RU2796322C1 - Device for expansion of puncture channel - Google Patents

Abstract

FIELD: medicine; surgery.

SUBSTANCE: invention relates to medical equipment and is used to perform percutaneous puncture-drainage interventions in the treatment of various parapancreatic lesions in patients with acute destructive pancreatitis, as well as in the complex treatment of intra-abdominal abscesses. The device for puncture channels expanding includes two-part sheath with a tapered end and an external screw thread. Detachable parts of two-part sheath are fixed to the half rings. One of the half-rings is attached to the main bracket in the form of a crescent, on the other side of the main bracket there are rigidly fixed screw post and an adjusting flly-nut. Another half-ring is made with the possibility of displacement towards the main bracket as a result of rotation of the adjusting flly-nut along the post screw to increase the diameter of the split two-part sheath.

EFFECT: invention is characterized by the fact that it is used in the process of timely replacement of cavity lesion drainages with larger diameter drainages and creation of conditions for transfistula retroperitoneoscopy or abscessoscopy with instrumental sequestrectomy.

1 cl, 1 dwg

Description

The invention relates to medicine, namely to surgery, is used to perform percutaneous puncture-drainage interventions in the treatment of various parapancreatic lesions in patients with acute destructive pancreatitis, as well as in the complex treatment of intra-abdominal abscesses.

Currently, in the surgical treatment of acute destructive pancreatitis and intra-abdominal abscesses of various localization, in the overwhelming majority of cases, preference is given to minimally invasive puncture-drainage interventions under navigation control. The advantage of these methods is obvious. Interventions are performed under local anesthesia, and due to the low traumatism they can be used in the most severe category of patients. (Surgical technologies for minimally invasive treatment of acute severe pancreatitis: guidelines No. 9 / edited by M.Sh. Khubutia. - M., 2017. - 40s.)

The complexity of the use of puncture-drainage interventions is due to the phase course of acute destructive pancreatitis. Regardless of the chosen tactics (combined or puncture treatment), at the first stage (IA and IB phases of the disease), for the purpose of surgical detoxification, percutaneous drainage of acute fluid accumulations in the abdominal cavity and areas of sequestration or fluid accumulations in the retroperitoneal tissue with small-diameter drains (8-12 Fr ).

However, the further transition of the pathological process to the 2nd phase - the phase of destructive complications (7-10 days from the onset of the disease), characterized by sequestration of the pancreatic infiltrate and / or the formation of an immature (unformed) pseudocyst, requires the use of larger-caliber drainages (up to 20 mm) . This is especially important during the development of purulent-destructive complications of acute pancreatitis (approximately from the 2-3rd week of the disease), when, on average, 40-70% of patients become infected with aseptic necrosis zones, which can be delimited (infected unformed pseudocyst, pancreatogenic abscess) or undelimited (retroperitoneal pancreatogenic phlegmon) purulent inflammation. Under such conditions, the main task in the treatment of this category of patients is also the creation of conditions for adequate removal of purulent exudate from the lesion. Currently, the use of transcutaneous puncture-drainage interventions, under radiation control, is associated with such a problem as the need for subsequent expansion of surgical access if it is necessary to change tubular catheters to larger ones in diameter, as well as the creation of conditions for transfistula retroperitoneoscopy with instrumental sequestrectomy. (Ivshin V.G. Ivshin M.V., Percutaneous treatment of patients with pancreatic necrosis and widespread parapancreatitis. Tula technology. - Tula: Grif and K, 2013 - 128s.)

A device for drainage is known, containing a tube and a rod with a sharp working end and a handle at the outer end placed in its lumen, while the tube is made shorter than the rod, a second tube is placed on the rod, while the tubes are joined at the ends with lateral perforations, and the rod consists of two parts with the possibility of separating them and extracting them from the tubes, and at the back of the rod there is an external thread, on which a nut is placed between the handle and the tube, and at the working end of the rod there is a cone-shaped extension with a rear support platform, the diameter of which is not less than the outer diameter of the tube ( patent of the Russian Federation No. 2329833, published on July 27, 2008).

The disadvantage of this technical solution is the impossibility of its use in case of intra-abdominal localization of the pathological focus, since the implementation of through drainage in this case is accompanied by an extremely high risk of damage to the abdominal organs.

A device for percutaneous drainage of cavity formations is known (RF patent No. 118854, published on August 10, 2012), containing a needle with a holder, a mandrel installed inside the needle, an outer tube with a holder, while the needle is made with a sharpened cut of the working end, characterized in that it equipped with a dilator located on the outer tube and a trocar placed on it, while the outer tube and dilator have tapering working ends, and the length of the outer tube is less than the length of the needle and mandrin, but more than the length of the dilator and trocar, while the tapering working end of the dilator has a surface ensuring its smooth entry into the tissue.

The disadvantages of the device are the technical complexity and complexity of manufacturing and use.

A disposable device is known, including an endoscopic port made in the form of a pipe with a channel for carrying out an instrument, divided by a flange into intracavitary and outer parts, and a stylet made in the form of a rod, limited at one end by a tip with a point and at the other end by a handle, in which on the wall of the outer part of the branch pipe there is an annular thinning in the form of a belt, made for pinching with fingers or a tool and sealing the branch pipe. The end surface of the protrusion on the rod is made in the form of a truncated cone with the apex facing the tip, and the corresponding end surface of the cavity on the wall of the branch pipe channel is made in the form of a truncated cone with the apex facing the port flange, a plug replaced by a fitting is movably fixed on the end of the endoscopic port. (Patent RF No. 2315575, А61В 17/34, published on January 27, 2008).

