result:

• After removing the restrained bowel loop from the restraining ring into the abdominal cavity, the carboxyperetoneum is removed so that the next stage of the operation can be carried out without constant release of CO2 from the surgical wound.

• The trocar is removed from the abdominal cavity in the umbilical region, then through the extracted trocar, outside the abdominal cavity, an intestinal laparoscopic forceps with a ratchet are inserted, its branches are diluted and a portable pulse oximeter is fixed in them with a ratchet of a laparoscopic clamp in an open form and a trocar is entered into the abdominal cavity, with a fixed pulse oximeter.

This stage is necessary to complete the next stage - putting on the pulse oximeter on the strangulated bowel loop.

• Re-create carboxyperitoneum to create an abdominal vision.

• After that, the laparoscope is inserted into the next trocar and, under video control, a pulse oximeter is put on the strangulated bowel loop by placing it with an intestinal laparoscopic clamp between the divorced branches of the pulse oximeter

Pulse oximetry is a hardware research method that allows you to establish the level of blood oxygen saturation.

Pulse oximetry is carried out using two LEDs fixed on the inner surface of each of the pulse oximeter branches in contact with the surface of the human finger, these are red and infrared LEDs on one side and the same on the other;

The pulse oximeter works according to the following principle:

An experimental data processing formula is established using Lambert-Beer's Law for the spectral absorption characteristics of reductive hemoglobin (HbR) and oxyhemoglobin (HbO2) in red light and near infrared light. The photoelectric oxyhemoglobin monitoring technology is adapted according to the power of the pulse scanning and recording technology so that two beams of light of different wavelengths (60 nm for the red light beam and 940 nm for the near-infrared range) can be focused on the tip of a person's nail through a sensing sensor built into the a clip on the finger. The measured signal goes to the photosensitive element, the information from which is transmitted to two groups of LEDs by means of processes in the electrical circuit and the microprocessor.

The light source emits waves in the red and infrared spectrum, and the blood absorbs them depending on the number of oxygen molecules bound by hemoglobin. Bound hemoglobin captures infrared flux, and unoxygenated hemoglobin captures red. The non-absorbed light is registered by the detector, the apparatus calculates the saturation and displays the result on the monitor of the pulse oximeter fixed on the strangulated bowel loop.

Areas of use:

Pulse oximetry is performed when:

- respiratory failure, regardless of its causes;

- oxygen therapy;

- anesthetic aid during operations;

- surgical treatment in the postoperative period, especially in vascular surgery, orthopedics;

- deep hypoxia with pathology of internal organs, blood system, congenital anomalies of erythrocytes, etc.;

- probable sleep apnea syndrome (respiratory arrest), chronic nocturnal hypoxemia.

Thus, there is no information on the use of pulse oximetry to determine the viability of the strangulated intestine in an inguinal hernia, in hernia surgery.

• Then the intestinal clamp is opened and the level of blood saturation of the restrained organ with oxygen is determined, and if the blood oxygen saturation is 80% and above, the intestine is determined as viable.

In the course of a series of experiments on laboratory animals, the target level of blood oxygen saturation (80%) in the intestinal loop that had been in the infringement was established, confirmed by the pathological examination of irreversible changes in the intestinal loop that occur when oxygen saturation is less than 80% after the infringement has been resolved.

The set of essential distinctive features is new and ensures the achievement of the technical result and the accomplishment of the objective of the invention.

Here are examples from clinical practice:

Example 1. Patient B. 47 years old, hospitalized on an emergency basis in 1 x / o KB No. 122 named after. L.G. Sokolov 03/27/2019. Complaints upon admission to a hernial protrusion in the left groin area, pain in the area of it.

Anamnesis of the disease considers herself sick during the year, when she noted a hernial protrusion on the left in the groin area, over the last month she noted an increase in hernia, in the evening of 03/26/2019 after physical. load, the protrusion increased in size, stopped adjusting, and pain in its area arose.

Anamnesis of life. Postponed diseases of GB.1 tbsp. Postponed operations. Laparosocopic appendekiomy 2009

Epidemiological history. Viral hepatitis denies, tuberculosis denies. Malaria denies. Dysentery denies. Denies other infectious diseases. He denies contact with infectious patients; blood and its components were not transfused by blood transfusion. Intravenous, intramuscular injections - YES last year. Resident of St. Petersburg. FLG January 2019.

Allergic history. Allergic reactions: denies.

Insurance history. The patient is working. Disability group: does not.

