RU2802674C1 - Method of pole wedge resection of the spleen - Google Patents

Abstract

FIELD: medicine; abdominal surgery.

SUBSTANCE: invention can be used to perform organ-sparing surgery for cysts, and traumatic damage to the spleen. A wedge-shaped resection of the upper or lower pole of the spleen is performed at an angle of 45–60°. The restoration of the anatomical integrity of the organ is carried out by using a through U-shaped suture with a resection depth of up to 2 cm or Sulfacrylate medical surgical glue with a resection of more than 2 cm in depth. A single-row interrupted microsurgical suture is applied to the spleen capsule under optical magnification.

EFFECT: method makes it possible to ensure the preservation of the spleen, reliable hemostasis with minimal trauma to the organ and precise layer-by-layer contact of homogeneous layers being stitched together.

1 cl, 11 dwg, 4 ex

Description

The invention relates to medicine, in particular to abdominal surgery, and can be used to perform organ-saving surgery for cysts, traumatic damage to the spleen in order to preserve the functionally active parenchyma of the organ. Spleen injury ranks first among all injuries to the abdominal cavity (Charyshkin A.L., 2012, Podkamenev V.V., 2015; Shabunin A.V. et al., 2018). The first place in the structure of surgical interventions on the spleen is occupied by its injuries - 76%, in second place are parasitic and solitary cysts - 8% (Ganzhiy V.V. Kravets N.S., 2015; Almyashev A.Z. 2016; Belyaeva O. A. et al., 2016).

At present, despite the methods of organ-preserving and organ-replacement operations that have already been developed and approved as clinical recommendations, the most common surgical tactic for spleen injuries is splenectomy (Useinov E.B., 2006; Shapkin Yu.G., 2006).

In comparison with organ-preserving operations, after splenectomy negative changes occur in both cellular and humoral immunity: the content of monocytes in the blood decreases, the content of immunoglobulins, various fractions of the compliment system, and interleukins decreases (Pavlovsky M.P., 1986; V.V. Maslyakov 2012). The advantage of using, if indicated, organ-preserving operations relative to splenectomy has been shown (Alekseev B.S., 1997; Abakumov M.M., 1998; Alimov A.I., 2005; Tokunada Y., 1995).

To date, numerous options for surgical interventions on the spleen have been developed and introduced into clinical practice, ranging from classical splenectomy, performed through a midline laparotomy, to robot-assisted resections using physical methods of hemostasis.

State of the art.

The literature describes many options for performing organ-saving operations on the spleen, including various options for resection. Resection of the spleen is an operation in which the damaged or pathologically changed part of the organ is removed. Depending on the indications, one or another method of spleen resection may be chosen.

For example, there is a known method for resection of the spleen, which consists in isolating the spleen while preserving the vessels of its upper pole, ligating the main trunks of the splenic artery and vein at the hilum of the organ, resection of the lower 2/3 of the organ along the ischemic border (Patent SU 1641285 A1 dated December 22, 1987) . Its disadvantages are the removal of a large volume of parenchyma; the remaining splenic tissue is deprived of the main blood supply, and also, the question of processing the remaining stump of the upper pole of the spleen remains open.

There is a known method for resection of the spleen, which consists in mobilizing the organ, carrying out and placing a ligature along the interlobar groove, ligating segmental vessels, resection of the damaged part of the spleen and peritonization of the cut with a strand of the greater omentum with preserved axial blood supply and subsequent fixation by suturing through the tissue of the omentum and spleen using a circular ligature (Patent RU 2113177 C1 dated November 16, 1994). Its disadvantages are the use of a strand of the greater omentum with preserved blood supply, which implies a change in the anatomy of the abdominal cavity, a more pronounced adhesive process, and, as a result, the risk of developing intestinal obstruction; also a disadvantage is the risk of developing a hematoma in the area where the strand of the greater omentum adjoins the splenic stump.

