RU2793514C1 - Method for performing single-port cholecystectomy through single laparoscopic access using standard laparoscopic instrumentation - Google Patents

Abstract

FIELD: medicine; abdominal surgery.

SUBSTANCE: through the transumbilical access, a 10 mm trocar is installed for the introduction of optics, 1 cm to the left of it, a 5 mm trocar is installed for working instruments. To the right of the trocar for optics, a 5 mm trocar for the coagulation hook is installed at a distance of 1 cm. For traction of the gallbladder, it is stitched through the anterior abdominal wall, visualizing the Kalo triangle. The coagulation hook performs the mobilization of the elements of the hepatoduodenal ligament. After isolation of the cystic artery and cystic duct, the right 5 mm trocar is replaced with a 10 mm trocar for insertion of the clipper. Scissors for crossing the cystic duct are also inserted through the right trocar, the gallbladder is removed from the abdominal cavity through the combined access between the right and central trocar, while the size of the access does not exceed the diameter of the gallbladder. The postoperative aponeurosis defect is sutured with interrupted sutures; the skin is sutured with a cosmetic intradermal suture.

EFFECT: method makes it possible to perform the operation with standard laparoscopic instruments, which reduces the invasiveness of the operation, does not require complex expensive instruments, improves the cosmetic effect, and reduces pain in the postoperative period.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used when performing cholecystectomy through a single laparoscopic access. May find application in the treatment of cholecystitis and gallbladder polyposis.

A known method of performing cholecystectomy through a single laparoscopic access (RU2530763, published: 10/10/2014), including the implementation of umbilical access, the introduction of a device for a single laparoscopic access, the imposition of carboxyperitoneum, performing cholecystectomy, with fixation of the bottom of the gallbladder, for which a through puncture of the abdominal wall is performed, a device is introduced into the abdominal cavity, containing a hollow needle pointed at the end, inside which a metal thread is placed, the device captures the wall of the gallbladder in the bottom area and traction, characterized in that a video laparoscope is inserted through the device for a single laparoscopic access, a through puncture of the anterior the abdominal wall in the right hypochondrium and a device is inserted containing a hollow needle pointed at the end, through which an electrosurgical metal loop for polypectomy is inserted, which is pulled out of the needle under visual control through a video laparoscope, an endoscopic clamp is inserted through a single laparoscopic access, which is passed through the lumen of the extended loop, the wall of the gallbladder in the area of its bottom is captured with a clamp and the wall is pulled into the loop, which is tightened, fixing the bottom of the gallbladder, the endoscopic clamp is removed, the traction of the bottom of the gallbladder to the diaphragm is performed with a loop, manipulating a hollow needle, an endoscopic clamp is inserted, the neck of the gallbladder is grasped and carried out its traction in the lateral direction, the duct and artery of the gallbladder are visualized, which are separately clipped and crossed, the gallbladder is separated from the bed using an electrosurgical hook, alternately changing the direction of traction of the neck and bottom of the bladder medially and laterally, after separation of the gallbladder from the bed, a metal loop is removed from its bottom and remove the needle with a loop from the abdominal cavity, electrocoagulate the bed, remove the gallbladder through the device for a single laparoscopic access, the umbilical access wound is sutured in layers.

This analogue describes a method for performing laparoscopic cholecystectomy using a special device for a single laparoscopic access - single-port, special tools to work through it.

A known method for performing a single transumbilical laparoscopic access (RU2465836, published: 11/10/2012), which consists in the fact that a single incision of the anterior abdominal wall is performed in the umbilical region, in which devices for the introduction of surgical instruments and optics are placed, characterized in that the skin incision between the inner and outer parts of the navel are O-shaped with a wedge-shaped excision of the skin scar to the umbilical ring, then the resulting skin flaps are separated in the region of the incision line from the underlying layers, after that, a trocar for the endoscope is inserted into the umbilical ring, and the edges of the skin wound are gradually maximally diluted into mutually opposite directions with two force vectors directed to the planned access points for working instruments, so that between the two access points, which are projected in the left and right rectus abdominis muscles, and the access point for the endoscope, a conditional triangle would be formed, the base facing the zone maximum operational impact, and the access point for the endoscope would serve as the apex, after the completion of the main stage of the operation and the removal of laparoscopic instruments, the edges of the O-shaped umbilical skin defect are evenly sutured with an absorbable thread to the edges of the sutured umbilical ring.