Objective data. The condition is relatively satisfactory. The food is satisfactory. The physique is normosthenic. Height 170 cm.Weight 64 kg. The skin and visible mucous membranes are normal in color. Pathological rashes are not defined. Pulse 88 beats per minute, satisfactory characteristics. HELL 134 and 86 mm. hg .. Heart sounds are rhythmic, clear. Breathing is hard, it is carried out in all departments. NPV 14.

Digestive system: Tongue moist. The abdomen is soft and painless. Active peristalsis. Percussion sound is muffled. Liver along the edge of the costal arch. The spleen is not palpable. Kidneys were normal. Symptoms of peritoneal irritation: none. The presence of positive pathological symptoms is not. Pounding on the lumbar region is painless on both sides. The chair was unremarkable. Urination is painless. In the left groin area, a hernial protrusion of 10.0 × 8.0 cm is determined. Densely elastic consistency, painful on palpation. The skin above it is not changed. Cannot be reduced into the abdominal cavity. C-m cough push (-). Diagnosis An impaired left-sided inguinal hernia. Treatment plan: diagnostic laparoscopy, the further scope of the operation will be resolved intraoperatively.

In the first 2 hours of hospitalization, the patient was examined, preoperative preparation.

ECG TAKING AND DECODING Conclusion: Sinus rhythm. Deviation of the electrical axis to the left. Left atrial enlargement. Violation of intraventricular conduction. Left ventricular hypertrophy with signs of systolic overload.

LABORATORY RESEARCH

Biochemical studies: ALT E / L - 23, Total bilirubin - 11.8 μmol / L, Direct bilirubin - 2.0 μmol / L, Glucose - 6.5 mmol / L, Creatinine - 0.120 mmol / L, Urea - 5.2 mmol / L

Hematological studies: Hematocrit - 46.5%, Hemoglobin - 148 g / l, Granulocytes - 81.7%, Anisotropy index (RDW) - 13.8%, Leukocytes - 9.9 × 10 ⁹ / L, Lymphocytes - 14.6%, Monocytes - 3.7%, Average content hemoglobin in 1 erythrocyte - 28.9 pg, Average erythrocyte volume - 90.5 fl, Platelets - 263 × 10 ⁹ / L, Erythrocytes - 5.13 × 10 ¹² / L

Diagnosis of infectious diseases:

Antigen and antibodies to HIV (form 50) - not detected

Antibodies to HCV - not detected

ELISA for HBsAg - not detected

Microreaction to syphilis with cardiolipin antigen - Negative

Urine tests: pH - 5.0, Bacteria - no, Protein - [-], Bilirubin (urine) - [-], Glucose (urine) - [-], Yeast cells - no, Ketone bodies - [-], Leukocytes - 0 -1-2, Leukocytes (analyzer) - [-], Nitrite - [-], Relative density - 1.025, Mucus - no, Salt - no, Urobilinogen - [NORMAL], Cylinders - no objects in the field of view, Epithelium of objects in field of view - flat unit, erythrocytes - no objects in the field of view, erythrocytes (analyzer) - [-].

Coagulological studies: MHO INR - 1.06, Percentage of prothrombin according to Quick - 92.0%

Ultrasound of the abdomen - no effusion in the abdominal cavity. The liver is not enlarged, the echo structure is homogeneous. The lobar intrahepatic bile ducts are not dilated. The gallbladder is 88 × 45 × 34 mm in size, there is a small amount of fluid in the lumen. The walls of the bladder are not thickened. There are no shadows of calculi. The pancreas is not enlarged, the echo structure is normal, the diameter of the Wirsung duct is 2-3 mm. Spleen, kidneys within normal limits. In the area of interest: in the left groin area, a hernial sac is visualized with its contents, which is a loop of the intestine, a small amount of fluid is determined in the hernial sac. Conclusion - left-sided inguinal hernia.

After 1 hour 50 minutes from hospitalization, the operation was performed:

