RU2258477C2 - Method for forming vasoepididymoanastomosis - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: one should apply microsurgical anastomosis between a spermatic duct and epididymis in area of isolated loop of epididymal duct. Moreover, at first, one should form a posterior "lip" of anastomosis, then it is necessary to form a free loop of coiled epididymal duct of 2 cm length. One should invaginate a loop with a button-type probe into the lumen of spermatic duct in urethro-loop direction. Above the loop invaginated into the lumen of spermatic duct one should form anterior "lip" of anastomosis. The innovation enables to simplify the technique to form vasoepididymoanastomosis at treating male sterility.

EFFECT: higher efficiency.

2 dwg

Description

The invention relates to medicine, to the field of surgery, and directly to the technique of forming an anastomosis of hollow organs.

A known method of invasive vasoepididymostomy, including a microsurgical anastomosis between the vas deferens and the epididymis in the area of the crossed convoluted tubule, in which the deferent duct is dissected to the lumen 12-15 mm in length, and the epididymis capsule is dissected in the tail region along the midline of 9-12 mm, form a loop of the convoluted tubule of the appendage of 2-2.5 cm, form the lower "lip" of the anastomosis between the muscle layer of the vas deferens and the edge of the capsule of the epididymis, cross the loop of the convoluted tubule in the middle, its distal section is coagulated, and the proximal section is modeled on a cannula inserted into the lumen of the canaliculus, medical glue is applied around the edge of the canaliculum, 1-3 “holders” of atraumatic suture material 8 / 0-10 / 0 are applied to the rim, after 1-3 minutes, the end of the tubule is immersed in the lumen of the vas deferens to a depth of 4-6 mm or connected by the type of "end to end", fixed with interrupted sutures and form the upper "lip" of the anastomosis. As an adhesive, take the medical composition MK-6, KL-3 (RF Patent No. 2195206, class 7 A 61 B 17/00, published December 27, 2002. Authors: Leonid Poluektov, Vladimir Leonid Poluektov, Evgeny Pavlovich Krikoryants, Makushin Dmitry Gennadievich, Kuznetskiy Yuri Yakovlevich).

There is a known method of invagination vasoepididymostomy with deep antegrade immersion and fixation of the free stump of the epididymal duct in the lumen of the dissected vas deferens (Patent of the Russian Federation for the invention of the same authors No. 2195205 was registered in the State Register of Inventions of the Russian Federation on December 27, 2002).

The objective of the invention is to increase the efficiency and simplification of the technique for the formation of vasoepididymoanastomosis to improve the treatment of male infertility in obstruction of the vas deferens.

The problem is solved in that in the method of forming a vasoepididymoanastomosis, which includes a microsurgical anastomosis between the vas deferens and the epididymis in the area of the marked loop of the convoluted duct of the appendage, form the posterior "lip" of the anastomosis, then form a free loop of the convoluted duct of the appendage of the anterior duct 2 cm long in the lumen of the vas deferens in the urethropetic direction and above the loop of the convoluted duct of the appendage immersed in the lumen of the duct, form the anastomic anterior lip a.

The proposed method is illustrated by drawings.

The figure 1 shows the location of the anastomosed holes.

The figure 2 shows the intussusception of an intact loop of the appendage duct into the lumen of the vas deferens, where 1 is the vas deferens, 2 is the epididymis, 3 is the loop of the convoluted tubule, 4 is the capsule-muscular suture of the posterior "lip" of the anastomosis.

In an experiment on dogs, the effectiveness of invasive vasoepididymostomy (RF Patent for an invention of the same authors No. 2195205 was registered in the State Register of Inventions of the Russian Federation on December 27, 2002), studied by retrograde injection of dye (methylene blue and black carcass) into the duct, amounted to 84.6% patency of 11 of 13 formed anastomoses (Poluektov V.L., Makushin D.G., Reis B.A., Matushenko A.A., Kuznetskiy Yu.Ya., Reis A.B. "Invasive vasoepididymoanastomosis in experiment" Appendix to the journal "Andrology and Genital Hiru rgiya ", Abstracts of scientific works of the PAAR, M., 2002, No. 3, p. 32). We conducted a histological examination of these 13 vasoepididymoanastomoses, within 6 months after surgery. A morphological study of serial sections of hematoxylin-eosin stained anastomotic preparations revealed in all cases the formation of an anastomosis not of the end-to-end type, as is the case with the creation of the anastomosis, but of the end-type of the bringing duct of the epididymis into the side of the duct of the vas deferens the area of the scar wall of the latter. Thus, in all the studied preparations, in the lumen of the vas deferens, there was no invaginated delivery stump of the appendage duct. We regard this fact as a consequence of ischemic necrosis with subsequent autolysis of the part of the appendage duct, which is isolated from the epididymal duct and is located in the lumen of the vas deferens. When retrograde staining of anastomoses with blue and mascara, 11 of 13 anastomoses (84.6%) were passable, while a morphological study revealed 12 of 13 anastomoses (92.3%) as passable, since in one retrograde impassable anastomosis, there was pronounced folding of the mucous membrane forming a valve for retrograde flow, while the anti-hail patency for the seed was preserved.