There is a known method for resection of the spleen, which consists in performing hemostasis by ligating the arteries of the second order and circular ligation of the spleen with a compression clip made of titanium nickelide attached at the distal end to a traction thread, the free end of which is passed out through the lumen of the drainage tube, resection of the damaged area, fixing a strand of the omentum to the stump of the spleen ( Patent RU 2334476 C1 dated April 23, 2007). The disadvantages of this method are the use of a strand of the greater omentum with preserved blood supply, which implies a change in the anatomy of the abdominal cavity, a more pronounced adhesive process, and as a consequence the risk of developing intestinal obstruction, the risk of developing a hematoma in the area where the strand of the greater omentum adjoins the stump of the spleen, as well as the risk of secondary traumatization of the spleen when removing the compression clip.

There is a known method for bloodless resection of the spleen, which consists in isolating and intersecting the vessels supplying the part of the spleen to be removed, performing radiofrequency ablation along the resection border, under ultrasound control, by immersing the electrode into the parenchyma of the spleen, followed by dissection of the parenchyma using a cutting instrument (Patent RU 2675355 C1 dated 06.06 .2018). The disadvantages of this method are the presence of a zone of necrosis of the spleen stump up to 0.5 cm at the resection border, as well as the need for special equipment to carry out radiofrequency ablation.

Today, in the arsenal of surgeons there are quite a lot of experimental and clinically tested techniques that make it possible to successfully perform organ-saving operations on the spleen. However, none of them is without drawbacks. They, in turn, are quite diverse, including technological, economic and other aspects of the operation. Microsurgical technology opens up real opportunities for creating and performing fundamentally new methods in abdominal surgery (Kagan I.I., Tretyakov A.A., 2015).

Prototype. As a prototype, the authors chose the method of atypical resection of the spleen, developed by Tarasenko S.V. et al. in 2010 (RU Patent No. 2387387 C1 dated April 27, 2010).

The essence of the method is as follows. Treatment of the wound surface of the spleen during its atypical resections is performed, which involves the application of hemostatic sutures to the wound surface of the organ. Manipulations are performed on a dry organ, along the border of the pathological formation and the parenchyma of the spleen, an incision is made in the capsule, a dissection is performed, forming a strongly concave wound surface, the largest vessels are ligated, then the wound surface begins to be sutured “from the bottom”, for this purpose several rows of continuous wrapping hemostatic sutures are applied , and the direction of the stitches is perpendicular to the course of the trabeculae or at an angle to them, and the wound surfaces are brought together like oyster valves, then in the projection of the “flaps” a second group of hemostatic sutures is applied in the form of wide through U-shaped sutures passing through both oyster valves. The disadvantage of this method is the abundance of suture material used, including material with a large diametrical cross-section, which implies severe trauma to the organ.

Disclosure of the invention The purpose of the invention is the development and anatomical and experimental substantiation of a new method of polar wedge resection of the spleen using a through U-shaped suture and microsurgical equipment or medical surgical glue and microsurgical equipment for cystic lesions and trauma to preserve the functionally active parenchyma of the spleen.

The novelty of the invention lies in the proposal of a new method of pole wedge resection of the spleen, based on the use of a through U-shaped suture and microsurgical equipment or medical surgical glue and microsurgical equipment to restore the anatomical integrity of the organ in case of cystic lesions and trauma. Technical result

The technical result achieved by the claimed invention is to ensure the anatomical integrity of the spleen when performing a polar wedge resection, through the use of a through U-shaped suture for a resection depth of up to 2 cm or medical surgical glue for a resection with a depth of more than 2 cm, followed by application of a single-row interrupted microsurgical suture, without capturing the parenchyma, under optical magnification. The inventive method is characterized by reliable hemostasis with minimal organ trauma and precise layer-by-layer contact of stitched homogeneous layers.

The essence of the invention.

The essence of the technique is as follows. The first step is access to the spleen. Next, the blood vessels supplying the operated pole are processed. Then a wedge-shaped resection of the splenic pole is performed at an angle of 45°-60°. Next, one of two methods of restoring the anatomical integrity of the organ is selected: mechanical or combined. With a resection depth of up to 2 cm, a mechanical method is used to restore the anatomical integrity of the organ, in which a through U-shaped suture is applied, followed by the application of an interrupted microsurgical suture to the spleen capsule, under optical magnification. For resection with a depth of more than 2 cm, a combined method is used to restore the anatomical integrity of the organ, in which the edges of the operated pole of the spleen are glued together with medical surgical glue, followed by the application of an interrupted microsurgical suture to the spleen capsule, under optical magnification.