Laparocentesis was performed under endotracheal anesthesia, after three times treatment of the operating field. Created carboxyperitoneum up to 10 mm Hg, when reviewing: in the left groin area is determined by the restraining ring, which includes the loop of the sigmoid colon. In the small pelvis there are about 200.0 ml of serous effusion. Upon further review, the internal organs were without visible pathology. Installed 2 additional trocars. The strangulated bowel loop was removed with a soft laparoscopic intestinal forceps. Hernia water is dark in color. Hernial sac with minor fibrin deposits. A restrained bowel loop with multiple diapedesic hemorrhages, pale pink in color, the pulsation of the marginal vessels is not detected, peristaltic waves are single. Intestine viability is questionable. The carboxyperitoneum was eliminated, the trocar was removed from the umbilical region, an intestinal laparoscopic forceps with a ratchet was inserted through the trocar, its branches were diluted and a sterile portable pulse oximeter was fixed in them in an open form, after which the Hassen method was again entered into the abdominal cavity with the creation of a carboxyperitoneum, and a carboxyperitoneum was created. an additional trocar and under video control, the pulse oximeter was put on the restrained loop of the intestine by placing it between the open branches of the pulse oximeter, then the intestinal clamp was removed, the pulse oximeter button was pressed to determine the level of blood saturation of the restrained organ with oxygen. The oxygen saturation level was 81% - the intestine is viable. The laparoscopic stage has been completed. Taking into account the inflammatory changes in the hernial sac, it was decided to perform open plasty according to Liechtenstein, without opening the hernial sac. In the left inguinal region, the groin canal was opened in layers by a cut parallel to and above the inguinal ligament, 10.0 cm long. In the projection of the medial inguinal fossa, a hernial sac measuring 8.0X6.0X5.0 cm was found, it was not opened. Performed suturing of the transverse fascia with immersion of the hernial sac, due to its pronounced weakness. Plasty of the posterior wall of the inguinal canal with a non-absorbable prolene mesh according to Liechtenstein. The aponeurosis of the external oblique muscle of the abdomen is sutured. Hemostasis during the operation is dry. Tool and material counts are correct. Layer-by-layer suturing of the surgical wound. Alcohol. Aseptic dressing.

P / o diagnosis: Left-sided straight inguinal hernia. L2Psin.

The use of narcotic analgesics was not required. The early postoperative period was uneventful. In a satisfactory condition, the patient was discharged from the hospital on the 5th day after the operation under the supervision of a surgeon to the polyclinic at the place of residence.

An example based on the prototype method. Patient E. 33 years old, hospitalized on an emergency basis in 1 x / o KB No. 122 named. L.G. Sokolov 11/12/2019. Complaints upon admission to a hernial protrusion in the right groin area, pain in the area of it.

The anamnesis of the disease considers himself ill for 2 years, when he noted a hernial protrusion on the right in the groin region, over the last month he noted an increase in hernia, in the evening of 11/12/2019 after physical. load, the protrusion increased in size, stopped adjusting, and pain in its area arose.

Anamnesis of life. Transferred operations. Elimination of inguinal hernia on the left 2011

Epidemiological history. Viral hepatitis denies, tuberculosis denies. Malaria denies. Dysentery denies. Denies other infectious diseases. He denies contact with infectious patients; blood and its components were not transfused by blood transfusion. Intravenous, intramuscular injections - denies. Resident of St. Petersburg. FLG June 2019.

Allergic history. Allergic reactions: denies.

Insurance history. The patient is working. Disability group: does not.

Objective data. The condition is relatively satisfactory. The food is satisfactory. The physique is normosthenic. Height 182 cm.Weight 93 kg. Skin and visible mucous membranes of normal color. Pathological rashes are not defined. Pulse 98 beats per minute, satisfactory characteristics. HELL 134 and 86 mm. hg .. Heart sounds are rhythmic, clear. Breathing is hard, it is carried out in all departments. NPV 16.

Digestive system: Tongue moist. The abdomen is soft and painless. Active peristalsis. Percussion sound is muffled. Liver along the edge of the costal arch. The spleen is not palpable. Kidneys were normal. Symptoms of peritoneal irritation: none. The presence of positive pathological symptoms is not. Pounding on the lumbar region is painless on both sides. The chair was unremarkable. Urination is painless. In the right groin area, a 13.0 × 7.0 cm hernial protrusion is determined, descending into the scrotum. Densely elastic, painful on palpation. The skin above it is not changed. Cannot be reduced into the abdominal cavity. C-m cough push (-). Diagnosis Strangulated right-sided inguinal hernia.

Treatment plan: diagnostic laparoscopy, the further scope of the operation will be resolved intraoperatively.

In the first 2 hours of hospitalization, the patient was examined, preoperative preparation.

ECG TAKING AND DECODING Conclusion: Sinus rhythm. Left ventricular hypertrophy with signs of systolic overload.