The disadvantages of this device is its complexity, the complexity of manufacturing and application.

The closest technical solution to the presented device is a device for expanding trocar access, including an X - shaped dilution device, a two-piece sleeve having a tapered end and an external screw thread, and the handles of the X - shaped dilution device are fixed in a predetermined position with a threaded axis having internal hex nut and external hex nut with knurled flange. (Patent for the invention of the Russian Federation No. 2778005, published on August 12, 2022, Bull. No. 23, 2022)

However, this device is quite cumbersome due to the presence of an X-shaped dilator, there is some difficulty in introducing the sleeve into the wound channel and the problem of long-term exposure due to the size of the device.

The result of the proposed technical solution is the possibility of its use in the process of timely replacement of cavity formation drainages with larger diameter drainages and the creation of conditions for transfistula retroperitoneoscopy or abscessoscopy with instrumental sequestrectomy.

The proposed device for expanding the puncture channel is shown in figure 1. The device consists of a half ring 1 and a half ring 2, fixed to the working part of a detachable two-piece sleeve 3, with a tapered distal end 4 and an external screw thread 5. The half ring 2 is attached to the main bracket 6, in crescent shape. On the main bracket 6, a pin 7 is rigidly fixed, with a thread 8 and an adjusting wing nut 9.

The expansion of the puncture channel using the proposed device is carried out as follows. A detachable two-part sleeve 3 is inserted into the existing puncture wound channel, with a tapering distal end 4 and an external screw thread 5. When rotating along the thread 8, the adjusting wing nut 9, the semi-ring 1 is shifted towards the main bracket 6, which leads to an increase in the diameter of the split two-part sleeve 3. Next, the detachable two-piece sleeve 3 is fixed in the open state, which allows the expansion of the puncture wound channel and, subsequently, to carry out drainages of a larger diameter.

Clinical example. Patient N-ev, 57 years old, was admitted on an emergency basis to the surgical department of the MBUZ GKB SMP in Stavropol on 03/05/22 with complaints of intense pain in the upper abdomen, nausea, repeated vomiting, and weakness. These symptoms appeared after a heavy intake of fatty foods. After further examination, a clinical diagnosis was established: acute pancreatitis. When performing ultrasound of the abdominal organs, the presence of fluid accumulation in the omental bag was noted. Estimated volume up to 250 ml. On 09.02.22, under navigational ultrasound guidance, the omental bursa was drained with a 14 Fr stylet catheter. The access point is 3 cm below the left costal arch along the midclavicular line. At the same time, about 200 ml of fluid with a pronounced hemorrhagic component was evacuated. Subsequently, the patient was in the intensive care unit, where complex conservative therapy and daily sanitation of the omental sac cavity through the existing drainage were carried out. On the 13th day from the moment the patient was admitted to the hospital, clinical signs of infection of the zone of pancreatogenic necrosis appeared, with characteristic clinical manifestations: an increase in body temperature up to 39 ° C with chills, weakness, dry mouth, leukocytosis up to 21⋅10 ⁹ /l, an increase in APACHEII scale index up to 20 points. On the 15th day, a control computed tomography with cavity contrast was performed, according to which several sequesters from 20 to 40 mm were determined in the omental sac. The patient was discussed at a clinical conference. A decision was made to replace the existing drainage with a drainage of a larger diameter in order to adequately sanitize the cavity and create conditions for transfistula retroperitoneoscopy with possible instrumental sequestrectomy.

Under local anesthesia, the skin and aponeurosis were dissected along the existing wound channel by 0.5-0.7 cm. semi-ring 1 was shifted towards the main bracket 6, which led to an increase in the diameter of the split two-part sleeve 3. After that, the split two-part sleeve 3 was fixed in the open state and exposure was made for 24 hours, after which the adjusting wing nut 9 was rotated again, half ring 1 was shifted towards the main bracket, which led to the expansion of the two-part split sleeve 3 and the wound puncture channel up to 10-12 mm. In this open state, the device was left for 48 hours. Thanks to the performed manipulations, the puncture wound canal was expanded to 12 mm in 72 hours, which made it possible to perform retroperitoneoscopy with sequestrectomy through a standard 10 mm sleeve and subsequently drain the cavity with 30 Fr drainage. After the manipulations, clinical stabilization was noted. The drainage was gradually replaced by smaller diameter drains. The drainage was completely removed on 03/19/22. At the control ultrasound and computed tomography, the residual cavity is not determined, there are no pathological formations.

This example shows that the use of a device for expanding the puncture channel made it possible to safely, effectively and in a short period of time replace the drainage with a drainage of a larger diameter, perform retroperitoneoscopy and evacuate sequesters, which led to clinical stabilization and recovery of the patient.

A device for expanding the puncture channel can be recommended for widespread use in surgical hospitals for puncture-drainage interventions in patients with acute destructive pancreatitis and intra-abdominal abscesses.

Claims (1)

A device for expanding the puncture channel, including a two-part sleeve having a tapered end and an external screw thread, characterized in that the detachable parts of the two-part sleeve are fixed to the half-rings, one of the half-rings is attached to the main bracket in the form of a crescent, on the other side of the main bracket a pin with thread and adjusting wing nut, while the other half ring is made with the possibility of displacement towards the main bracket as a result of rotation of the adjusting wing nut along the thread of the pin to increase the diameter of the split two-part sleeve.

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