RU2800567C1 - Method of laparoscopic ligation of the appendix during appendectomy - Google Patents

Abstract

FIELD: medicine, endoscopic surgery.

SUBSTANCE: trocars are inserted into the abdominal cavity, carboxyperitoneum is created, the appendix is isolated and ligated. The running end of the ligature is passed into the abdominal cavity through the trocar and circled around the base of the appendix so that the running end of the ligature passes to the right of the base of the appendix and fits over the root end of the ligature. The running end is crossed with the root end of the ligature and applied over it. Thus, a circular loop is formed around the base of the process with a diameter of 4 cm. Then, the root end of the ligature is taken from the place of intersection, while cutting it at the entrance to the trocar, thus freeing the root end of the ligature, without releasing the place of the intersection, lay the root end of the ligature in such a way that it formed a diametrical line crossing the circle formed by the running end of the ligature through the center to divide it in half. Moreover, the base of the process is adjacent to the root end of the ligature and is distal to it, remaining in the far sector of the circle, then the root end of the ligature is passed through the entire circle until it intersects and overlays on the running end from the diametrically opposite side. The second loop of the knot is formed in the following way: a section of the running end of the ligature, laid in a circle, is captured in the middle of this proximal sector, at 6-00 o'clock position of the virtual dial, the center of which is the base of the appendix, and at 3-00 and 9-00 o'clock position there are sections crossing the running end of the ligature and the root end of the ligature; the section of the running end of the thread is rotated counterclockwise with a clamp, a loop is obtained, into which the clamp is pulled through and the tip of the appendix mobilized from the mesentery is pulled; then both loops of the knot are brought down to the base of the process so that they are parallel to each other, without crossing, and the running end and the root end of the ligature are directed in opposite directions and come out from under the knot, grabbing the ends of the ligature with clamps, slowly pulling in opposite directions tighten node, pinching the base of the appendix. The divergence of the knot loops on the opposite side from the knot should not exceed 3 mm. Using the same technique, a double knot is applied to the removed part of the appendix, after which it is crossed and evacuated.

EFFECT: method is simple, while the time of surgical intervention is accelerated, intracorporeal knot tying is possible, and the postoperative period is painless.

1 cl, 4 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, pediatric surgery, and is intended for use in emergency surgery to remove the appendix, as well as for planned appendectomy for diseases of the appendix, and is used during laparoscopy.

An important step in the operation of appendectomy is the ligation of the base of the process and the formation of its stump after cutting off. In emergency surgical practice, methods of appendectomy are known, including ligation of the base of the appendix, both by an open method and during laparoscopic intervention.

A known method of ligature appendectomy used during open surgery in young children (Kolesov V.I. Clinic and treatment of acute appendicitis. L., 1972, 342 S.; Isakov Yu.F., Stepanov E.A., Dronov A. F. Acute appendicitis in childhood. M., 1980 - 176 pp.; Khromova V. M. Mistakes, dangers and complications in surgery. L., 1972. 391 pp.)

A ligature method for processing the appendix stump is known, which consists in the fact that the stump is tied with a non-absorbable suture material, treated with an iodine solution and not immersed in the intestinal wall (Isakov Yu.F., Stepanov E.A., Dronov A.F. Acute appendicitis in childhood Moscow, 1980, 176 p.).

Also known submersible method of processing the stump of the appendix, in which the stump after ligation of its base is immersed in the wall of the cecum with a purse-string suture (Kolesov VI Clinic and treatment of acute appendicitis. L., 1972 - 342 C.).

Known laparoscopic method of appendectomy, in which the stump of the appendix is ligated twice with a loop of Raeder, without immersion. When using the Raeder endoligature and the extracorporeal method of knot formation, the number of early postoperative intra-abdominal complications is minimal. But it should be noted that with the extracorporeal formation of the node, complications occur more often than with the use of Raeder's endoligature (Konovalov A.A. Evaluation of laparoscopic appendectomy methods without immersion of the stump of the appendix: Abstract of the thesis of Candidate of Medical Sciences: - M., 2010. - 48 pp.; Sholokhova V.R. Methods of processing the stump of the appendix as the main aspect of the prevention of postoperative complications / V.R. Sholokhova. - // Young scientist. - 2017. - No. 17 (151). - P. 146-148 .).

