Method and device for carrying out minimum invasive access for making surgical abdominal and gynecological operations

FIELD: medicine; medical engineering.

SUBSTANCE: method involves piercing anterior abdominal wall tissues. Device is set into the abdominal cavity. The abdominal cavity is filled with gas. Mechanical stretching of tissues is carried out along pierce hole perimeter to make its size enough for performing visual control of surgical actions. Abdominal cavity is unsealed and minimum scale surgical intervention is carried out. Then, the abdominal cavity is sealed and the operation is to be continued with laparoscopic stage. Device has ring-shaped body, spatulas, removable cover having sealing member and stiletto mounted on the cover. The cover and stiletto are coaxially mounted with the ring-shaped device body on its external surface. The spatulas have three parts - the upper one, the middle one and the lower one. The parts are arranged at the same angle to each other and form a convex structure. The convex structure is directed towards inside of the ring-shaped body. The lower part of the spatulas surrounds the stiletto allover its whole length. A hinge having horizontal rotation axis is available in the middle and upper parts zone on the same side with concave part. The hinge is mounted on the ring-shaped body support member. Pushers are available in radial slots of the ring-shaped body. The pushers are engageable with the upper part of the spatulas on one side and with mechanism for making their radial movement on the other side.

EFFECT: accelerated and simplified surgical intervention method.

3 cl, 3 dwg

 

The proposed group of inventions relates to medicine, in particular to abdominal surgery and gynecology, and can be used for emergency and planned surgical treatment.

The known method (patent RU NO. 2123297, AND 61 IN 17/02, And 61 In 17/42) minimally invasive access minilaparotomy operation, which consists in the fact that you are a small incision (3-5 cm), after which the wound is expanding, this creates operational space in the deep tissues.

The disadvantages are the counterpart long, almost as if laparotomy, time of access, the difficulties of manipulation on large bodies, a limited review of the operated organ.

The closest in technical essence is a method of minimally invasive access in laparoscopic (endosurgical operations, namely, what is the tissue puncture, is filling the abdominal cavity with gas, and then entered the laparoscope or an instrument for the further operation Ashbelites. Endoscopic abdominal surgery. - Moscow, 1996. - p.6-26. A well-known tool for the implementation of this method, which represents the stylet or trocar having a site seal, through which are inserted laparoscope or tool.

The disadvantage of the prototype is the high cost of consumables - linking and the preparations clips, loops Roeder, etc., limitation in performing complex operations on large and abdominal organs with high manual techniques. This often causes the need for combined operations, providing the consistent implementation of laparoscopic and minilaparotomy operations. This approach allows a complete overview of the abdominal cavity, to assess pathology and perform minilaparotomy the operation of the refined laparoscopy access. This does not exclude the disadvantages listed above. In addition, they added: lengthening of the period of operation, because the transition from laparoscopic surgery to minilaparotomy takes time; it takes two teams of surgeons.

A well-known tool (patent RU NO. 2123297, AND 61 IN 17/02, And 61 In 17/42) for minimally invasive access minilaparotomy operations containing an annular cage (corps) and the holders with blades. The owners and the blades are connected back to back with the hinge with elastic walls. Each blade has a C-shaped portion, oriented bulge inside the cage (corps). This device is used as a prototype of our proposed device.

The objective of the invention is the ability to perform complex operations on large and abdominal organs; reducing the cost of surgery; laparoscopy and mini is paroemia in one operation and one team of surgeons; the ability minilaparotomy access at any stage of laparoscopy in the required number of times.

The technical result in the use of the invention is to reduce the time and simplify the operation.

To achieve the specified result, in the method of minimally invasive access, which perform the puncture tissue, carry out filling the abdominal cavity with gas and begins laparoscopic surgery, according to the invention, with the use of the device is carried out by mechanical expansion of the tissues around the perimeter of the puncture so that the access area has increased to a size sufficient for visual inspection operating activities, further carry out the decompression of the abdominal cavity and perform minilaparotomy phase of the operation, after which produce a seal of the abdominal cavity by filling it with gas. Then continue laparoscopic phase of the operation.

To achieve a technical result, when implementing the proposed method using the device for operations in abdominal surgery and gynecology, containing a circular casing and blades. According to the invention the device comprises a quick-release cover with hub seal and placed in her stiletto mounted coaxially with the annular casing on its outer surface. The blades have three sections - the upper, redni and bottom, located at an obtuse angle to each other, forming a bulge towards the inside of the ring body. The lower part of the blades along the length covers the stiletto, and in the area of the middle and upper parts of the blades from the side of the concavity of the completed hinge with a horizontal axis of rotation, mounted on a support ring of the housing. In addition, the device contains pushers placed in the radial grooves of the ring body and interacting with one hand with the upper part of the blades, and on the other, with the mechanism of their radial movement (e.g., transmission screw-nut).

