RU2173965C1 - Retractor - Google Patents

Abstract

FIELD: medicine, in particular, herniology. SUBSTANCE: the retractor has retractive feet that are made integral in their proximate part and form a V-shaped plate. One of the feet is installed on this plate with the aid of a hinge for movement in one plane relative to the other fixed foot with formation of an angle between them. The movable foot is fixed in the necessary position with the aid of a screw engageable with two lugs rigidly installed near the internal faces of the feet. One of the lugs installed on the movable retractive foot is threaded. In the other foot the screw end is flared out for rotation. The base of the feet is rigidly fastened on a cylindrical bar for turning, and whose inner surface is congruent to the bar outer surface. For turning the bush with the feet up an arm is rigidly fastened on their base. A row of coaxial holes for a cotter pin for fixing the feet in the preset position at their lifting and lowering on the generator of the bush and bar respectively. EFFECT: enhanced efficiency of operative treatment of inguinal hernias due to reduced traumatism of operations, use of a synthetic net for closing of a hernial defect, reduced period of patient stay in the surgical hospital. 3 dwg

Description

 The invention relates to medicine, namely to general surgery and, in particular, to its section - herniology.

 Modern herniology has accurate anatomical information and the greatest practical experience, however, the problem of the treatment of hernias of any localization remains relevant and very far from its solution. Evidence of this fact is the presence of more than 400 surgical methods, but none of them can guarantee the patient from a hernia recurrence. According to the authors, relapse after open hernioplasty occurs in 5-7% of the operated patients, and with repeated interventions up to 30% or more. Modern endoscopic technology has allowed a number of radical changes to be made to the hernia repair technique, which has significantly reduced the occurrence of hernia relapse by up to 4.5%. However, this method also brings with it a number of negative aspects: the use of gas for the purpose of applying pneumoperitoneum can become a source of subcutaneous emphysema. Also, the use of gas in extraperitoneal LTP (laparoscopic hernioplasty) to create a cavity in the preperitoneal space during perforation of the peritoneum can become a source of pneumoperitoneum, and this complicates the course of further surgery. In connection with the presence of all the above circumstances, we offer a new method and device that allows you to use the minimally invasive surgical method without using gas for the operating room.

 A device for hernia repair by laparoscopic means, which is a shell of a tubular shape, inside which is located a piston. The device has a bifurcated distal part, which forms a loop, the proximal part of this device is facing the surgeon. A patch is fixed on the loop, which moves together with the loop, which allows you to bring and fix the patch in the right place, covering hernial defects (A 61 B 19/00 (10) 0362. 02.007.96. USA 5366460 A. Inventions of the world, 1996 ., N 2, p. 82).

The disadvantages of this tool:
- the use of gas to create a cavity in the field of operational action;
- the inability to re-strengthen the patch on the loop in case of an unsuccessful first attempt to establish and fix the patch;
- the need to use the entire complex of laparoscopic and endoscopic equipment to perform the intervention.

 Known surgical retractor containing two movable rods, between which a flexible elastic web is reinforced. After insertion into the stomach, the rods are released and their distal ends are pulled apart so that a triangular shape is formed with a canvas stretched in its lumen (A 61 B 17/02 (10) 0611.06.007.96 PCT 9507052 AL. Inventions of the world, 1996 , N 6, p. 138).

The disadvantages of this tool:
- the possibility of its use only in the abdominal cavity, which is due to its design and the impossibility of its use for preperitoneal LPG;
- the need to use the entire complex of laparoscopic equipment.

 Known retractor for creating a surgical workspace by lifting the abdominal wall, consisting of two retractor legs, a lift and a lifting rod. After introduction through the laparoscopic canal, the legs of the retractor are spread apart and held in parallel position (A 61 B 17/02 (10) W 09508952 PCT / US 94 // 10537. Inventions of the world, 1996, N 7, p. 112).

The disadvantages of this tool:
- the need to impose at least one or two laparoscopic channels for the introduction of a retractor;
- the ability to use the tool only in the abdominal cavity, which makes it inaccessible to use it to perform non-tension hernioplasty.