In this technique, an O-shaped skin incision is made between the inner and outer parts of the navel with a wedge-shaped excision of the skin scar up to the umbilical ring; in our technique, a transumbilical incision is performed - a vertical incision through the umbilical ring.

The technical problem of this method is a large surgical trauma, therefore, a pronounced pain syndrome in the postoperative period and traces of clearly visible scars.

A known method of laparolifting with a single laparoscopic access (RU2553192, published: 06/10/2015), including laying the patient with his back on the operating table, conducting anesthesia, making an incision on the patient's abdomen, inserting a trocar into the incision, screwing into the abdominal cavity a retractor made of an elastically deformable material in in the form of a rod bent in perpendicular planes, having a straight vertical arm with a bend at the end for fixation and a horizontal arm twisted in a spiral, traction of the abdominal wall with the help of a retractor and creation of an operating space in the abdominal cavity for subsequent instrument manipulations, fixation of the retractor in the lifting fixing device, characterized in that the incision is made in the abdominal wall in the area of the umbilical ring 2-2.5 cm long, and a thin-walled silicone cylinder with an expanded, thickened and rounded lower part is used as a trocar, which is squeezed with a standard clamp and brought into the incision of the umbilical rings, and through the upper part of the silicone cylinder, made in the form of a truncated cone, the larger base of which is directed upwards and bent inward at an angle of 90°, a retractor is screwed into the abdominal cavity, while the silicone cylinder remains in the operating wound until the end of the operation.

The method presented in the analogue is used to perform a minimally invasive operation without the introduction of an inert gas, more often in gynecology, it consists in the mechanical lifting of the anterior abdominal wall with an instrument inserted into the abdominal cavity through the umbilical ring. This method also uses a device for a single laparoscopic access.

Not applicable for single-port laparoscopic cholecystectomy using standard laparoscopic instruments.

The closest analogue is the method of cholecystectomy through a single laparoscopic access for acute cholecystitis (RU2546955, published: 2015.04.10), including the implementation of an umbilical access, the introduction of a device for a single laparoscopic access, the imposition of carboxyperitoneum, the performance of cholecystectomy with fixation of the bottom of the gallbladder, the performance of a through puncture of the abdominal walls in the right hypochondrium, insertion into the abdominal cavity of a hollow needle pointed at the end and puncture of the gallbladder wall under the control of a video laparoscope, characterized in that the contents of the gallbladder are aspirated through a hollow needle, the end of the needle is removed from the gallbladder, the form of inflammation of its wall is visually assessed for selection diameter of the string, a metal string with a diameter of 0.1-0.3 mm folded in half is inserted into the needle, the metal string is advanced in the form of a loop into the abdominal cavity, it is placed in the region of the lateral surface of the gallbladder neck wall, an endoscopic clamp is inserted through the device for a single laparoscopic access , pass it through the lumen of the advanced loop, grab the wall of the gallbladder neck with it and pull it into the lumen of the loop, tighten the loop, fix the ends of the string outside the abdominal cavity by capturing it with a surgical clamp along the outer edge of the needle, remove the endoscopic clamp from the wall of the gallbladder neck and move it to towards the bottom of the gallbladder, grasp the bottom of the gallbladder with it, blocking the puncture site, and carry out traction of the bottom with an endoscopic clamp in the direction of the diaphragm, perform traction of the neck of the gallbladder with a loop caudally and laterally, manipulating the needle, which provides visualization of the Calot triangle, with an electrosurgical hook inserted through the device for a single laparoscopic access, the duct and artery of the gallbladder are isolated, which are separately clipped and crossed, the gallbladder is separated from the bed using an electrosurgical hook, alternately changing the direction of traction of the neck medially and laterally, after separation of the gallbladder from the bed, a loop is removed from the wall of the neck of the gallbladder , the string is removed from the abdominal cavity, the bed is electrocoagulated, the gallbladder is removed through the device for a single laparoscopic access, the umbilical access wound is sutured in layers.

This method is carried out using a special device for a single laparoscopic access-single-port, special tools for working through it. This makes the process of performing a surgical operation dependent on the availability of these instruments.

In addition, all known solutions are characterized by technical difficulties that are observed in patients with overweight, hepatomegaly, hypertrophy of the third segment of the liver, severe adhesions, inflammatory changes in the neck of the gallbladder. In such cases, the use of several trocars is required, which increases the invasiveness of the operation.

