RU2674860C1 - Method of laparoscopic tubectomy or adnexectomy - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to the field of medicine, namely gynecology, and can be used to perform tub- or adnexectomy. Transumbilical access to the abdominal cavity is performed, while performing two incisions in the lower semicircle of the navel. Anterior abdominal wall is punctured in the iliac region on the side of the lesion by introducing a thread into the abdominal cavity on a needle that is stitched with mesosalpinx on the side of the lesion in the distal part of the ampulla of the fallopian tube. Perform needling on the opposite side of the lesion. Free ends of the thread is removed on the skin on both sides. By pulling the thread at its free ends, create an exposure of the organ to be removed. Mobilization and excision of the organ to be removed are performed through the transumbilical access incisions created. Removed drug is removed from the abdominal cavity.EFFECT: method provides tubectomy or adnexectomy with minimal surgical trauma, the absence of significant pain in the postoperative period, good cosmetic effect by creating the exposure of the organ to be removed using a thread instead of a third instrument.3 cl, 3 dwg, 3 ex

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to gynecology, and can be used to perform tubal or adnexectomy on one or both sides with minimal trauma to the anterior abdominal wall, in the event of a tubal pregnancy without bleeding, which threatens the patient's life; neoplasms of the uterine appendages of small sizes requiring adnexectomies; torsion of uterine appendages requiring adnexectomy.

State of the art

The prior art method for conducting tubal and adnexectomy using mini-laparoscopic technique. A laparoscope is installed through a 2-3.5 mm port at the lower point of the tracing paper, two working trocars - in the iliac regions. The port diameter in the left iliac region is 2 mm, and in the right, depending on the size of the removed drug, 5 or 10 mm. Tools used: clamps, dissectors, straight and curved scissors, bipolar clamps. The technique of operation is similar to the technique of laparoscopic tube and adnexectomy using bipolar clamps (Stegniy K.V., Sarvanov I.A., Matsak V.A., Krekoten A.A.

"Mini-laparoscopy in abdominal surgery" Pacific Medical Journal, No. 1 (31), 2008, pp. 77-81).

The prior art also known method of tubal and adnexectomy using single-port transumbilical laparoscopy. Using a Veres needle, an abdominal puncture is performed through the umbilical ring and a strained carboxyperitoneum is applied. A 5-mm trocar is installed transumbilically, an endoscope is inserted and a laparoscopy is performed. An endoscope and trocar are removed. An incision is made in the abdominal cavity with a length of 3 cm, a device for single-port intervention is installed. The operation technique is similar to the classical laparoscopic tube and adnexectomy technique. The drug is recovered through port access. (Marinkin I.O., Odintsov V.A., Shevela A.I., Anischenko V.V. Experience in performing subtotal hysterectomies from a single access. Journal of Obstetrics and Female Diseases, 65 (1), 43-47, 2016 - prototype). However, the disadvantage of this technique is the need for a 3 cm long incision, which allows one to challenge the advantages of this option in comparison with the claimed technique.

The prior art method of tub- and adnexectomy using laparotomy access (Gynecology: textbook / B. I. Baisova and others; edited by G. M. Savelyeva, V. G. Breusenko. - 4th ed., Revised . and additional - 2011 .-- 432 p.). With laparotomy access for surgery on the pelvic organs, it is necessary to open the anterior abdominal wall. The most acceptable in gynecology are median gluttony and cross section according to Pfannenstiel. In the midline incision, the anterior abdominal wall is opened in layers from the bosom (upper edge) to the navel. When the Pfannenstiel incision is made, the skin, subcutaneous tissue are dissected by a transverse incision parallel to the bosom and above it by 3-4 cm. The incision length is usually 10-12 cm. The aponeurosis is opened in the form of a horseshoe, the upper edges of the incisions on both sides should be at the navel . Intramuscular fascia (between the rectus abdominis muscles) at any incision is opened by the acute route. When opening the peritoneum, it is important to raise it with soft tweezers and carefully cut it (in the middle between the womb and the navel) so as not to damage the loops of the intestine and the bladder under the bosom. The peritoneum is fixed with clamps to napkins, which are laid along the cut on both sides. The anterior abdominal wall can be dissected with either a scalpel or an electric knife with coagulation or ligation of the vessels with suture material (silk, catgut, vicryl). After dissection of the anterior abdominal wall, it is necessary to visually and palpate with a hand inserted into the abdominal cavity to revise the abdominal organs. Then the dilator is introduced, and the intestinal loops are carefully moved with a napkin to the upper abdominal cavity, thereby providing an overview and accessibility of the pelvic organs. When removing an organ or part of an organ, first of all, the vessels are pinched, and then they cross with subsequent ligation. It is possible to dissect fabrics with scissors. For suturing the ligamentous apparatus, blood vessels, stumps of the cervix and the walls of the vagina, silk, catgut, vicryl, etc. are used.

