RU2768591C1 - Method of laparoscopic spleen resection - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method of laparoscopic spleen resection refers to medicine, namely to abdominal surgery. Patient is placed on the operating table on his/her back in the Fowler position. Under aseptic conditions under combined intubation anaesthesia in a supraumbilical region, a skin incision of 1 cm is performed, laparolifting is performed by means of clamps, and laparocentesis is performed with a Veress needle. 10 mm camera trocar is introduced with a viewing angle of 30 degrees; the instrument trocars are introduced under the control of an optics in the proposed topographic-anatomical area of the operation. Thunderbeat apparatus is used to open an omental bursa, and a gastro-splenic or colonic-splenic ligament is transected depending on the localization of the pathological focus and the required resection border. Spleen is mobilized; a splenic artery is separated at distance of 4 cm in the proximal direction from the splenic hilum to the point of branching into segmental arteries from the surrounding tissues; a soft vascular DeBakey clamp is applied on the artery with a laparoscopic clamp. Using the Thunderbeat apparatus, a pathological neoplasm is resected along the border of a healthy tissue, haemostasis of the resection line is performed by bipolar coagulation, haemostatic plates Tachocomb and haemostatic system PerClot are applied to the resection site, resected area is placed in a plastic container, removed from the abdominal cavity through a minilaparotomic incision in the left iliac region.

EFFECT: method enables performing a surgical intervention on a "dry" surgical site, which provides adequate haemostasis and visibility of clear boundaries of the resection of the organ; perform an economical resection of the organ, thereby maximally preserving the immunological and hematopoietic functions of the spleen; allows performing surgical intervention on various topographic and anatomical areas of spleen due to convenient viewing angle; also minimally invasive approach allows reducing pain syndrome and accelerating postoperative rehabilitation, which reduces time of patient’s stay in hospital.

1 cl, 1 ex

Description

The method of laparoscopic resection of the spleen refers to the field of medicine, in particular to abdominal surgery, and can be used for surgical organ-sparing treatment of benign diseases of the spleen.

The prior art method of resection of the spleen (Patent RU 2090145 C1 published 20.09.1997 IPC A61V 17/00), which consists in performing laparotomic access to the spleen, introducing into the removed tissue of the spleen 0.1% solution of adrenaline in a volume of 1 ml to performing resection, wrapping the organ along the resection line with hemostatic gauze and suturing the spleen through the gauze with a machine suture, then performing resection and fixing the hemostatic gauze to the wound surface of the organ with bioglue.

The disadvantages of this method are: traumatic laparotomy access, the possibility of cutting through the tissues of the body with a mechanical suture, the lack of reliable compression of the underlying tissues, which does not always provide reliable hemostasis, the presence of a foreign body after resection in the form of hemostatic gauze, staples from a machine suture, which leads to a more pronounced inflammatory reactions and increased risk of developing adhesive disease of the abdominal organs.

Closest to the present invention is a method of resection of the spleen (Patent RU 2145802C1 published 27.02.2000 IPC A61 B17/00), which consists in performing laparotomic access to the spleen, ligation of the vascular pedicle, isolation and ligation of short gastric vessels in the gastro-splenic ligament, performing subtotal longitudinal resection of the spleen with preservation of the organ tissue along the splenic-diaphragmatic ligament, hemostasis by targeted diathermocoagulation, treatment of the cut plane with local hemostatic agents and peritonization of the spleen stump by suturing the folds of the parietal peritoneum.

The disadvantages of this method are: traumatic laparotomy access, increasing pain, increasing the patient's rehabilitation time and the number of complications; subtotal volume of spleen resection, which reduces the hematopoietic and immunological functions of the organ; the method is not universal, since it does not allow performing organ resection at different localization of the pathological focus; irreversibility of occlusion of the main blood flow due to ligation of the splenic artery, which calls into question the adequacy of the blood supply to the distal part of the organ.

The problem of treatment of focal formations in the spleen is relevant, since, regardless of size and location, the presence of education is an indication for surgical treatment. In case of a benign disease of the spleen, organ-preserving operations are indicated, which are aimed at preserving the parenchyma of the organ.

The technical result of the proposed method of laparoscopic resection of the spleen is to reduce blood loss during laparoscopic resection of the spleen using temporary occlusion of the splenic artery and work on a "dry organ", reducing the trauma of surgical access and maintaining the function of the organ due to the possibility of economical resection.

The technical result is achieved due to the fact that the method of laparoscopic resection of the spleen includes laparoscopy, occlusion of the splenic artery and resection of the spleen. In this case, temporary occlusion of the splenic artery is used by applying a soft vascular clamp when performing laparoscopic resection of the spleen.

