The way of fixing the drainage of the common bile duct during laparoscopic operations

 

(57) Abstract:

The invention relates to medicine, surgery may be used in the treatment of gallstone disease. Kopiruyut the proximal division of the cystic duct in the neck of the gallbladder. Create a hole in the wall. Enter drainage with a pre-fixed methodoloy thread in the common bile duct. Fix the drainage to the cystic duct. Cross cystic duct between clips in the neck. While fixing the drainage is carried out by flashing the front and rear walls of the cystic duct in the form of policyset. Ligatures are secured in the proximal part of the cystic duct in a state of moderate tension. Cross cystic duct simultaneously with ligatures. The method can reduce the probability of insolvency drainage. 1 C. p. F.-ly, 10 ill.

The invention relates to medicine, namely to laparoscopic surgery, and is intended for rational fixing the drainage tube in choledocho during laparoscopic operations.

CHARACTERIZATION OF ANALOGS

1. A known way of fixing drainage in choledocho during laparoscopic operations with clips. Proximal cystic duct cleroidea, distal to the BCI is a side clipping area of the cystic duct at the injection site drainage. The density of clipping the wall of the cystic duct determines the consistency and reliability of fixing of drainage.

The disadvantages of the method:

Most likely migration of the drainage tube.

- The difficulty of determining the insertion depth of the drainage tube.

- The impossibility of application of the method when sclerotiorum, narrow duct of the gallbladder.

(Christian Klaiber, Alegandro Metzger, Joseph C. Petelin. Manual of Laparoscopic Surgeri. Hogrefe & Huber Publishers. Seattle. Toronto. Bern. Gottingen. 1993. 136-137).

2. A known way of fixing the use of drainage from an inflated cuff. Drainage tube with an inflated cuff is introduced into the choledoch through the stump of the cystic duct, when increasing the size of the cuff is clamping the tube in the channel.

The disadvantages of this method:

- Possibility of migration of drainage for reducing the volume of the cuff.

- Obturation duct cuff eliminates the possibility of the opposite control departments of the bile ducts.

The difficulty of choosing and the inability to control the generated volume of the cuff.

- The high cost of the drainage tube with the cuff.

(Karl A. Zucker, M. D. Surgical Laparoscopy update. St. Louis, Missouri 1993).

3. Known installation method, fiksaciya through choledochotomy hole, the defect in the wall of the choledochus removed the stitches. Drainage is recorded in the choledoch due to the T-shaped seam choledocholithiasis holes.

The disadvantages of this method:

- Execution of choledochotomy.

- The probability of geleistete after removal of the drains.

Most invasiveness and complexity of the method.

- High cost of a standard T-shaped tube.

("Endoscopic surgery", 2-3, 1995 Technical aspects of laparoscopic cholecystectomy. Century Century Fedorenko et al. 11-15).

4. A known way of fixing the drainage tube in choledocho with open online access. Drain pipe, pre-fixed methodoloy thread, is inserted into the stump of the cystic duct. One end methodoloy thread stitch the edge of the stump of the cystic duct, connect and alloyed both threads together. Next tie methodoloy thread stump of the cystic duct with drainage and alloyed.

The disadvantage of this method:

- High effort to accomplish during laparoscopic access.

- The possibility of squeezing drainage ligature.

(B. C. Zemke, M. E. Shore Chudkowski, B. E. Kolesnikov. Errors and complications Nar is b fixing the drainage tube silicone elastic ligature with open online access. After carrying out a drainage tube in the choledoch through the stump of the cystic duct around him spend silicone elastic ligature. The ligature is pulled and swallowed by the clamp against the walls of the stump of the cystic duct. Between the clamp and the wall of the cystic duct elastic ligature Perevoznaya nylon thread. Nylon thread stitch peritoneum hepatoduodenal ligament and tied. This technique can prevent the slippage of elastic ligatures with the stump of the cystic duct.

The disadvantage of this method:

- High effort to accomplish during laparoscopic access.

- Perform and unreliable fixation with a short stump of the cystic duct.

(B. C. Pozdnyakov, I. N. Doctor. The rational way of fixing drainage at the stump of the cystic duct. "Herald of the Department of surgery, 1991. so 146. 5-6, S. 110-111).

6. A known way of fixing the drainage tube in the cystic duct during laparoscopic technology using endometry of Roeder. The stump of the cystic duct installed in her drainage tube is fixed in the loop of Roeder.

The disadvantages of this method:

- Lack of control of the length of the introduction of a drainage tube in the choledoch.