Carrying out the invention

After performing a midline or oblique left subcostal laparotomy, the spleen is mobilized into the surgical wound. Next, ligation and intersection at the hilum of the spleen of one or more branches of the splenic artery with accompanying veins are carried out, according to the site of injury (if the lower pole is damaged, the lower branches are ligated, if the upper pole is damaged, the upper branches of the splenic vessels and short gastric arteries are ligated). A wedge resection is then performed such that a wedge-shaped fragment of the splenic pole is excised. The height of the fragment should be up to craniocaudal length of the organ. The base of the resected fragment is part of the surface of the splenic pole, covered with a capsule. The lateral walls of the fragment in the dorsoventral direction are parts of the visceral and parietal surface of the spleen.

Based on the experimental resections we performed, at different angles, on sectional material, it was found that the most optimal resection angles are 45°-60°. Since, with such a volume of surgery, during the restoration of the anatomical integrity of the organ, there is no excessive tension of the spleen capsule and cutting of sutures. And also, choosing the resection angle within this range allows you to process the required volume of affected tissue.

The exposed splenic parenchyma is dried using gauze pads.

Next, one of two methods of restoring the anatomical integrity of the organ is selected: mechanical or combined. The mechanical method involves restoring integrity through the use of suture material. Indications for it are damage to the pole of the spleen, requiring resection up to 2 cm deep. a similar volume of resection does not affect large vessels with a diameter of 0.6 mm or more. If these conditions are met in the area of resection, the spleen tissue closes tightly without the formation of cavities, and as a result, the risk of developing intraorgan postoperative hematomas, which serve as a source of infectious complications, is minimized. When choosing a mechanical method for restoring the anatomical integrity of the organ, the edges of the operated pole formed during resection of the spleen are brought together and fixed in the reduced state with a through U-shaped suture. 5 Ph polyester is used as suture material. Eur. - synthetic multifilament suture material. The latter allows you to avoid cutting through the spleen tissue and reducing the strength of the formed joint. After the edges of the resected pole of the spleen are brought together, the anatomical integrity of the organ is restored by applying a single-row interrupted microsurgical suture to the spleen capsule. The peculiarity of this suture is to perform precision suturing of the edges of the splenic capsule under optical magnification, without capturing the spleen parenchyma in the surgical suture. Prolene W8706 6/0 75 cm is used as a suture material. After applying a single-row interrupted microsurgical suture, the edges of the splenic capsule must be tightly connected to each other.

A combined method of restoring the anatomical integrity of the organ is chosen in cases where the resection depth is more than 2 cm. Since, based on our macromicroscopic study of 10 preparations of the human spleen, it has been established that at a depth of more than 2 cm from the capsule there are vessels with a diameter of more than 0.6 mm in an amount from 4 to 6 per 1 cm per unit cross-sectional area of spleen tissue in the frontal plane. Working with vessels of this diameter involves more reliable provision of hemostasis, in order to reduce the risk of postoperative bleeding and the formation of intraorgan hematomas. The edges of the operated pole formed during resection of the spleen are treated with medical surgical glue; “Sulfacrylate” was used in the experiment. The glue is applied to the splenic parenchyma in a thin layer using a syringe; the most optimal for this task is a standard 1 ml disposable syringe. for insulin injections. The consumption of surgical glue “Sulfacrylate” is approximately 0.6-0.7 ml, subject to working with a spleen that has normal morphometric characteristics. Next, the edges of the resected pole are brought together and fixed in the brought state manually for 10-15 seconds. Medical surgical glue, in particular “Sulfacrylate”, performs hemostatic, bactericidal and adhesive functions. Next, the splenic capsule is restored by applying a single-row interrupted microsurgical suture using Prolene W8706 6/0 75 cm under optical magnification.