The proposed method of laparoscopic resection of the spleen is performed as follows. The patient is placed on the operating table on his back in the Fowler position. Under aseptic conditions, under combined intubation anesthesia in the supraumbilical region, a skin incision of 1 cm is made, laparolifting is performed with claws, laparocentesis is performed with a Veress needle, which is confirmed by a drop test, syringe test, hardware test, carboperitoneum is created, a laparoscope connected to the camera is inserted. An audit of the abdominal organs is performed and the localization of the pathological process is specified. Under the control of optics, trocars for instruments are inserted in the proposed topographic and anatomical area of the operation. Using the Thunderbeat apparatus, the omental sac is opened, the gastrosplenic, colonic-splenic, renal-splenic or diaphragmatic-colic ligaments are transected, depending on the location of the pathological focus and the required resection margin, and the spleen is mobilized. The splenic artery is isolated from the surrounding tissues at a distance of about 4 cm proximal to the hilum of the spleen to the point of branching into segmental arteries. A soft DeBakey vascular clamp is applied to the artery with a laparoscopic clamp for temporary occlusion. Thus, minimal blood loss and good visualization are achieved by working on a “dry” surgical field. Using the Thunderbeat apparatus, a pathological neoplasm is resected along the border of healthy tissue. Hemostasis of the resection line is performed by bipolar coagulation. The DeBakey vascular clamp is removed and removed from the abdominal cavity. Tachocomb hemostatic plates are applied to the resection site, PerClot hemostatic system is applied. Visual control of hemostasis is performed. The resected area is placed in a plastic container, removed from the abdominal cavity through a minilaparotomic incision in the left iliac region. Perform desufflation. Instruments, trocars are removed from the abdominal cavity. Trocar wounds are sutured using the EndoClose system. The integrity of the anterior abdominal wall is restored in layers.

The effectiveness of the proposed method of laparoscopic resection of the spleen is confirmed by a clinical example.

Patient Zh. was admitted to the clinic with a diagnosed spleen cyst. During a planned ultrasound of the abdominal organs in January 2019, a spleen cyst (~5.0 cm) was diagnosed. Dynamic observation is recommended. In dynamics, the formation is preserved, increases in size. Performed SCT - a picture of a cyst of the spleen. The spleen is enlarged due to the formation of an ovoid shape with clear, even contours. The dimensions of the formation are 87*81*70, the structure is homogeneous, without signs of contrast accumulation.

The operation was performed: laparoscopy, resection of the spleen with temporary occlusion of the arterial bed.

At survey laparoscopy: no effusion. The peritoneum is smooth, shiny. Subdiaphragmatic space, liver, loops of the small intestine and large intestine without visible changes. The spleen is of normal size and color, from the upper pole comes a rounded formation with a diameter of up to 70 mm, a dense structure, a white capsule with a bumpy surface. The stomach is of normal size and color, in the region of greater curvature, a rounded formation is determined on a wide base with a diameter of 5 mm, white in color, and of a dense consistency. Using the Thunderbeat apparatus, the gastrosplenic and colonosplenic ligaments were transected, and the spleen was mobilized. The splenic artery was isolated at a distance of 4 cm proximal to the gate to the point of branching into segmental arteries. A soft DeBakey vascular clamp was applied to the artery for temporary occlusion. Using the Thunderbeat device, resection of the upper pole of the spleen with cystic formation along the border of healthy tissue was performed. Hemostasis by bipolar coagulation. The bed of the removed cyst was additionally strengthened with 2 Tachocomb plates, PerClot hemostatic system. The DeBakey vascular clamp was removed and removed from the abdominal cavity. The warm ischemia time was 20 minutes. Hemostasis control - dry. With the help of scissors in the cold mode, excision of the neoplasm of the stomach to the submucosal layer was performed. A muscular-serous interrupted suture was applied with Poly sorb 3-0 thread. Hemostasis control - dry. The removed preparations were placed in a plastic container, removed from the abdominal cavity through an incision in the left iliac region, and sent for histological examination. The abdominal cavity was drained through the left counter-opening. Instruments, trocars were removed from the abdominal cavity. Desufflation. Trocar wounds were sutured with the EndoClose system. The integrity of the anterior abdominal wall was restored in layers. Intradermal sutures were placed on the skin. Aseptic stickers.

The course of the postoperative period is smooth. Conducted infusion, antibacterial, symptomatic therapy. The patient was discharged in a satisfactory condition on the second day after the operation. Subfebrile temperature (37.1°C) was noted up to two days after the operation.

Thus, the method of laparoscopic resection of the spleen with temporary occlusion of the splenic artery allows: to minimize blood loss during the operation; perform surgery on a “dry” surgical field, which ensures adequate hemostasis and visibility of clear boundaries of organ resection; perform an economical resection of the organ, thereby preserving the immunological and hematopoietic functions of the spleen as much as possible; The implementation of laparoscopic access allows for surgical intervention in various topographic and anatomical areas of the spleen due to a convenient viewing angle; also, minimally invasive access allows reducing pain syndrome and speeding up rehabilitation after surgery, which reduces the patient's stay in the hospital.

Claims (1)

The method of laparoscopic resection of the spleen, which consists in the fact that the patient is laid on the operating table on his back in the Fowler position, under aseptic conditions, under combined intubation anesthesia in the supraumbilical region, a skin incision of 1 cm is made, laparolifting with claws, laparocentesis is performed with a Veress needle, a trocar for camera 10 is inserted mm, with a viewing angle of 30 degrees, under the control of optics, trocars for instruments are inserted in the proposed topographic and anatomical zone of the operation, using the Thunderbeat apparatus, the omental sac is opened, the gastrosplenic or colonosplenic ligament is transected, depending on the location of the pathological focus and the required resection margin , the spleen is mobilized, the splenic artery is isolated at a distance of 4 cm proximal to the hilum of the spleen to the point of branching into segmental arteries from the surrounding tissues, a DeBakey soft vascular clamp is applied to the artery with a laparoscopic clamp, using the Thunderbea apparatus t resection of a pathological neoplasm is performed along the border of healthy tissue, hemostasis of the resection line is performed by bipolar coagulation, hemostatic plates Tachocomb and hemostatic system PerClot are applied to the resection site, the resected area is placed in a plastic container, removed from the abdominal cavity through a minilaparotomic incision in the left iliac region.