As a prototype, a method of surgical treatment was chosen - ligation of the stump of the appendix, using the method of forming a node of the "constrictor" type, in which the ligation of the stump occurred with one thread with two loops that are mirror-image relative to each other, and the tightening ends of the thread are located in opposite directions with respect to to the loop, and when tightening one end, the other is kept taut, which allows you to tighten the loops. After the necessary tightening, the ends are tied into an anti-loosening knot - a “lock”. The loop is formed extracorporeally, it is desirable to use monofilament. The knot is formed outside the abdominal cavity, then, using a spatula, it is inserted through the trocar into the abdominal cavity and put on the appendix, previously separated from the mesentery (according to the method proposed by F. Gotz). The appendix is cut off leaving a 5-6 mm stump. Next, by pulling one end of the thread, the suture is tightened on the base of the stump, after which an anti-decoupling knot is applied - a “lock”, which is also formed extracorporeally. Complications in patients operated by this laparoscopic method, associated with the failure of the node on the stump, the authors did not observe. The proposed two-loop method of ligation of the appendix stump, according to the authors, is simple and effective (Seydinov Sh.M., Ashurmetov R.I., Orazbakhov Zh..B., Babakhanov A.T., Tairov V.R. Two-loop ligation method appendix stump in laparoscopic appendectomy // International Journal of Applied and Fundamental Research - 2015. - No. 4-2. - P. 213-215).

In the described surgical method "Two-loop method of ligation of the appendix stump in laparoscopic appendectomy" has the following disadvantages. The proposed method provides for the obligatory formation of a knot extracorporeally, i.e. outside the abdominal cavity. This approach lengthens the time of surgical intervention and switches the operator's attention away from objects in the abdominal cavity. Holding and tightening the loop in this case requires the use of additional tools (spatula, pusher for the knot). All this technically complicates the appendectomy technique. In addition, tying knots is carried out in two stages - first with one knot, and then with a knot of the "constrictor" type - (lock). It is also important to note that the technique should not be used in inflammatory-destructive conditions of the wall of the dome of the caecum, that is, it is not a guaranteed reliable way to close the appendix stump.

The purpose of the invention is to create a reliable, effective method of laparoscopic appendectomy using surgical ligatures applied intra-abdominally.

The method involves applying a ligature during laparoscopic appendectomy to the appendix stump, which is formed intracorporeally.

The purpose of the invention is to improve the results of surgical treatment of acute appendicitis, reduce the likelihood of postoperative complications, increase the functional results of the operation.

The proposed invention is based on the task of developing an objective, accessible and easily reproducible method for treating the appendix stump, which eliminates the disadvantages of known methods of appendectomy, primarily the risk of inflammatory complications, hematoma formation, followed by suture divergence.

The technical result is the simplicity and ease of the method, while the time of surgical intervention is accelerated, intracorporeal knot tying is possible, and the postoperative period is painless.

The technical result of the invention is achieved by the fact that the so-called "node-boa" is formed from a group of nodes - "constrictors". A feature of knots - “constrictors” is that they practically do not bloom after being tightened, they are easily tightened and firmly hold the tissues.

In the proposed method, the operational approach is as follows. During laparoscopic appendectomy, the mesentery is treated with a bipolar clamp, the mesentery is transected; appendix (4) is fixed at the apex in a stretched position. The working (running) end of the ligature 1 is passed into the abdominal cavity through the trocar and circled around the base of the appendix (3) in such a way that the running end of the thread is guided to the right of the base of the appendix and placed over the root end, forming 1 stage of a tightening knot, while the running end (1) is crossed with the root end (2) and put on top of it (Fig. 1). Thus, around the base of the process, a circular loop of the required diameter of 4 cm is indicated with a thread, crossing to the left of the base of the process, which is the center of the loop circle. The area of intersection is fixed by grasping both threads with an endo-clamp with the left hand.

2nd stage - from the place of intersection, the root end of the thread is taken with an endoclamp of the right hand, while cutting it at the entrance to the trocar and, thus, freeing the root end (2) to completely insert it into the abdominal cavity. Without releasing the crossover with the clamp of the left hand, the root end of the thread (2) is laid with the clamp of the right hand so that it forms a diametrical line crossing the circle formed by the running end (1) through the center in order to divide it in half (Fig. 2), and the base process (3) is adjacent to the root end and is distal to it, remaining in the far sector of the circle. Next, the thread of the root end (2) is passed through the entire circle until it intersects and overlays the running end (1) from the diametrically opposite side. Having removed the endo-clamp of the left hand from the place of fixation to the left of the base of the process (3), it is transferred to the right and the place of the intersection of the root end of the thread (2) and the running end (1) of the circle is captured.

Stage 3 - "formation of the second loop of the node" - is performed as follows. They capture a section of the thread of the running end (1), laid in a circle, in the middle of this proximal sector, at 6-00 o'clock of the virtual dial, the center of which is the base of the appendix, and at 3-00 and 9-00 o'clock there are sections of the crossing of the running thread ( 1), and the root end of the thread (2). By rotating the section of the running end (1) counterclockwise with the clamp, a loop is obtained, into which the right hand is clamped and the tip (4) of the appendix mobilized from the mesentery is retracted. The key point of the stage is the rotation of the loop by 180 degrees, resulting in an 8-shaped additional loop (Fig. 3).

