RU2221501C2 - Method for laparoscopic performance of compression anastomosis - Google Patents
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- RU2221501C2 RU2221501C2 RU2002105416/14A RU2002105416A RU2221501C2 RU 2221501 C2 RU2221501 C2 RU 2221501C2 RU 2002105416/14 A RU2002105416/14 A RU 2002105416/14A RU 2002105416 A RU2002105416 A RU 2002105416A RU 2221501 C2 RU2221501 C2 RU 2221501C2
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Изобретение относится к медицине и может применяться в эндохирургии для лапароскопического выполнения компрессионного анастомоза. The invention relates to medicine and can be used in endosurgery for laparoscopic compression anastomosis.
Известен способ лапароскопического выполнения анастомозов с использованием сшивающих аппаратов типа Эндо-GiA, заключающийся в том, что под видеолапароскопическим наблюдением сближают анастомозируемые части органов, выполняют отверстия, через которые вводят в просвет бранши сшивающего устройства, которым прошивают стенки органов, и рассекают перегородку внутри формируемого анастомоза. При этом образуется механический скрепочный шов (В. П. Сажин, В.В. Диденко, А.С. Ригин. Эндоскопическая хирургия - M. 1995. - С. 23). A known method of laparoscopic execution of anastomoses using Endo-GiA-type staplers is that anastomosed parts of organs are brought together under video-laparoscopic observation, holes are made through which branches of the stapling device are inserted into the lumen, and the walls of the organs are sutured, and a partition is cut inside the anastomosis being formed . In this case, a mechanical stitch seam is formed (V.P. Sazhin, V.V. Didenko, A.S. Rigin. Endoscopic surgery - M. 1995. - P. 23).
Недостатком этого способа является использование сшивающего аппарата, выполняющего механический скрепочный шов. Данный вид шва не исключает несостоятельность, грубое рубцевание анастомоза. Кроме того, в результате прокалывания стенок органов множеством скрепок по периметру анастастомоза повреждаются кровеносные сосуды, что может привести к кровотечению из анастомоза. Вокруг остающегося в организме не рассасывающегося шовного материала формируется хронический воспалительный процесс (Н.Н. Каншин. Хирургия. - 1981. - 7. - С. 86-89). The disadvantage of this method is the use of a stapler that performs a mechanical stitch seam. This type of suture does not exclude insolvency, severe scarring of the anastomosis. In addition, as a result of piercing the walls of organs with many clips around the perimeter of the anastastomosis, blood vessels are damaged, which can lead to bleeding from the anastomosis. Around the non-absorbable suture material remaining in the body, a chronic inflammatory process is formed (NN Kanshin. Surgery. - 1981. - 7. - P. 86-89).
Известен способ лапароскопического выполнения компрессионного анастомоза, выбранный в качестве прототипа (патент РФ 21412263, бюл. 32, опубл. 20.11.99). A known method of laparoscopic execution of a compression anastomosis, selected as a prototype (RF patent 21412263, bull. 32, publ. 20.11.99).
Данный способ лапароскопического выполнения компрессионного анастомоза заключается в том, что в условиях пневмоперитонеума или лапаролифтинга под видеонаблюдением сближают стенки анастомозируемых органов и на их прилежащих сторонах формируют отверстия, через которые вводят сшивающее устройство, представляющего собой два витка проволоки из металла с "памятью формы", соприкасающиеся по образующей, снабженные термоэлементом для его охлаждения. Прекращение охлаждения приводит к нагреванию устройства и соединению стенки органов путем их компрессии. Стенки органов внутри анастомоза рассекают эндоножницами. Оставшийся дефект (окно) анастомоза ушивают любым из способов. This method of laparoscopic compression anastomosis consists in the fact that under the conditions of pneumoperitoneum or laparolifting, the walls of the anastomosed organs are brought together under video surveillance and holes are formed on their adjacent sides through which a stapler is inserted, which is two turns of metal wire with “shape memory” in contact along a generatrix equipped with a thermocouple for its cooling. The cessation of cooling leads to heating of the device and the connection of the walls of the organs by their compression. The walls of the organs inside the anastomosis are cut with endoscissors. The remaining defect (window) of the anastomosis is sutured in any way.
Существенными недостатками этого способа являются:
1. Технические сложности, связанные с необходимостью постоянного охлаждения сплава с "памятью формы" и использования с этой целью термоэлемента, обусловливающего громоздкость всей конструкции. Это затрудняет манипулирование в брюшной полости при наложении анастомоза и усложняет ход операции, что отрицательно влияет на его надежность анастомоза.Significant disadvantages of this method are:
1. Technical difficulties associated with the need for constant cooling of the alloy with a “shape memory" and the use of a thermocouple for this purpose, which makes the entire structure cumbersome. This makes it difficult to manipulate in the abdominal cavity when applying an anastomosis and complicates the course of the operation, which negatively affects its reliability of the anastomosis.
