RU2796758C1 - Device for sanitation of purulent cavities containing sequesters - Google Patents

Abstract

FIELD: medical equipment.

SUBSTANCE: invention can be used during video-assisted retroperitoneoscopic sequestrectomy, staged sanitation of purulent cavities containing sequesters, as well as for evacuation of pathological effusion, necrotic tissues, remnants of a pyogenic capsule from the cavity of an intra-abdominal abscess. The device for sanitation of purulent cavities containing sequesters includes a sleeve, a screw coaxially located in the sleeve, a drive gear rotation handle and a protective casing of a gear train, including a drive gear and a driven gear rigidly connected to the auger, made with the possibility of rotation by the drive gear handle. The screw contains protrusions and through holes on the blades, and a hole is made in the sleeve for removing sequesters.

EFFECT: invention is characterized by being used for the sanitation of purulent cavities containing sequesters in the process of sanitation of the abdominal cavity, closed cavities of complex shape, in the presence of clots and purulent-necrotic masses.

1 cl, 1 dwg

Description

The invention relates to medicine and can be used in video-assisted retroperitoneoscopic sequestrectomy (VARS), staged sanitation of purulent cavities containing sequesters, as well as for the evacuation of pathological effusion, necrotic tissues, remnants of the pyogenic capsule from the intra-abdominal abscess cavity.

At the moment, the surgical aspect in the complex treatment of pancreatic necrosis remains the most relevant and debatable. With purulent complications of acute pancreatitis, surgical intervention is indicated, the purpose of which is the sanitation of the retroperitoneal tissue. The structure of abscesses (mainly liquid or sequestral) and the degree of their prevalence vary widely. (V.R. Goltsov Acute pancreatitis: problems and ways to solve them. Clinical lectures. - St. Petersburg: SpecLit, 2020). When deciding on the primary drainage of purulent-necrotic parapancreatitis, it is recommended to give preference to minimally invasive interventions: drainage under ultrasound guidance, retroperitoneoscopy, minilaparotomy using a special set of instruments, etc. (Shabunin A.V., Lukin A.Yu., Shikov D. B. "Optimal treatment of acute pancreatitis depending on the "model" of pancreatic necrosis." Annals of Surgical Hepatology. 2013. V. 18. 3. P. 70-78).

Minimally invasive interventions can effectively evacuate the "liquid" component of the abscess. To remove the "sequestral" component, it is necessary to perform a traditional laparotomy with necrosequestrectomy. In order to minimize the amount of operational assistance, devices are being developed that allow sanitizing purulent cavities containing sevesters.

A disposable trocar-drainage is known (RF patent No. 2310407, publ. 20.11.2007), including an endoscopic port made in the form of a pipe with a channel for conducting an instrument and having a stylet, in the form of a rod, characterized in that in the wall of the endoscopic port is placed an additional channel that starts in the front part of the port from the inside and goes behind the flange in the form of a tube oriented at an angle to the outer surface of the port, and on the wall of the outer part of the pipe there is a local annular thinning in the form of a belt having a length corresponding to the anatomical dimensions of the surgeon's fingers or 2 -3 nozzle calibers, the nozzle is made of an elastic polymer material, and the stylet is made of a rigid polymer material and has an annular protrusion and a tip with a diameter in the area where the nozzle adjoins the tip that is larger than the diameter of the nozzle, while the annular protrusion is placed on the rod in the zone of interface with the tip, and a corresponding depression is made on the wall of the nozzle channel.

The disadvantage of this device is the impossibility of performing fragmentation of dense necrotic tissues during the sanitation of the purulent cavity with their subsequent aspiration from the pathological focus of the abdominal cavity.

A device for endoscopic hydropressive processing, irrigation and aspiration is known, in which an additional tube is attached along the main tube. On the proximal part of the additional tube there is a valve mechanism that regulates the flow of fluid, connected by a hose to a pump of 4-5 atm. The distal part of the additional tube is bent in such a way that the bending elbow is located at the level of the distal cut of the main tube. The distal parts of both tubes are inside the nozzle, which is a cylinder 16-20 mm in diameter, 3-4 cm high with two circular grooves 6-7 mm wide, up to 3 mm deep, dividing the cylinder into three equal parts. At the distal end of the cylinder there is a spherical recess with a hole at the bottom. On the proximal chamfer there are four holes opposite each other. (RF patent for the invention RU2294766 C2, published on March 10, 2007).

But this device is multi-component and ineffective in the presence of a complex-shaped cavity, dense contents in it, or areas of purulent-necrotic tissues fixed to the walls of the cavity.

The closest in technical essence is a device - a nozzle for an aquapurator (RF patent for the invention RU 2778006 C1, publ. 08/12/2022), containing a sleeve with a diameter of 10 mm, with a funnel-shaped stop in the proximal part of the sleeve, an auger, a disk-shaped handle for rotating the auger. The standard 5 mm tip on the aquapure serves as a guide and axis for the auger, which is coaxially connected to the sleeve. When the disc-shaped handle rotates, the screw rotates, which fragments, captures and moves dense fractions (clots, necrotic tissues) along the sleeve.

However, a simple screw screw is not always able to capture, fragment and move sequestered tissue. The disk-shaped handle for screw rotation, located perpendicular to the axis of the screw, makes continuous rotation difficult, and during rotation it can displace the entire device, which complicates the precise use of the nozzle in problematic anatomical areas.