4th stage - "final formation and tightening of the knot" - both loops of the knot are lowered closer to the base of the process (3) so that they are parallel to each other, without crossing, and the running end of the thread (1) and the root end (2) were directed in opposite directions, and came out from under the node (Fig. 4). Grasping the ends of the threads with clamps, slowly pulling in opposite directions tighten the knot until the base of the appendix is completely clamped (3). In this case, the permissible divergence of the loops of the knot on the opposite side of the knot should not exceed 3 mm. The ends of the threads are evenly cut with endoscissors, leaving 3-4 mm. Using the same technique, a double knot is applied to the removed part of the process, after which it is crossed, evacuated, and then the abdominal cavity is sanitized. Trocars are removed from the abdominal cavity. Skin incisions in the inguinal areas are sutured with long-term absorbable sutures (polysorb).

The advantages of the proposed method are as follows.

The claimed invention allows you to quickly and efficiently perform laparoscopic surgery for appendicitis, all of the above generally increases the functional effect of the operation, reduces the consumption of anesthetic and carbon dioxide, without compromising the radicalness of the operation.

The claimed method improves the results of treatment of acute appendicitis, reduces the duration of surgery and helps to reduce the number of complications of the disease.

The essence of the invention is illustrated by drawings, where in Fig. 1 shows the first stage of the formation of a constrictor node for ligation of the appendix,

in fig. 2 - the second stage of the formation of a double node-constrictor for ligation of the appendix.

Fig. 3 - the third stage of the formation of a double node-constrictor for ligation of the appendix.

Fig. 4 - 4th stage - "final formation and tightening of the knot" for ligation of the appendix.

Clinical example of the implementation of the method.

Example 1: patient N., 46 years old, was admitted to the hospital surgery clinic with a diagnosis of acute appendicitis, gangrenous perforated appendicitis was detected during laparoscopy, a decision was made to perform a laparoscopic appendectomy using an endoscopic two-loop method of ligation of the base of the appendix. During laparoscopic appendectomy, the mesentery was treated with a bipolar clamp, the mesentery was transected; the appendix was fixed at the apex in a stretched position. The working (running) end of the ligature was passed into the abdominal cavity through the trocar and circled around the base of the appendix so that the running end of the thread was to the right of the base of the appendix and was laid over the root end; around the base of the process, a circular loop with a diameter of 4 cm was marked with a thread. The root end of the thread was taken with an endo-clamp of the right hand, while cutting it at the entrance to the trocar outside the abdominal cavity, thus freeing the root end for its complete insertion into the abdominal cavity. Without releasing the place of the cross with the clamp of the left hand, the root end was laid across the “virtual dial” with the clamp of the right hand, the base of the process is adjacent to the root end and is distal to it, remaining in the far sector of the “virtual dial”. Having removed the endo-clamp of the left hand from the place of fixation to the left of the process base, it was moved to the right and captured the place of intersection of the root end of the thread and the running end. The next movement captured a section of the thread of the running end, laid in a circle of the "virtual dial", in the middle of this proximal sector, at 6-00 o'clock of the virtual dial, the center of which is the base of the appendix, and at 3-00 and 9-00 o'clock there are sections of the cross running thread. By rotating the section of the running end counterclockwise with a clamp, a loop was obtained, into which the top of the appendix mobilized from the mesentery was passed. Both loops of the knot were brought down closer to the base of the process so that they were parallel to each other, without crossing. Having seized the ends of the threads with clamps, slowly pulling in opposite directions tightened the knot until the base of the appendix was completely clamped. At the same time, the allowable divergence of the knot loops on the opposite side of the knot did not exceed 3 mm. The ends of the threads were cut with endoscissors leaving 3-4 mm. Using the same technique, a double knot was placed on the removed part of the process, after which it was removed through the trocar, and the abdominal cavity was sanitized. Desufflation. The trocars were removed from the abdominal cavity. Skin incisions in the inguinal regions were sutured with long-term absorbable sutures (Polysorb).

New in the proposed method is the formation of a two-loop knot according to the type of "constrictor knot" directly in the abdominal cavity, while for the formation of the knot a model is used in the form of a virtual "dial" formed by the running part of the thread laid in a circle; the center of the "dial" is the base of the appendix, and the right and left sides are marked by areas of intersection of the running and root ends of the threads. The formation of the second loop of the knot occurs by twisting the section of the root thread section captured at 6-00 hours of the virtual “dial” with a clamp counterclockwise, followed by throwing this loop over the appendix and bringing it down to the base, while the coils of the knot are parallel to each other, divergence they should not exceed 3 mm.