 As a prototype, the device according to A.S. N 1544388, A 61 B 17/02, 1987, BI N 7, 1990, p. 43. This is a lift containing a rack with a crossbar in the form of a U-shaped cylindrical rod. A screw mechanism is pivotally mounted on it, the hinge is made in the form of an arm with grooves. The lifting mechanism is equipped with a traction with a stopper, on which a hook equipped with a movable fixed stop is detachably mounted. The device contains a conservator and a mirror. The retractor is installed by means of a sleeve with emphasis on the axis with the ability to move and fix the latter in the slot of the strap.

The disadvantages of this tool:
- does not allow you to adjust the size of the area of operational action simultaneously in the vertical and horizontal planes;
- does not provide the ability to perform non-tension hernioplasty.

 The objective of the invention is to increase the efficiency of surgical treatment of inguinal hernias by reducing the invasiveness of the operation, the ability to install a synthetic mesh to close the hernial defect, and reducing the length of the patient’s stay in the surgical hospital. The task is achieved thanks to the proposed retractor, in which: retractor legs are rotatably connected with a U-shaped cylindrical rod, retractor legs form a V-shaped plate, while one of the legs is mounted on this plate using a hinge with the ability to move in one plane relative to another fixed paw with the formation of an angle between them, fixing in the desired position of the moving paw is feasible using a screw interacting with two rigidly mounted at the inner faces paws with eyes, one of which is mounted on a movable retractor foot, is threaded, and in the other, the screw is rolled with its end rotatably, while the plate is rigidly fixed to a cylindrical sleeve mounted on a U-shaped cylindrical rod with the possibility of rotation and the inner the surface of which is congruent with the outer surface of the rod, to rotate the sleeve with the paws on top, a handle is rigidly fixed on their base, along the forming sleeve and, accordingly, a number of coaxial holes for the plinth for fixing the tines at a predetermined position when lifting and lowering.

The novelty of the invention:
Performing one movable, the other motionless in the horizontal plane of the retractor paws provides the largest and necessary zone of the abdominal wall (skin, subcutaneous tissue, muscles), lifted up to create a cavity below this area, sufficient for the operation. By the movements of one of the paws of the retractor, it is possible to regulate the dimensions of this cavity in the horizontal plane.

 Raising the retractor paws using a cylindrical sleeve with a lock allows you to adjust the size of the area of operational action in a vertical plane and fix it statically for the required period of time using a cylindrical cotter pin.

 The invention is illustrated by drawings, where in FIG. 1 shows a general view of the device; in FIG. 2 - installation of the retractor on the operating table; in FIG. 3 - performing an incision under the retractor.

The proposed retractor consists of a working part containing a leg fixed in the horizontal plane 1 and a movable leg 2, forming a V-shaped plate, the leg 2 by means of a hinge 3 moves relative to the stationary leg 1 with the formation of an angle between them. Moreover, the angle formed by the external borders of the paws, varies from 10-15 ^o to 80-85 ^o . The dimensions of the angle vary depending on the need and are fixed by means of a screw 4, interacting through the eyes 5 and 6, mounted rigidly on the legs 1 and 2 directly at the inner faces of the legs. In the eye 5 there is a thread, which allows you to move the eye 5 along the thread on the screw 4, and together with this eye and paw 2, thereby achieving a change in the angle formed by the legs of the device. The end part of the screw 4 is flared in the eye 5 with the possibility of rotational movement of the screw inside this eye. The movable 1 and fixed 2 legs at the base are made integral, forming a V-shaped plate 7, which bottom surface is rigidly fixed to a semi-cylindrical sleeve 8 mounted for rotation on a cylindrical rod 9 having a U-shape, the ends of which 10 and 11 are attached to the handrails of the operating table. On the outer part of the plate 7, a handle 12 is rigidly mounted, which, forming a single unit - the handle-plate of the base of the paws - the sleeve when moving forward - backward (away from you - towards yourself), allows the working part of the retractor to move along an arc of a circle determined by the mobility of the sleeve 8 relative to the rod 9. In this case, the inner cylindrical surface of the sleeve 8 is congruent with the outer cylindrical surface of the rod 9. The working part of the retractor - paws 1 and 2 - when extending or lowering to a given angle are fixed in a predetermined position required during the operation, with the help of a latch formed by coaxially made holes 14, 13 respectively along the edge of the sleeve and in the rod, and actually fixing the paws is carried out by a cotter pin 15 installed in the holes of the sleeve and the rod.