Thus, we have revealed the mechanism of morphogenesis of this variant of vasoepididyimanastomosis, passing through a heart attack and autolysis of the free adductor duct stump extracted from the tissue and giving, even in the presence of sperm passage, a high percentage of patency of the formed anastomosis after 6 months (92.3%).

The healing mechanism revealed in the described study can be used to increase the efficiency and significantly simplify the technique of vasoepididymoanastomosis.

The method is as follows:

Before surgery, a permanent urethral catheter is inserted into the bladder, which is fixed to the penis with a band-aid. Under endotracheal or intravenous dissociative anesthesia after shaving and treatment of the surgical field with antiseptics with a scrotum access 4-4.5 cm long with hemostasis, a testicle with an appendage 2 and an initial section of the vas deferens 1 is excreted, which is removed into the wound. From this moment, an operating microscope (stereoscopic microscope MBS-10) with a magnification of 2x-6x, microsurgical instruments and equipment is used. In the projection of the tail of the appendage, the vas deferens are punctured in the distal direction with a needle No. 21, through which a dye is injected with a syringe in a volume of 1.5-2 ml. By staining urine in the urethral catheter, the patency of the vas deferens is assessed on the test side. In the case of patency of the vas deferens 1, on it, as close as possible to the tail of the appendage, choose an avascular zone that does not contain branches of the lower sperm nerve. In a selected place with a scalpel No. 11, the vas deferens 1 is dissected along 12-15 mm through the entire thickness of the duct wall to its lumen. With scissors above the stagnant loops of the epididymis, the capsule of the last 2 is cut in the midline along 9-12 mm. The edges of the dissected capsule are used in the future to create an anastomosis by the outer row of sutures 4 between the capsule of the appendage 2 and the muscular wall of the vas deferens 1. Using m / x technique with atraumatic material 3 / 0-4 / 0 with separate interrupted sutures with a step of 0.8-1, 0 mm impose anastomosis between the posterior lip of the wound of the vas deferens and the corresponding lip of the dissected capsule of the epididymis 4. Two tissue anatomical tweezers divide the tissue around the duct of the appendage, releasing it from the surrounding tissue, and form an uninjured The instrument free loop 2 cm. The free flow loop 3 appendage invaginate into the lumen of the vas deferens in one direction uretropetalnom bellied probe without tension. Above the free loop of the appendage duct immersed in the lumen of the vas deferens, the anastomosis anterior “lip” is formed, in the same way as its posterior “lip”. The scrotum wound is sutured in layers on a rubber graduate left for one day.

The mechanism of morphogenesis of the healing of anastomosis during deep invagination of the free part of the epididymal duct that flows through the infarction and autolysis of the latter, revealed in the experiment (RF Patent for an invention of the same authors registered in the State Register of Inventions of the Russian Federation on December 27, 2002), makes it possible to exclude surgical manipulations on the convoluted duct of the appendage, which allows us to significantly simplify the technique of forming a vasoepididymoanastomosis, limiting ourselves only to immersion of the isolated stated failures loop ductal appendage into the lumen of the vas deferens and the formation of capsule-muskulyarnogo suture anastomosis.

This method of forming an anastomosis is the least traumatic, since the anastomosis line itself not only has no seams, but is also formed without experiencing mechanical stress.

Claims (1)

A method of forming a vasoepididymoanastomosis, including a microsurgical anastomosis between the vas deferens and the epididymis in the area of the allocated loop of the duct of the appendage, characterized in that the posterior "lip" of the anastomosis is formed, then a free loop of the convoluted duct of the appendage 2 cm long is formed, which invaginate the ducts of the ducts in the urethropetic direction, and above the free loop of the appendage duct immersed in the lumen of the vas deferens, the anastomosis anterior “lip” is formed.

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