The objective of the invention is to eliminate the above technical problems specific to known methods.

The technical result of the invention is the possibility of performing the operation with standard laparoscopic instruments, which makes it possible to reduce the trauma of patients after laparoscopic cholecystectomy without sacrificing the quality of this treatment. In addition, there is no dependence of the possibility of performing this surgical operation on the availability of complex expensive instruments.

This technical result is achieved due to the fact that the claimed method of performing a single-port cholecystectomy through a single laparoscopic access for acute cholecystitis, including the implementation of an umbilical access, the introduction of a device for a single laparoscopic access, including the installation of a trocar through a transumbilical access for introducing optics, characterized in that through a transumbilical access, a standard 10 mm trocar is installed for the introduction of optics, a standard 5 mm trocar is installed 1 cm to the left of it in another plane, for working instruments, to the right of the trocar for optics, a 5 mm trocar is installed at a distance of 1 cm for a coagulation hook; placing the assistant on the right hand of the surgeon, hold the camera with the left hand, helping to avoid conflict between the trocars and instruments with the right, insert the instruments into the trocars; for optimal traction of the gallbladder, it is stitched through the anterior abdominal wall in order to visualize the Calot triangle at an acceptable level; the elements of the hepatoduodenal ligament are mobilized with a coagulation hook, after the cystic artery and cystic duct are isolated, the right 5 mm trocar will be replaced with a standard 10 mm trocar for the introduction of the clipper; scissors for crossing the cystic duct are also inserted through the right trocar, the gallbladder is removed from the abdominal cavity through the joint access between the right and central trocar, keeping the size of the access not exceeding the diameter of the gallbladder; the postoperative defect of the aponeurosis is sutured with interrupted sutures; the skin is sutured with a cosmetic intradermal suture.

If it is necessary to ligate the cystic duct through the right 5 mm trocar, a 90 cm ligature is inserted, using a dissector, the knot is formed extracorporeally, lowered and tightened with a pusher.

Brief description of the drawings

Figure 1 shows the scheme of setting trocars.

Figure 2 shows a diagram of the introduction of tools.

Figure 3 shows the scheme of setting trocars after changing the right trocar.

Figure 4 shows the stage of mobilization of the elements of the hepatoduodenal ligament.

Figure 5 shows clipping of the cystic duct and artery.

Figure 6 shows the intersection of the cystic duct and artery.

Figure 7 shows the implementation of access to remove the gallbladder (the gallbladder is removed from the abdominal cavity through the joint access between the right and central trocar).

Figure 8 shows the removal of the gallbladder.

9 shows a practical example of placing trocars on a patient.

Figure 10 shows the stage of mobilization of the elements of the hepatoduodenal ligament using a coagulation hook.

In Fig.11 selected cystic artery and duct using a coagulation hook.

Figure 12 shows the stage of inserting a clipper to clip the cystic artery and cystic duct.

Figure 13 shows the step of crossing the cystic duct with scissors.

Figure 14 shows how the gallbladder is removed from the abdominal cavity through the joint access between the right and central trocar.

Figure 15 shows a section of the aponeurosis and skin.

On Fig shows a view of the sutured wound immediately after surgery.

Figure 17 shows the appearance of the scar 14 days after the operation.

On the drawings: 1 - transumbilical access, 2 - standard trocar 10 mm, 3, 4 - standard trocar 5 mm right and left, respectively, 5 - optics, 6 - coagulation hook, 7 - laparoscopic clamp (working tool), 8 - bile bladder, 9-cystic artery, 10-cystic duct, 11 - clip, 12 - laparoscopic scissors, 13 - line of intersection, 14 - incision line, 15 - clipper.

Implementation of the invention

Single-port cholecystectomy (SCE) is the least traumatic, accompanied by a less pronounced pain syndrome, which reduces the rehabilitation time, is more cost-effective, and has the maximum cosmetic effect.

The present invention has developed a safe technical algorithm for performing the operation with standard laparoscopic instruments, which makes it possible to reduce the cost of treating patients after laparoscopic cholecystectomy without sacrificing the quality of this treatment.