(Christian Klaiber, Alegandro Metzger, Joseph C. Petelin. Manual of Laparoscopic Surgeri. Hogrefe & Huber Publishers. Seattle. Toronto. Bern. Gottingen. 1993. 124-126).

CHARACTERISTICS OF PROTOTYPE

A known way of fixing drainage of the cystic duct during laparoscopic surgical technology with flash and doping duct stump.

This method consists in the following. Proximal division of the cystic duct cleroidea, in its distal nadequate wall. In the created hole is inserted a drainage tube with a pre-fixed methodoloy thread. The thread on the drainage fixed at a specified distance required for drainage of the choledochus. Needle ligature stitched the front wall of the cystic duct, drainage is fixed to the channel three intracorporeal knots. Cystic duct between the clip and the drainage crosses.

The disadvantages of this method:

The duration of the manipulation.

Technical difficulties in performing intracorporeal knots and a high risk of thread breakage during alloying.

Failure of the drainage and the presence of postoperative complications.

(A. L. Andreev, E. P. Rybin, V., Achatcialis, complicated diseases of the terminal segment of the common bile duct. "Bulletin of surgery, 156 so. 3. 1997 , S. 30-34).

A method of fixing the drainage of the common bile duct during laparoscopic operations has the following tasks:

- Reducing the complexity of performing laparoscopic drainage of the common bile duct.

- Reduction of time of the operation.

- Reducing the probability of insolvency drainage.

Warning insolvency stump of the cystic duct after removal of the drains.

In the event of insolvency of the stump of the cystic duct after removal of the drain remains a landmark in the tissues (clip) to search for it, if relaparoscopy.

1. The problem solved by the invention, is to reduce the time and complexity of the operation, prevention of postoperative complications. This object is achieved by clipping the two clips of the proximal cystic duct, creating a hole in the wall, the introduction of drainage with a pre-fixed methodoloy thread in the common bile duct and fixing drainage by flashing the cystic duct in the form of policyset. Ligaturing duct simultaneously with ligatures between the proximal 1 and 2 clips.

2. New in the present invention is that the proximal division of the cystic duct kopiruyut two clips, fixing drainage produced by the flashing of the cystic duct in the form of policyset and ligatures fix due to clipping to the proximal part of the cystic duct in a state of moderate tension. Cross cystic duct between the proximal 1 and 2 clips simultaneously with ligatures. The totality of these distinctive features is not known from the prior art and is not obvious to a specialist, so it is the proposed solution meets the criteria of the invention "novelty and inventive step".

This solution has passed clinical testing at the Department of General surgery, Central hospital, Strezhevoy, Tomsk region, thus it meets the criteria of the invention "industrial application".

The proposed method of fixing drainage choledochus (Fig. 1. the scheme consists of the following:

To the drainage tube is fixed kathaluwa ligature and introduced into the abdominal cavity through the epigastric trocar.

- Double clipping of the cystic duct from the gallbladder infundibulum (Fig. 2).

- Introduction to choledoch through the window of the cystic duct drainage fixed ligature (Fig. 5).

- Fixing drainage polyacetyl seam to the wall of the cystic duct (Fig. 6, Fig. 7).

- Clipping of ligatures to the proximal part of the cystic duct in a state of moderate tension (Fig. 8).

- Simultaneous crossing of the cystic duct and ligatures between clips in the neck of the gallbladder (Fig. 9).

These procedures can be performed in time to a strict set forth in the sequence.

Conditions for the exercise of laparoscopic method under visual control on the monitor screen. Used tools and materials: tools for laparoscopic surgery, a silicone catheter with a diameter of 2-3 mm, kathaluwa thread 3 with atraumatic needle, clips 3-4 pieces of titanium.

The method of fixation performed as follows.

Scheme of the proposed method of fixing shown in Fig. 1. Proximal to the cystic duct from the gallbladder infundibulum put 2 clips (Fig. 2). At a given distance in the distal segment of the drainage tube fixed methodology the ligature 3.0 with atraumatic needle. The drainage tube is introduced into Brusno Ssireum disection (Fig. 3, Fig. 4), and the hole injected drainage to the ligature (Fig. 5). Drainage is fixed to the cystic duct by flashing the front and rear walls in the form of policyset (Fig. 6, Fig. 7). Seam and tighten in a state of moderate tension produce clipping of ligatures to the proximal part of the cystic duct (Fig. 8). The last step is a one-stage crossing of the cystic duct between 1 and 2 clips together with ligatures (Fig. 9).

View the stump of the cystic duct with a fixed drainage of the common bile duct (Fig. 10).