The technical result is achieved by performing a wedge-shaped resection of one of the poles of the spleen at a pre-selected angle. Then the remaining fragments of the operated pole are brought together and fixed using a through U-shaped suture or using medical surgical glue. Next, a single-row interrupted microsurgical suture is applied to the capsule under optical magnification. Indications for choosing a mechanical method for restoring the anatomical integrity of an organ are resections for injuries, cysts and other pathological conditions up to 2 cm deep. Indications for a combined method for restoring anatomical integrity are resections more than 2 cm deep.

The method of polar wedge resection of the spleen allows for the preservation of the spleen, as well as reliable hemostasis with minimal trauma to the organ.

The proposed method achieves improved results in the treatment of spleen diseases, since reliable hemostasis is ensured, precise layer-by-layer contact of stitched homogeneous layers is achieved, cutting through the spleen parenchyma is prevented, and almost all functionally active splenic parenchyma is preserved.

Examples of using. On the cadaveric spleen of a 65-year-old man who died from causes unrelated to the pathology of this organ, a wedge-shaped resection was performed according to the described technique at an angle of 60° (Fig. 1). Next, the operated pole was sutured using a through U-shaped suture made of 5 Ph polyester. Eur. Then a single-row interrupted microsurgical suture was applied to the spleen capsule using Prolene W8706 6/0 75 cm material, under optical magnification of 4 times (Fig. 2). There were no technical difficulties during the manipulation.

On the cadaveric spleen of a 63-year-old woman who died from causes unrelated to the pathology of this organ, a wedge-shaped resection was performed according to the described technique at an angle of 45°, similar to that shown in figure 1. Next, the edges of the operated pole were glued with medical surgical glue “Sulfacrylate” (fig. 3). Then a single-row interrupted microsurgical suture was applied to the spleen capsule using Prolene W8706 6/0 75 cm material, under optical magnification of 4 times (Fig. 4). There were no technical difficulties during the manipulation.

On a laboratory rabbit of the “Grey Giant” breed, under intravenous anesthesia, an oblique left subcostal laparotomy was performed, the spleen was mobilized into the median wound (Fig. 5), segmental blood vessels supplying the upper pole were identified in the thickness of the gastrosplenic ligament (Fig. 6), subsequently ligated, crossed. Next, a wedge-shaped resection of the upper pole of the spleen was performed at an angle of 60° (Fig. 7). Next, the operated pole was sutured with a through U-shaped suture using Prolene W8706 5/0 75 cm. Then a single-row interrupted microsurgical suture was applied to the splenic capsule using Prolene W8706 6/0 75 cm, under optical magnification 4 times (Fig. 8). There were no technical difficulties during the manipulation.

On a laboratory rabbit of the "Grey Giant" breed, an oblique left subcostal laparotomy was performed under intravenous anesthesia, the spleen was mobilized into the median wound, the segmental blood vessels supplying the upper pole were identified in the thickness of the gastrosplenic ligament as demonstrated in figures 5 and 6, subsequently ligated and crossed . Next, a wedge-shaped resection of the upper pole of the spleen was performed at an angle of 60°, as shown in Figure 7. Next, the edges of the operated pole were glued with medical surgical glue “Sulfacrylate” (Figure 9, Figure 10). Then a single-row interrupted microsurgical suture was applied to the spleen capsule using Prolene W8706 6/0 75 cm material, under optical magnification of 4 times (Fig. 11). There were no technical difficulties during the manipulation.

Literature

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Claims (1)

A method of polar wedge resection of the spleen, including isolation, ligation and intersection of blood vessels in the area of the hilum of the spleen, feeding the operated pole, performing a wedge resection of the upper or lower pole, characterized in that the resection of the spleen is carried out at an angle of 45-60°, restoration of the anatomical integrity of the organ is carried out by using a through U-shaped suture for a resection depth of up to 2 cm or medical surgical glue “Sulfacrylate” for a resection depth of more than 2 cm, followed by applying a single-row interrupted microsurgical suture to the spleen capsule under optical magnification.