Technique for removal of the fallopian tube. To remove the fallopian tube, a clamp (Kocher) is applied to the mesosalpinx and the isthmus of the fallopian tube, in which the branches of the ovarian and uterine arteries and veins pass. The tube is cut off above the clamps and removed from the abdominal cavity (the material is sent for histological examination). The mesosalpinx under the clamp is stitched and tied with a ligature, carefully removing the clamp of Kocher. At the corner of the uterus after cutting off the isthmus of the tube, 1-2 individual sutures are applied. Peritonization can be performed with a continuous suture, connecting the peritoneum sheets of the wide uterine ligament. The area of the isthmus of the tube, as a rule, is peritonized with a round uterine ligament (Gynecology: textbook / B.I. Baisov et al .; edited by G.M.Savelyeva, V.G. Breusenko. - 4th ed., Revised and add. - 2011 .-- 432 p.).

Technique for removing uterine appendages. Surgical clamps (Kocher) are placed on the funnel-pelvic ligament, in which the ovarian artery passes; mesosalpinx; own ligament of the ovary with branches of the ovarian and uterine vessels passing through it; isthmus pipe. Uterine appendages are cut off above the clamps. The cults are ligated with separate sutures. Peritonization is carried out by the peritoneum sheets of the wide uterine ligaments and the round uterine ligament. The appendages of the uterus after clipping are removed from the abdominal cavity and sent for histological examination (Gynecology: textbook / B.I. Baisova et al .; edited by G.M.Savelyeva, V.G. Breusenko. - 4th ed., Revised) . and add. - 2011. - 432 p.). However, the known method is significantly more invasive, accompanied by higher levels of intraoperative blood loss and a high likelihood of adhesions in the abdominal cavity.

Disclosure of invention

A technical problem to be solved is the achievement of a good cosmetic effect when performing a tubectomy or adnexectomy.

Achievable technical result is a tubectomy or adnexectomy with minimal surgical trauma, the absence of significant pain in the postoperative period, a good cosmetic effect, by creating an exposition of the removed organ using a thread instead of the third instrument.

The reduction in the invasiveness of the intervention is due to the execution of 2 incisions of 5 mm with an interval of 2 mm along the lower pole of the navel and two punctures. Unlike single-port laparoscopy, in which the required incision length is 3 cm, the small incision length can significantly reduce the risk of umbilical hernia.

In addition, the implementation of the developed method is not accompanied by significant damage to the anterior abdominal wall, as well as high numbers of intraoperative blood loss.

These aspects of the technical result are provided by the following set of essential features:

- carry out transumbilical access into the abdominal cavity, while performing two incisions in the lower umbilical semicircle (optimal sizes are 5.0 mm length each incision, incisions are made at a distance of 2 mm from each other);

- carry out a puncture of the anterior abdominal wall in the iliac region on the lesion side, introducing a thread on the needle into the abdominal cavity, with which mesosalping is sewn on the lesion side in the region of the distal part of the ampullar uterine tube, puncture with a needle on the side opposite to the lesion, the free ends of the thread are brought to the skin on both sides, by pulling the thread at its free ends, create an exposure of the removed organ;

- the mobilization and excision of the removed organ is performed through the created sections of transumbilical access. After excision of the removed preparation, the said sections are connected and inserted into the abdominal cavity through the endocontainer obtained by access. The removed preparation is placed in a container and removed from the abdominal cavity.

The method is as follows.

Under combined endotracheal anesthesia after processing the surgical field with emphasis on the navel along the lower pole of the navel, in its inner part, 2 incisions of 5 mm with an interval of 2 mm are performed. Set the trocar 5 mm and pump the carboxyperitoneum. A 5 mm trocar is installed through the second incision, the patient is transferred to the Trendelenburg position, and the organs of the abdominal cavity and pelvis are revised.

After intraoperative confirmation of the diagnosis, a thread is inserted into the abdominal cavity through the anterior abdominal wall in the right iliac region on an integrated large diameter needle. The mesosalpinges of the fallopian tube are stitched on the affected side in the projection of the distal part of the ampullar section. Knotted knot. The free end of the thread with a needle is punctured in the left iliac region. Further, the assistant has the ability to create an exposure of the removed organ by pulling the ends of the thread. Using a dissector with connected monopolar coagulation (depending on the preferences of the surgeon, the bipolar coagulation and scissors can be used alternately) intersect the funnel-pelvic ligament, the ovary's own ligament, mesosalping and the ischemic uterine tube. The removed organ remains fixed on the thread.

Then a working trocar is removed, skin incisions are connected, an endocontainer is inserted into the abdominal cavity and, under the control of vision (trocars are set back), they are placed in the adjacent space.

The removed organ is placed in a container and removed from the abdominal cavity.

If necessary, sanitize the pelvic cavity, carboxyperitoneum is removed, trocars are removed. Separately sutured aponeurosis and skin.

The invention is illustrated by the figures:

FIG. 1. Scheme of two cuts in the lower semicircle of the navel 5.0 mm long each at a distance of 2 mm from each other for the installation of trocars.

FIG. 2. The position of the instruments during the operation. Stitching of the mesosalpinges of the fallopian tube on the affected side in the projection of the distal part of the ampullar section.

FIG. 3. Providing exposure to the removed organ by pulling the thread.