It was possible to choose the criteria for selecting patients for performing CCE with standard instruments: BMI less than 35 kg/m2, CVR less than 150 according to ultrasound, no inflammation in the gallbladder neck according to ultrasound. In patients operated on using a single port, the pain syndrome is lower than in patients after traditional LCE.

The operation technique for acute cholecystitis is as follows.

Through the transumbilical access, a standard 10 mm trocar is installed for the introduction of optics, 1 cm to the left of it, in another plane, a standard 5 mm trocar is installed for working instruments (soft laparoscopic clamp). To the right of the trocar for optics at a distance of 1 cm, a 5 mm trocar for the coagulation hook is installed (see examples in Fig.1, Fig.2).

The assistant is located on the right hand of the surgeon, holds the camera with his left hand, with his right hand helps to avoid conflict between trocars and instruments, helps to insert instruments into trocars. The surgeon manipulates two instruments. For optimal traction of the gallbladder, it is stitched through the anterior abdominal wall in order to visualize the Calot triangle at an acceptable level.

Coagulation hook performs mobilization of the elements of the hepatoduodenal ligament, after the selection of the cystic artery and cystic duct, the right 5 mm trocar is replaced by a standard 10 mm trocar for the introduction of the clipper (see Fig.3).

The schemes of the operation process are expressed by the main stages:

- Stage of mobilization of the elements of the hepatoduodenal ligament (Figure 4).

- Clipping of the cystic duct and artery (Figure 5).

- The intersection of the cystic duct and artery (Fig.6).

- Performing access to extract the gallbladder (Fig.7) (the gallbladder is removed from the abdominal cavity through the joint access between the right and central trocar).

- Extraction of the gallbladder (Fig.8).

If it is necessary to ligate the cystic duct through the right 5 mm trocar, a 90 cm monofilament ligature is inserted, using a dissector, the knot is formed extracorporeally, lowered and tightened with a pusher.

It is possible to use a standard 5 mm endoscopic multi-charge clipper for clipping the cystic duct and cystic artery - without changing the right 5 mm trocar to a 10 mm trocar. Scissors for crossing the cystic duct in this case are also wound through the right trocar.

The gallbladder is removed from the abdominal cavity through the combined access between the right and central trocar, while the size of the access does not exceed the diameter of the gallbladder. The postoperative defect of the aponeurosis is sutured with interrupted sutures. To reduce the pain syndrome, the aponeurosis in the surgical area is chipped with a solution of ropivacaine. The skin is sutured with a cosmetic intradermal suture. The incision line of the aponeurosis passes conditionally, connecting the installation sites of the remaining trocars.

Approbation of the method is illustrated by the following example. A practical example of the installation of trocars on a patient is shown in Fig.9. The operation begins with the mobilization of the elements of the hepatoduodenal ligament using a coagulation hook (see Fig.10). Then, with the help of a coagulation hook (see Fig.11), the cystic artery and duct are isolated. Next, clipper 15 is inserted to clip the cystic artery and cystic duct (see Fig. 12). After that, the cystic duct is crossed with scissors (see Fig.13). At the final stage, the gallbladder is removed from the abdominal cavity through the combined access between the right and central trocar (see Fig.14).

From Fig.15 shows that the incision of the aponeurosis and skin does not exceed the diameter of the removed gallbladder. The aponeurosis is sutured with interrupted sutures. A cosmetic suture is applied to the skin (see Fig. 16).

The claimed method, implemented with standard tools, is safe if the technology used, the patient selection algorithm are observed, and allows to achieve the maximum cosmetic effect, reduce pain in the postoperative period, and reduce the economic costs of treating the patient.

The characteristics of the operation according to the claimed method are shown in Table 1.

Table 1 Patient position Left side, head up Location of the surgeon To the left of the patient Used trocars and instruments 2 trocars 10 mm, 2 trocars 5 mm
Standard kit for laparoscopic cholecystectomy Operation steps Mobilization of the cystic artery and duct, their clipping, mobilization of the gallbladder from the bed

The implementation of the claimed method is shown in the following examples.

Example 1

Patient G., 35 years old, was admitted for planned surgical treatment with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. For the first time cholecystolithiasis was detected 1 year ago, she did not complain. Body mass index 25 kg/m ² . According to the ultrasound of the OBP, the gallbladder is not enlarged, the wall thickness is 3 mm. Access was made to the abdominal cavity through an incision in the navel, a standard 10 mm trocar was installed, revision of the abdominal cavity. The gallbladder is not tense. Additional trocars were placed. A single-port laparoscopic cholecystectomy was performed in stages using standard medical instruments according to the claimed method. The umbilical access wound was sutured in layers.