The result of the proposed technical solution is the possibility of its use in the process of sanitation of the abdominal cavity, closed cavities of complex shape, in the presence of clots and purulent-necrotic masses.

In FIG. 1 shows a device for the rehabilitation of purulent cavities containing sequesters, where 1 is a sleeve with a diameter of 10 mm, 2 is an auger, 3 is a protrusion on the auger blades, 4 is through holes in the auger blades, 5 is a driven gear rigidly connected to the auger, 6 - drive gear, 7 - drive gear rotation knob, 8 - gear guard, 9 - standard 5 mm tip for aquapurator, 10 - hole in the sleeve to remove the contents.

The tip on the aquapurator 9 serves as a guide and an axis for the screw 2, which is coaxially connected to the sleeve 1.

The technical action of the device for the sanitation of purulent cavities containing sequesters is carried out by the rotation handle 7, the drive gear 6. In this case, the driven gear 5 rotates and, due to the rigid connection, the screw 2 rotates, which moves the sequesters and other dense fractions (clots, necrotic tissues ) along the sleeve 1, subsequently removing them through the hole in the sleeve 10. Additional elements for capturing, fixing, fragmenting and moving the sequesters are protrusions on the screw blades 3 and through holes 4 in the screw blades.

Example

Patient N-s, 47 years old, was admitted on an emergency basis to the surgical department of the MBUZ GKB SMP of Stavropol on May 27, 22 with a clinic of acute alcohol-induced pancreatitis. The diagnosis was also confirmed by clinical and laboratory studies. On the day of admission, an ultrasound scan of the abdominal organs was performed: the gallbladder was enlarged in size 137 × 45 mm, the choledochus was up to 8 mm. In the omental bag there is a delimited accumulation of fluid up to 470 ml. Taking into account these data and due to the ineffectiveness of conservative therapy, on May 28, 22, under ultrasound navigation, percutaneous transhepatic cholecystostomy was performed (12 Fr pigtail drainage was used) and drainage of the omental sac with an 18 Fr stylet catheter. The access point is 4 cm below the left costal arch along the anterior axillary line. At the same time, about 450 ml of a brown, moderately turbid liquid was evacuated. Subsequently, complex conservative therapy and daily sanitation of the cavity of the omental sac were carried out, and drainage was installed. Over the next 15 days, a gradual replacement of the drainage of the stuffing bag with drainages of a larger diameter (20-24-28 Fr) was carried out. From the 17th 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, leukocytosis up to 21⋅10 ⁹ /l, an increase in the index of the APACNEII scale to 24 points. On the control computed tomography (15.06.22), a cavity 107 × 51 × 59 mm is visualized, in which several sequesters from 41 to 52 mm were determined. The patient was discussed at a clinical conference. It is noted that sanitation of the cavity through the existing drainage is ineffective due to the presence of large sequesters. A decision was made to perform transfistula retroperitoneoscopy for adequate sanitation of the cavity and instrumental sequestrectomy.

Surgery was performed on 05/16/22. Under intravenous anesthesia, the skin and aponeurosis were dissected along the existing wound channel by 0.5 cm. A trocar sleeve was inserted along the wound channel for retroperitoneoscopy. After the introduction of optics, a cavity 120×50×60 mm, irregular in shape, with rigid edges covered with fibrin, was visualized. Several sequesters were determined in the cavity, the largest was up to 45-50 mm, dirty black. On instrumental palpation it is dense. Additionally introduced trocar 10 mm through a separate puncture in the left hypochondrium. Used device for sanitation of purulent cavities containing sequesters. At the same time, the tip on the standard aquapurator 9 served as a guide and axis for the screw 2, which is coaxially connected to the sleeve 1. due to the rigid connection rotation of the screw 2. Due to the presence in the screw 2 of the protrusions on the blades of the screw 3 and through holes 4 in the blades of the screw, sequesters were captured, fragmented and moved along the sleeve 1, followed by their removal through the hole in the sleeve 10. As a result of surgical intervention the cavity was completely freed from sequesters. The operation was completed by draining the cavity of the omental sac with 16 Fr drainage.

In the postoperative period, there was a stabilization of the condition, followed by positive dynamics. The cavity was washed with antiseptics. Fistulography was performed on 06/25/22: the dynamics is positive. Significant reduction of the cavity to 37×29×31mm Drainage was removed on 06/27/22. The patient was discharged in a satisfactory condition on June 30, 22.

The use of a device for the sanitation of purulent cavities containing sequesters made it possible, without additional surgical trauma, to safely and effectively perform fragmentation and evacuation of sequesters. This was the determining factor in adequate sanitation of the cavity of the omental bag and ultimately led to the clinical stabilization of the patient.

This device can be recommended for widespread use in surgical hospitals, when performing video-assisted retroperitoneoscopic sequestrectomy (HARS), staged sanitation of purulent cavities containing sequesters, as well as for the evacuation of pathological effusion, necrotic tissues, remnants of the pyogenic capsule from the intra-abdominal abscess cavity.

Claims (1)

A device for the sanitation of purulent cavities containing sequesters, including a sleeve and a screw coaxially located in the sleeve, characterized in that it additionally contains a drive gear rotation handle, a protective casing of a gear train, including a drive gear and a driven gear rigidly connected to the screw, made with the possibility of rotation by the handle drive gear, while the auger contains protrusions and through holes on the blades, and a hole is made in the sleeve for removing sequesters.

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