LABORATORY RESEARCH

Biochemical studies: ALT E / L - 20, Total bilirubin - 13.9 μmol / L, Direct bilirubin - 1.9 μmol / L, Glucose - 6.9 mmol / L, Creatinine - 0.100 mmol / L, Urea - 4.1 mmol / L

Hematological studies: Hematocrit - 45.4%, Hemoglobin - 128 g / l, Granulocytes - 80.7%, Anisotropy index (RDW) - 12.8%, Leukocytes - 11.9 × 109 / L, Lymphocytes - 13.6%, Monocytes - 2.7%, Average hemoglobin content in 1 erythrocyte - 27.6 pg, Average erythrocyte volume - 89.5 fl, Platelets - 345 × 109 / L, Erythrocytes - 4.23 × 1012 / L

Diagnosis of infectious diseases:

Antigen and antibodies to HIV (form 50) - not detected

Antibodies to HCV - not detected

ELISA for HBsAg - not detected

Microreaction to syphilis with cardiolipin antigen Negative

Urine tests: pH - 5.1, Bacteria - no, Protein - [-], Bilirubin (urine) - [-], Glucose (urine) - [-], Yeast cells - no, Ketone bodies - [-], Leukocytes - 0 -1-2, Leukocytes (analyzer) - [-], Nitrite - [-], Relative density - 1.025, Mucus - no, Salt - no, Urobilinogen - [NORMAL], Cylinders - no objects in the field of view, Epithelium of objects in field of view - flat unit, erythrocytes - no objects in the field of view, erythrocytes (analyzer) - [-].

Coagulological studies: MHO INR - 1.11, Percentage of prothrombin according to Quick - 89.0%

Ultrasound of the abdomen - no effusion in the abdominal cavity. The liver is not enlarged, the echo structure is homogeneous. The lobar intrahepatic bile ducts are not dilated. The gallbladder measures 58 × 35 × 32 mm, there is a small amount of fluid in the lumen. The walls of the bladder are not thickened. There are no shadows of calculi. The pancreas is not enlarged, the echo structure is normal, the diameter of the Wirsung duct is 2-3 mm. Spleen, kidneys within normal limits. In the area of interest: in the left groin area, a hernial sac is visualized with its contents, which is a loop of the intestine, a small amount of fluid is determined in the hernial sac.

Conclusion - right-sided inguinal hernia.

After 1 hour 55 minutes from hospitalization, the operation was performed:

Under endotracheal anesthesia, after three times treatment of the operating field, laparocentesis was performed. Created carboxyperitoneum. When reviewing: in the right groin area, a restraining ring is determined, into which the loop of the small intestine enters. In the small pelvis there are about 500.0 ml of serous effusion. Upon further review, the internal organs were without visible pathology. Installed 2 additional trocars. The strangulated bowel loop was removed with a soft laparoscopic intestinal forceps. Hernia water is dark in color. Hernial sac with minor fibrin deposits. A restrained bowel loop with multiple diapedesic hemorrhages, pale pink in color, the pulsation of the marginal vessels is not detected, peristaltic waves are single. Intestine viability is questionable. To determine the viability of the intestine and the final volume of the surgical intervention, a lower midline laparotomy was performed - the loop of the small intestine was brought into the wound, palpation of the pulsation of the vessels is determined throughout, with the introduction of novocaine into the mesentery of the intestine, its pronounced peristalsis is noted - the intestine is viable. Performed layer-by-layer suturing of the laparotomy wound. In the right groin area, an incision parallel to and above the inguinal ligament, 10.0 cm long, opened the inguinal canal layer by layer. The spermatic cord was taken on a holder. From the elements of the spermatic cord, a hernial sac with dimensions of 10.0X8.0X3.0 cm was isolated. The hernial sac was isolated, tied, crossed, immersed according to Barker. The spermatic cord was restored with a continuous suture. Plasty of the posterior wall of the inguinal canal with a non-absorbable prolene mesh according to Liechtenstein. The aponeurosis of the external oblique muscle of the abdomen is sutured. Hemostasis during the operation is dry. Tool and material counts are correct. Layer-by-layer suturing of the surgical wound. Alcohol. Aseptic dressing.

P / o diagnosis: Strangulated oblique right-sided inguinal hernia. M2Psin

In the early p / o period on the 3rd day after the operation, the patient showed a deterioration in his general condition, there were complaints of pain in the lower right abdomen. On examination: Condition of moderate severity. Pulse 108 beats per minute, satisfactory characteristics. HELL 114 and 76 mm. hg .. Heart sounds are rhythmic, clear. Breathing is hard, it is carried out in all departments. NPV16.

Digestive system: Tongue dry, coated with white bloom. The abdomen is distended, tense and painful in the right iliac, paraumbilical, right mesogastric region, there are also positive symptoms of peritoneal irritation. Peristalsis is sluggish. Percussion sound is muffled. Liver along the edge of the costal arch. The spleen is not palpable. Kidneys were normal. Pounding on the lumbar region is painless on both sides. The chair was unremarkable. Urination is painless.

Diagnosis Small Intestine Perforation? Peritonitis.

Treatment plan: diagnostic laparoscopy, the further scope of the operation will be resolved intraoperatively.