The duration of the operation was 25 minutes. Visualization of the gallbladder structures was adequate, there was no instrument conflict. Traction of the gallbladder made it possible to reliably visualize the elements of the hepatoduodenal ligament. There were no intraoperative and postoperative complications, the wound healed by primary intention. An excellent cosmetic result was noted. The length of stay in the hospital is 1 day. Recovery has come.

Example 2

Patient M., 42 years old, was admitted for planned surgical treatment with a diagnosis of cholelithiasis. Chronic calculous cholecystitis. For the first time cholecystolithiasis was detected 1.5 years ago. Body mass index 24 kg/m ² . According to the ultrasound of the OBP, the gallbladder is not enlarged, the wall is not thickened. Access was made to the abdominal cavity through an incision in the navel, a standard 10 mm trocar was installed, revision of the abdominal cavity. The gallbladder is not tense. Additional trocars were placed. A single-port laparoscopic cholecystectomy was performed in stages using standard medical instruments according to the claimed method. The umbilical access wound was sutured in layers.

The duration of the operation was 38 minutes. Visualization of the gallbladder structures was adequate, there was no instrument conflict. Traction of the gallbladder made it possible to reliably visualize the elements of the hepatoduodenal ligament. There were no intraoperative and postoperative complications, the wound healed by primary intention. An excellent cosmetic result was noted. The length of stay in the hospital is 1 day. Recovery has come.

Example 3

Patient G., aged 50, was admitted for planned surgical treatment with a diagnosis of Polyposis of the gallbladder. An ultrasound examination 1 year ago revealed a polyp of the gallbladder up to 9 mm, after 6 months with ultrasound control, the growth of the polyp up to 14 mm was noted. Body mass index 29.5 kg/m ² . According to the ultrasound of the OBP, the gallbladder is not enlarged, the wall is not thickened. In the area of the neck of the gallbladder, a neoplasm up to 14 mm Access was made to the abdominal cavity through an incision in the navel, a standard 10 mm trocar was installed, revision of the abdominal cavity. The gallbladder is not tense. Additional trocars were placed. A single-port laparoscopic cholecystectomy was performed in stages using standard medical instruments according to the claimed method. The umbilical access wound was sutured in layers.

The duration of the operation was 32 minutes. Visualization of the gallbladder structures was adequate, there was no instrument conflict. Traction of the gallbladder made it possible to reliably visualize the elements of the hepatoduodenal ligament. There were no intraoperative and postoperative complications, the wound healed by primary intention. Histological examination was consistent with a gallbladder polyp. An excellent cosmetic result was noted. The length of stay in the hospital is 1 day. Recovery has come.

The examples show that CCE with standard instruments is safe if the technology used, the patient selection algorithm are followed, and allows you to achieve the maximum cosmetic effect (see the appearance of the scar 14 days after surgery in Fig. 17), reduce pain in the postoperative period, as well as reduce economic costs of patient care.

Claims (1)

A method for performing single-port cholecystectomy through a single laparoscopic approach in acute cholecystitis, including performing an umbilical access, installing trocars, characterized in that a 10 mm trocar is installed through the transumbilical access for introducing optics, a 5 mm trocar is installed 1 cm to the left of it for working instruments, to the right of the trocar for optics at a distance of 1 cm, a 5 mm trocar is installed for the coagulation hook; placing the assistant on the right hand of the surgeon, hold the camera with the left hand, helping to avoid conflict between the trocars and instruments with the right, insert the instruments into the trocars; for traction of the gallbladder, it is stitched through the anterior abdominal wall, visualizing the Kalo triangle; coagulation hook perform the mobilization of the elements of the hepatoduodenal ligament; after isolation of the cystic artery and cystic duct, the right 5 mm trocar is replaced with a 10 mm trocar for insertion of the clipper; scissors for crossing the cystic duct are also inserted through the right trocar, the gallbladder is removed from the abdominal cavity through the combined access between the right and central trocar, while the size of the access does not exceed the diameter of the gallbladder; the postoperative defect of the aponeurosis is sutured with interrupted sutures; the skin is sutured with a cosmetic intradermal suture.

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