The method is implemented as follows.

Perform the puncture tissue and carry out filling the abdominal cavity with gas, according to the traditional technique of laparoscopy set the laparoscope, precise localization of the installation of additional trocars and the proposed device. Perform the puncture tissue of the anterior abdominal wall with the help of the developed device to be installed in abdominal cavity as traditional laparoscopically trocar, preserving the integrity of the abdominal cavity to maintain the imposed gas (pneumoperitoneum, carboxypropyl). Then carry out mechanical tissue expansion around the perimeter of the puncture so that the access area has increased to a size sufficient for visual inspection further op the operating action (the process of tissue expansion can be controlled using a laparoscope). Next, perform the depressurization of the abdominal cavity by removing the quick-release cover with the stiletto and implement minilaparotomy phase of the operation. After completion of producing the sealing of the abdominal cavity by installing a quick-release lid and filling the abdominal cavity with gas recovery pneumoperitoneum. Then continues laparoscopic phase of the operation. If necessary minilaparotomy access using the developed device is provided at any stage of laparoscopy in the required number of times.

The invention is illustrated by the following illustrations:

Figure 1 shows a device for operations in abdominal surgery and gynecology (left part shows the original position of the elements of the device, and right - to-work). Figure 2 shows a section a-a in figure 1. Figure 3 - the proposed method on the example appendectomy consistently presents: 1 - the laparoscopic phase (installation of the trocars, the intersection of the mesentery of the Appendix coagulation); 2 - install the device into the abdominal cavity under the control of the laparoscope; 3 - disclosure of the device, removing gas from the abdominal cavity; 4 - conducting minilaparotomy stage surgery - appendectomy; 5 - sealing device (re laparoscopic phase - control of hemostasis, sanitation); 6 - final VI the anterior abdominal wall after removal of the trocars and instruments.

The device includes a circular casing 1, blade 2, which has three sections - the top 3, middle 4, and bottom 5 located at an obtuse angle to each other, forming a bulge towards the inside annular body 1, a snap cap 6 with node seal 7 and placed in her stiletto 8, mounted coaxially with the annular housing 1 on its outer surface, in the zone of the medium 4 and the top 3 parts of the blades 2 by concavity of the completed hinge 9 with a horizontal axis of rotation, mounted on a support ring 10 of the housing 1 and communicates with one side of the upper 3 part of the blade 2 by means of the plungers 11, from the other - with the mechanism 12 of their radial movement (e.g., transmission screw-nut).

A device that implements the proposed method works as follows.

In the initial position, the blade 8 is located over the site of the seal 7 in the cover 6 mounted on the housing 1, and is covered by a bottom 5 parts of the blades 2. Such a mutual arrangement of the elements of the device allows the tissue puncture. After that, through the mechanism 12 is a radial movement of the plungers 11, which in turn interacts with the upper part 3 of the blade 2, exercise their rotation around the axis of the hinges 9, mounted on the supports 10. The rotation of the blades 2 leads to deformation of the tissue and provides about the education access zones “B” and operational space, increasing as the distance from the skin. Thereafter, the stylet 8 is removed, the gas is discharged, and the clamp cap 6 is removed, opening up access in the operational space. The dimensions of operational zones (upper, middle, lower) depend on the size of the parts 3, 4 and 5 blades 2, which in turn depend on the thickness of the fabric.

Thus, the inventive method and device for its implementation provide: the ability to perform complex operations on large and abdominal organs; reducing the cost of surgery; laparoscopy and minilaparotomy in one operation and one team of surgeons; the ability minilaparotomy access at any stage of laparoscopy in the required number of times.

The method applied in clinical practice for 25 patients. In all cases, there were no intraoperative complications. In all cases, the postoperative period was uneventful. In this way online access operation performed in emergency abdominal surgery in acute appendicitis, destructive cholecystitis, perforated duodenal ulcer complicated by bellbottom, penetrating wound of the abdomen with damage to the small intestine. In a planned surgery for cholelithiasis, peptic ulcer and duodenal ulcer. In gynecology at cystectomy Diarmuid is Oh cysts, tubectomy about pyosalpinx, hydrosalpinx.