The claimed method provides a reliable functional and cosmetic result of the operation, is a low-traumatic, effective method of treatment, allows to reduce possible complications, including the development of stump failure and peritonitis.

An operation of this type reduces the risk of the consequences of a "typical" appendectomy according to McBurney-Volkovich.

The alleged invention can be applied in the conditions of elective and emergency surgery, in the surgical treatment of the pathology of the vermiform process in both children and adult patients. The method allows to reduce the period of rehabilitation after surgery. It is possible to use the proposed method as a simultaneous operation during laparoscopy.

Bibliography

1. Kolesov V.I. Clinic and treatment of acute appendicitis. L., 1972, 342 p.;

2. Isakov Yu., Stepanov E.A., Dronov A. Acute appendicitis in childhood. M., 1980. 176 p.;

3. Khromova V.M. Mistakes, dangers and complications in surgery. L., - 1972 - 391 p.

4. Konovalov. A.A. Evaluation of methods of laparoscopic appendectomy without immersion of the stump of the appendix: Abstract of the thesis. dis. … cand. honey. Sciences: - M., 2010. - 48 p.

5. Sholokhova V.R. Ways of processing the stump of the appendix as the main aspect of the prevention of postoperative complications / V.R. Sholokhov. - // Young scientist. - 2017. - No. 17 (151). - S. 146-148.

6. Seidinov Sh.M., Ashurmetov R.I., Orazbakhov Zh.B., Babakhanov A.T., Tairov V.R. Two-loop method of ligation of the appendix stump in laparoscopic appendectomy. // International Journal of Applied and Fundamental Research. - 2015. - No. 4-2. - S. 213-215.

BRIEF DESCRIPTION OF THE DRAWINGS

Fig. 1.

In FIG. 1 shows the first stage of the formation of a double constrictor knot for ligation of the appendix, where 1 is the running end of the thread, 2 is the root end of the ligature, 3 is the base of the appendix, 4 is the tip of the appendix mobilized from the mesentery.

Fig. 2.

In FIG. 2 shows the second stage of the formation of a double constrictor knot for ligation of the appendix, where 1 is the running end of the thread, 2 is the root end of the ligature, 3 is the base of the appendix, 4 is the tip of the appendix mobilized from the mesentery.

Fig. 3.

In FIG. 3 shows the third stage of the formation of a double knot-constrictor for ligation of the appendix.

Fig. 4.

In FIG. 4 shows the 4th stage - "the final formation and tightening of the knot" for ligation of the appendix.

Claims (1)

A method for laparoscopic ligation of the appendix during appendectomy, including the introduction of trocars into the abdominal cavity, the creation of a carboxyperitoneum, the isolation of the appendix and its ligation, characterized in that the running end of the ligature is passed into the abdominal cavity through the trocar and circled around the base of the appendix in such a way that the running end the end of the ligature passed to the right of the base of the appendix and was placed over the root end of the ligature, while the running end is crossed with the root end of the ligature and placed over it, thus forming a circular loop around the base of the appendix with a diameter of 4 cm; then, the root end of the ligature is taken from the place of intersection, while cutting it at the entrance to the trocar, thus freeing the root end of the ligature, without releasing the place of intersection, lay the root end of the ligature so that it forms a diametrical line crossing through the center formed by the running end ligature circle to divide it in half, and the base of the process is adjacent to the root end of the ligature and is distal to it, remaining in the far sector of the circle, then the root end of the ligature is drawn through the entire circle until it intersects and overlays on the running end from the diametrically opposite side; a second loop of the knot is formed, for this they capture a section of the running end of the ligature, laid in a circle, in the middle of this proximal sector at 6-00 o'clock of the virtual dial, the center of which is the base of the appendix, and at 3-00 and 9-00 o'clock there are sections of the cross the running end of the ligature and the root end of the ligature; the section of the running end of the thread is rotated counterclockwise with a clamp, a loop is obtained, into which the clamp is carried out and the tip of the appendix mobilized from the mesentery is pulled; then both loops of the knot are brought down to the base of the process so that they are parallel to each other, not crossing, and the running end and the root end of the ligature are directed in opposite directions and come out from under the knot, grabbing the ends of the ligature with clamps, slowly pulling in opposite directions tighten knot, pinching the base of the appendix, while the divergence of the loops of the knot on the opposite side from the knot should not exceed 3 mm; using the same technique, a double knot is applied to the removed part of the appendix, after which it is crossed and evacuated.

Images