2. Рассечение стенок органов эндоножницами через небольшое окно анастомоза может привести к случайному травмированию стенок органов. 2. Dissection of the walls of organs with endoscopic shears through a small window of the anastomosis can lead to accidental injury to the walls of organs.
Задачей изобретения является упрощение способа лапароскопического выполнения компрессионного анастомоза и возможность безопасного рассечения тканей внутри компрессионного элемента. The objective of the invention is to simplify the method of laparoscopic compression anastomosis and the possibility of safe dissection of tissues inside the compression element.
Поставленная задача решается тем, что чрескожно в брюшную полость вводят атравматическую прямую или лыжеобразную иглу с нитью, которой накладывают серозно-мышечный шов на анастомозируемые органы, иглу с нитью вновь выкалывают из брюшной полости наружу и натягивают нить таким образом, чтобы анастомозируемые части органов находились в подвешенном состоянии, при этом оба конца нити снаружи фиксируют, а в отверстия органов с помощью аппарата для компрессионного анастомоза вводят компрессионное устройство, выполненное в виде анастомозной клипсы из нержавеющей пружинной стали, и рассекают ткани внутри компрессионного устройства ножом аппарата, затем изнутри потягивают за концы атравматической нити, вновь погружают последнюю в брюшную полость и ушивают окно анастомоза той же нитью. The problem is solved in that an atraumatic straight or ski-shaped needle with a thread is inserted percutaneously into the abdominal cavity, with which a sero-muscular suture is placed on the anastomosed organs, the needle with the thread is again punctured from the abdominal cavity and the thread is pulled so that the anastomosed parts of the organs in a suspended state, while both ends of the thread are fixed from the outside, and a compression device made in the form of an anastomotic is inserted into the openings of organs using the apparatus for compression anastomosis clips made of stainless spring steel, and they cut the tissue inside the compression device with a knife of the device, then from the inside they pull at the ends of the atraumatic thread, again immerse the latter in the abdominal cavity and suture the anastomosis window with the same thread.
На. фиг.1 изображен этап выполнения двух отверстий на подвешенных на нити-держалке анастомозируемых органах. On the. figure 1 shows the step of making two holes on anastomosed organs suspended on a thread-holder.
На фиг.2 показан этап ввода браншей аппарата для компрессионного анастомоза в сформированные отверстия в органах. Figure 2 shows the step of introducing the branches of the apparatus for compression anastomosis into the formed openings in the organs.
На фиг. 3 законченный анастомоз с видом компрессионного устройства в просвете органов. In FIG. 3 complete anastomosis with the appearance of a compression device in the lumen of the organs.
Предлагаемый способ лапароскопического наложения компрессионного анастомоза осуществляется следующим образом. The proposed method of laparoscopic application of compression anastomosis is as follows.
В условиях пневмоперитонеума под видеонаблюдением сближают анастомозируемые органы: желчный пузырь 1 и петлю тонкой кишки 2. В брюшную полость через кожу проводят иглу с нитью 4 из рассасывающегося шовного материала (vicryl) так, чтобы конец нити 4 остался снаружи. Накладывают серозно-мышечный шов между органами 1 и 2. Подтягивая за наружный конец нити 4, приподнимают их в брюшной полости. С помощью электрокоагулятора 5 в режиме резания формируют отверстия 6 в стенках органов 1, 2 таким образом, чтобы они располагались рядом с нитью-держалкой 4. В сформированные отверстия 6 вводят бранши аппарата О.Б. Оспанова для компрессионных анастомозов 7 (патент РФ 2128012, опубл. 27.03.99) с помощью эндозажима 11. Между бравшими аппарата 7 разведены силовые витки компрессионного устройства (анастомозной клипсы) 8, представляющего собой два витка проволоки, соприкасающейся по образующей и имеющей овальную форму. Сводят бранши аппарата 7, накладывают анастомозную клипсу 8 на стенки органов 1, 2 и одновременно рассекают ткани внутри клипсы 8 с помощью ножа аппарата 7. Компрессия анастомозируемых органов 1, 2 осуществляется за счет упругости анастомозной клипсы 8. Дефект в анастомозе 9 после извлечения аппарата 7 ушивают нитью-держалкой 4 ручным способом узловыми швами 10. Under the conditions of pneumoperitoneum, anastomosed organs are brought together under video surveillance: the
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