Clinical application of this method carried out in 12 patients operated about gallstone disease, surgical complications of opisthorchiasis. The method is applicable in all situations where it is necessary drainage of the common bile duct (the phenomenon of obstructive jaundice, choledocholithiasis, opisthorchosis hepathology, pancreatitis, papilla and stricture of bile ducts).

The drain is removed after the approval of the pathology of the bile ducts in the absence of biliary hypertension.

In all cases, the clinical use was not observed inter - and postoperative complications. The proposed method allows reliable and hermetico consequences.

Example 1. Ill, A. S. 63. History 987. Diagnosis: ECB. Acute calculous cholecystitis. Choledocholithiasis. Chronic opisthorchiasis. XP. opisthorchosis hepathology. 10.07.98 operation - overlay laparola, cholecystectomy, drainage of the choledochus, subhepatic space - laparoscopic access. During the operation after the selection of the cystic duct proximally imposed two clips at a distance of 3 mm Cystic duct dadsetan distal 5 mm of the choledochus. The drainage tube is introduced into the abdominal cavity and installed in the cystic duct by a given distance, limited methodoloy a ligature. This ligature needle stitched medial and lateral wall of the cystic duct in the form of policyset. Ligatures in a state of moderate tension clamped to the cystic duct. Check for leaks - bile is not leaking. Ligatures with the cystic duct is cut off simultaneously between 1 and 2 clips. Complete drainage of the subhepatic space. To install drainage in the bile duct additional trocar was not introduced. In the postoperative period of catching drainage of bile leakage was not observed. After conducting three sessions remote lithotripter of the choledochus removed with prior training and without any technical difficulties. Complications were observed. The patient was discharged in good condition on the 26th day after the operation.

Example 2. Patient C. M. P. 36 years. History 488. Diagnosis: cholelithiasis. Acute flegmonoznih calculous cholecystitis. Opisthorchosis hepathology. 16.04.98 surgery - laparoscopic cholecystectomy, drainage of the common bile duct drainage subhepatic space. During the operation after the selection of the cystic duct proximally imposed two clips at a distance of 2 mm Cystic duct dadsetan distal 5 mm of the choledochus. The drainage tube is introduced into the abdominal cavity and installed in the cystic duct by a given distance, limited methodoloy a ligature. This ligature needle stitched medial and lateral wall of the cystic duct in the form of policyset. Ligatures in a state of moderate tension is fixed by clipping to the cystic duct. Check for leaks - bile is not leaking. The cystic duct is transected proximally simultaneously with ligatures. Complete drainage of the subhepatic space. In the postoperative period of catching drainage of bile leakage was not observed. Drainage choledochus function is through drainage. After relief of biliary hypertension and test rentgenocraniology drainage removed from the choledochus with advanced training. Complications were observed. The patient was discharged on the 12th day in a satisfactory condition.

A positive effect.

The way of fixing the drainage of the common bile duct during laparoscopic operations, by flashing the cystic duct purse string suture and strengthen the ends of the ligatures in the position of moderate tension by clipping to the proximal part of the cystic duct. The ligature is fixed to the drainage tube, determines the depth of insertion of the drainage. Fixing drainage by flashing as polyacetale seam wall of the cystic duct and fixation of ligatures in a state of moderate tension creates the necessary tightness and prevents leakage of bile into the free abdominal cavity. Fixation of ligatures to the cystic duct clips gives you the opportunity to opt out of intracorporeal tying knots, which significantly reduces the operation time and its complexity, increases the reliability and consistency of drainage, reduces the likelihood of postoperative complications. Relatively delicate and at the same time reliable fixate is their clips on the stump of the cystic duct is a guide makes it easy to find when needed relaparoscopy.

Mounting and fixing drainage does not require the introduction of additional trocars, thereby reducing the invasiveness of the surgery and gives cosmetic effect.

1. The way of fixing drainage choledochus, including clipping of the proximal cystic duct in the neck of the gallbladder, the creation of openings in its wall, the introduction of drainage with a pre-fixed methodoloy thread in the common bile duct, fixing it to the cystic duct and the intersection of the cystic duct between clips in the neck of the gall bladder, characterized in that the fixing drainage is carried out by flashing the front and rear walls of the cystic duct in the form of policestate and ligature clip clips in the proximal part of the cystic duct in a state of moderate tension and cross cystic duct simultaneously with ligatures.

2. The way of fixing drainage choledochus under item 1, characterized in that the clipping of the proximal cystic duct spend two clips.

 

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