The positions in the figures indicate: 1 - transumbilical access: two incisions 5 mm long at a distance of 2 mm from each other in the lower semicircle of the navel; 2 - ovary; 3 - fallopian tube;

4 - the uterus; 5 - puncture of the anterior abdominal wall of the iliac region for introducing the thread on the needle into the abdominal cavity; 6 - thread for flashing mesosalpinges on the lesion side in the distal part of the ampulla of the fallopian tube, by pulling the thread at its free ends, create an exposure of the organ to be removed; 7 - a place for flashing mesosalpinges with a thread; 8 - trocars; 9 - laparoscopic instruments; 10 - bladder; 11 - the rectum; 12 - the back wall of the pelvic cavity; 13 - external iliac vessels.

The developed method performed 37 such operations. During operations and in the postoperative period, complications were not recorded. The average duration of operations was 30 min for tubectomies, 40 min for adnexectomies, and 50 min for bilateral adnexectomies. The length of stay of patients in the hospital was 1-2 days after surgery.

Example No. 1.

Patient A., 30 years old. Received complaints of spotting on the 15th day of delayed menstruation, a positive urinary pregnancy test. Ultrasound: in the uterine cavity, the fetal egg is not visualized, the formation of mixed echogenicity near the right ovary is 20 * 15 mm in size, there is no free fluid in the abdominal cavity. Beta-hCG - 1010 mIU / ml.

Diagnosis: tubal pregnancy on the right.

Achieved: transumbilical access to the abdominal cavity (two incisions in the lower semicircle of the navel, 5.0 mm long, each at a distance of 2 mm from each other); puncture of the anterior abdominal wall in the right iliac region, insertion of a thread on the needle into the abdominal cavity. Mesosalpinges is stitched on the right in the region of the distal part of the ampulla of the fallopian tube, a needle is poked out on the left. Using monopolar coagulation, the mesosalpinges and fallopian tube in the isthmic section were crossed and removed from the abdominal cavity in the endocontainer.

The postoperative period without complications, pain was absent.

Example No. 2.

Patient N., 60 years old. Diagnosis at admission: neoplasm of the right ovary in menopause. Ultrasound: anechogenic formation of the right ovary 30 * 20 mm, other pelvic organs without pathology. Gastroscopy, colonoscopy - without features.

Achieved: transumbilical access to the abdominal cavity (two incisions in the lower semicircle of the navel, 5.0 mm long, each at a distance of 2 mm from each other); puncture of the anterior abdominal wall in the right iliac region, insertion of a thread on the needle into the abdominal cavity. Mesosalpinges is stitched on the right in the region of the distal part of the ampulla of the fallopian tube, a needle is poked out on the left. Crossed, the funnel-pelvic ligament, meso-ovarian, own ovarian ligament, fallopian tube in the isthmus on the right. The uterine appendages on the right are removed from the abdominal cavity in the endocontainer. Histological examination: serous cyst of the right ovary.

The postoperative period without complications, pain was absent.

Example No. 3.

Patient N., 58 years old. Diagnosis at admission: neoplasm of both ovaries in menopause. Ultrasound: anechogenic formation of the right ovary 30 * 20 mm, the left ovary - 15 * 25 mm, other pelvic organs without pathology. Gastroscopy, colonoscopy - without features.

Achieved: transumbilical access to the abdominal cavity (two incisions in the lower semicircle of the navel, 5.0 mm long, each at a distance of 2 mm from each other); puncture of the anterior abdominal wall in the right iliac region, insertion of a thread on the needle into the abdominal cavity. Mesosalpinges are sewn on the right and left in the region of the distal part of the ampullar section of the fallopian tube, the needle is punctured on the left. Crossed, the funnel-pelvic ligament, meso-ovarian, own ovarian ligament, fallopian tube in the isthmus on both sides. The appendages of the uterus on the right and left are removed from the abdominal cavity in the endocontainer. Histological examination: serous cysts of the right and left ovaries.

The postoperative period without complications, pain was absent.

Claims (3)

1. The method of laparoscopic tubectomy or adnexectomy, including the implementation of transumbilical access to the abdominal cavity, mobilization, excision of the removed drug and removing it from the abdominal cavity, characterized in that access to the abdominal cavity is limited by transumbilical access, while performing two incisions in the lower semicircle of the navel; Then, the anterior abdominal wall is punctured in the iliac region on the lesion side, introducing a thread on the needle into the abdominal cavity with which mesosalpses are stitched on the lesion side in the region of the distal part of the ampulla of the fallopian tube, then the needle is punctured on the side opposite to the lesion, the free ends of the thread are brought out on the skin on both sides, by pulling the thread at its free ends, create an exposure of the removed organ; mobilization and excision of the latter is performed through the created sections of transumbilical access; the removed preparation is removed from the abdominal cavity. 2. The method according to p. 1, characterized in that the length of the cuts in the lower semicircle of the navel is 5.0 mm each, while the distance between the cuts is 2 mm 3. The method according to p. 1, characterized in that after excision of the removed preparation, the said incisions are connected and inserted into the abdominal cavity through the obtained access endocontainer, into which the removed preparation is placed for extraction.

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