Example 1: Emergency surgery. Patient A., 25 years. With suspected acute appendicitis, the patient produced a diagnostic laparoscopy. (Set 10 mm trocar in paraumbilical region, superimposed carboxymaltose entered the laparoscope). The diagnosis of Gangrenous appendicitis. Peritonitis-1. In the left iliac region additionally equipped with a 5 mm trocar in the right iliac region established the developed device. Produced laparoscopic phase of the operation is the primary remediation of serous effusion, the selection of the Appendix, the intersection of the mesentery of the Appendix coagulation. Minilaparotomy phase of the operation: the device is under the control of the laparoscope disclosed in minilaparotomy access 3.5 cm, the depressurization gas is removed from the abdominal cavity, the wound removed the dome of the caecum and Appendix. Ligation of the Appendix at the base of the two ligatures, the Appendix is cut off, the stump is immersed in a purse string suture. The device is sealed imposed carboxymaltose performed laparoscopic stage - examination of the abdominal cavity on hemostasis, sanitation. The device is transferred to the trocar position, under the control of the laparoscope extracted from the abdominal cavity, extracted the remaining trocars. Wounds sutured tightly. Operative time was 40 minutes. The postoperative period smooth, wipes is on day 7 after the operation.

Example 2. Emergency surgery. Patient B., aged 47. Suspected penetrating wound of the abdomen produced diagnostic laparoscopy. (Set 10 mm trocar in paraumbilical region, superimposed carboxymaltose entered the laparoscope). Diagnosed with penetrating wound of the abdomen with multiple damage to the small intestine. In the course of stab wounds, penetrating into the abdominal cavity, right mesogastric installed device. An additional 5 mm trocar is mounted above the fold. Invalid loop of the small intestine connected to the device. Minilaparotomy stage: the device is opened, the gas is removed, the loop of intestine removed in the wound, perforating wounds sutured typical double-row suture. The device is sealed. Laparoscopic stage: further revision, still revealed a damaged loop of the small intestine connected to the device. Second minilaparotomy stage: the device is depressurized. Invalid loop of the small intestine removed in the wound sutured. The sealing. Superimposed gas. Second laparoscopic stage: audit - other pathology it is not revealed. Sanation of abdominal cavity, installing drainage in the right side channel. Device into the trocar extracted. Extracted the remaining trocars. The operation time is 45 minutes. The postoperative period is smooth, the drainage was removed on the 2nd day. The patient was discharged after 10 bottom is after the operation.

Example 3. Patient C., 26 years. The planned operation. The diagnosis of a Dermoid cyst of the right ovary. The volume of surgery: laparoscopic cystectomy, minilaparotomy removing remote cysts. Installed 10 mm trocar in paraumbilical region, superimposed carboxymaltose entered the laparoscope. Under the control of the laparoscope is an additional 5 mm trocar in the left iliac region and the device in the right iliac region. Laparoscopic stage: cystectomy in modes of coagulation and cutting using laparoscopic instruments inserted through a 5 mm trocar and through the device. Esecanna dermoid cyst connected to the device. The device disclosed in minilaparotomy access, depressurized, the cyst is extracted from the abdominal cavity. The device is sealed, the applied gas. Laparoscopic stage - execution control inspection, rehabilitation, installation of control drainage. Device into the trocar, extracted under the control of the laparoscope. Extracted the remaining trocars. The operation time was 35 minutes.

1. The method is minimally invasive access, which is to puncture tissue, filling the abdominal cavity with gas, conducting laparoscopic phase of the operation, characterized in that as the instrument trocar install the device according to claim 2, then carry out mechanical is the expansion of the tissues around the perimeter of the puncture so to access zone increased to a size sufficient for visual control of operating activities, further carry out the decompression of the abdominal cavity, perform minilaparotomy phase of the operation, after which produce a seal of the abdomen and continue laparoscopic phase of the operation.

2. Device to puncture tissue and implementation minilaparotomy access abdominal surgery and gynecology, containing a circular casing and vanes, characterized in that it is provided with a removable cover with a site seal and placed in her stiletto mounted coaxially with the annular casing on its outer surface, and the blades have three sections - top, middle and bottom, located at an obtuse angle to each other, forming a bulge directed inward of the annular body, the lower part of the blades along the length covers the stiletto, and in the area of the middle and upper parts of the blades from the side of the concavity of the completed joint with a horizontal axis of rotation, mounted on a support ring body, and in the radial grooves of the annular body is placed pushers capable of interacting with one hand with the upper part of the blades, and on the other, with the mechanism of their radial movement.

3. The device according to claim 2, characterized in that the radial movement mechanism is made in view of the pumping screw - nut.



 

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