Control LABORATORY STUDIES

Hematological studies: Hematocrit - 44.3%, Hemoglobin - 118 g / l, Granulocytes - 81.7%, Anisotropy index (RDW) - 14.8%, Leukocytes - 18.9 x 109 / L, Lymphocytes - 13.6%, Monocytes - 2.7%, Average hemoglobin content in 1 erythrocyte - 27.6 pg, Average erythrocyte volume - 89.5 fl, Platelets - 345 × 109 / L, Erythrocytes - 4.23 × 1012 / L

Ultrasound of the abdomen - effusion in all parts of the abdominal cavity. The liver is not enlarged, the echo structure is homogeneous. The lobar intrahepatic bile ducts are not dilated. The gallbladder measures 58 × 35 × 32 mm, there is a small amount of fluid in the lumen. The walls of the bladder are not thickened. There are no shadows of calculi. The pancreas is not enlarged, the echo structure is normal, the diameter of the Wirsung duct is 2-3 mm. Spleen, kidneys within normal limits.

Laparocentesis was performed under endotracheal anesthesia, after three times treatment of the operating field. Created carboxyperitoneum. On review: in the abdominal cavity about 1000.0 ml of dark purulent effusion, loops of the small intestine with multiple deposits of fibrin, edematous, with multiple diapedetic hemorrhages. Installed 2 additional trocars. In the area of the intestine that was in the hernial sac, a loose infiltrate is determined, during the division of which a perforation of the small intestine with dimensions of 1.5 × 1.0 cm is revealed, with small intestinal discharge coming from it. Taking into account the diffuse purulent peritonitis, a total midline laparotomy was performed - the loop of the small intestine was brought into the wound, the small intestine was resected to healthy tissues not involved in the infiltrate with the imposition of a small intestinal anastomosis with a stapler - a three-row stapling cassette - 65 mm. Sanitation of the abdominal cavity with 10.0 liters of saline. The abdominal cavity is drained with 4 PVC drains. Performed layer-by-layer suturing of the laparotomy wound. Aseptic dressing.

For the next 2 days, the patient was in the intensive care unit. The further postoperative period proceeded with the prevalence of pain syndrome. Required the use of narcotic analgesics, as well as intravenous administration, a / b drugs.

In a satisfactory condition, he was discharged from the hospital on the 16th day after the operation under the supervision of a surgeon in the polyclinic at the place of residence.

Using the proposed method, we operated on 17 patients with good early postoperative and long-term results. There were no relapses during the observation period and no complications.

According to the prototype, more than 100 people are operated on in our hospital every year, just like in all surgical hospitals of the city. From the given example, according to the prototype, it can be seen that, despite the performed laparotomy to determine the viability of the intestine, during the first operation, it was not possible to finally correctly identify the necrotic organ, which is associated with changes in the intestinal wall, which may appear in the form of perforation after 1-5 days after the operation, which was described at the end of the 20th century. And when using a pulse oximeter, these risks are excluded.

Thus, the claimed method for endovideosurgical determination of the viability of the intestine strangulated in the inguinal hernia is new and allows, in comparison with the prototype, in a minimally invasive way to objectively assess the viability of the intestine, reduce the risk of removal of a viable organ and reduce the risk of developing necrosis that has been in the strangulated hernia of the intestinal area in the early postoperative period and, as a result, reduce the risk of developing peritonitis in the postoperative period.

Claims (1)

A method for endovideosurgical determination of the viability of the intestine strangulated in an inguinal hernia, including laparocentesis, creation of carboxyperitoneum, installation of two additional trocars, removal of the strangulated bowel loop from the restraining ring into the abdominal cavity using two intestinal laparoscopic clamps inserted into two additional trocars after removing the restrained bowel loop from the restraining ring into the abdominal cavity eliminates carboxyperetoneum, removes the trocar from the abdominal cavity in the peri-umbilical region, then through the extracted trocar, outside the abdominal cavity, an intestinal laparoscopic clamp with a ratchet is carried out, its branches are bred and a portable laparoscope clamp is fixed in them with a laparoscopic clamp open pulse oximeter and enter the abdominal cavity with a trocar with a fixed pulse oximeter in it with repeated creation of carboxyperitoneum, after which the laparoscope is inserted into the next trocar and under video control for The pulse oximeter is placed on the restrained loop of the intestine by placing it with an intestinal laparoscopic clamp between the diluted branches of the pulse oximeter, then the intestinal clamp is opened and the level of blood saturation of the restrained organ with oxygen is determined, and when the blood is saturated with oxygen of 80% and higher, the intestine is determined as viable.