A device, hereinafter referred to as a retractor, operates as follows. The patient lies on the operating table in a supine position. The rod 7 is installed using the ends 10 and 11 and is rigidly fixed to the handrails of the operating table so that its horizontal part is above the patient in an oblique direction as follows:
- direction from the edge of the costal arch on the left to the iliac wing on the right;
- direction from the edge of the costal arch to the right to the left ilium.

 The direction of the bar is chosen from the need to perform an intervention for a right-sided or left-sided inguinal hernia. After the rod is installed, processing and covering of the surgical field is performed according to the standard method. The surgical field includes the umbilical region and the ileo-inguinal region. A linear skin incision is applied up to 4 cm long perpendicular to the line connecting the navel and the middle of the inguinal ligament, at the border of the proximal and medial third of this line. Then, the incision is deepened to the preperitoneal fatty tissue in the direction of the inguinal ligament. Retractor paws 1 and 2 are inserted into the formed channel in the closed state, and the retractor itself is mounted on the horizontal rod 7. Then, by screwing in the screw 4, the retractor paws are extended and the formed channel increases in the horizontal direction, by a distance sufficient to perform surgical intervention. To create a cavity in the preperitoneal space, it is necessary to raise the abdominal wall, which is achieved by pulling yourself behind the handle 6 of the retractor: the handle of the retractor describes the movement of the radius of the circle centered at the fixation point of this handle 6, and since it is rigidly fixed to the V-shaped plate of the retractor paws, then the plate moves, carried away by the movement of the handle. Retractor legs 1 and 2 move after the V-shaped plate, raising the abdominal wall in its path. Upon reaching the required vertical size of the operating cavity, the entire structure is fixed on the rod 9 by means of a cotter pin 15 inserted into the holes combined on the sleeve 8 and cotter pin 9. This is followed by the actual operation: the allocation of a hernial sac, immersion of its contents in the abdominal cavity, followed by closing the medial and lateral fossae with a synthetic mesh. Surgery is accompanied by endoscopic support. A laparoscope can be inserted into the operating cavity through the same incision, or through an additional channel directly above the hernia. At the end of the operation, the screw 4 is unscrewed, the legs of the retractor are shifted to their original position and the retractor is removed. The wound is sutured in layers.

 Clinical example.

 Patient Sh., 36 years old, average physique, was hospitalized in the clinic with a diagnosis of Right-sided inguinal hernia.

 Anamnesis: first discovered the appearance of a hernia about 4 months ago.

 Hospitalized as planned.

 Objectively: a visual inspection of the changes is not determined. On palpation, a hernial formation is also not determined. The diameter of the external opening of the inguinal canal is 1.2-1.4 cm. Weakly positive symptom of a cough push on the right. There are no skin changes, movement in full.

Operation: the patient is laid on the operating table in the "on the back" position. General anesthesia - ETN. After processing the surgical field, a U-shaped bar is installed and fixed with standard clamps on the handrails of the operating table. Shelter of the patient according to the standard method with five sheets. Next, a linear skin incision is applied, 4 cm long, in the umbilical region on the right, below the navel. The wound is deepened to preperitoneal fiber. Next, tunneling of the preperitoneal space was performed in a blunt manner and retractor legs were introduced into the formed tunnel and spread apart by screwing screw 4 through an angle of 60 ^° . The angle is sufficient for the intervention in this patient, since the size of the subcutaneous fat layer is moderate and the patient’s body width is also medium in size. By pulling on the handle 12, the abdominal wall is raised above the peritoneum and preperitoneal fat. A laparoscope was inserted into the projection of the distal end of one of the retractor paws, and a manipulator was introduced into the projection of the adjacent paw. The inguinal ligament, the lateral and medial fossae, and the internal opening of the inguinal canal are distinguished. A hernial sac is isolated and removed from the inguinal canal. Its size is 1.5-2.0-3.0 cm, the contents are immersed in the abdominal cavity. On the forceps, a patch (synthetic mesh) is inserted into the preperitoneal space, straightened and closed with its help: the internal inguinal ring, the medial and lateral fossa of the peritoneum. Control of hemostasis. The retractor is closed, removed. Laparoscope and manipulator removed. Suturing muscle wounds, aponeurosis, skin. Aseptic dressing. Thus, with the help of this retractor, 11 people were operated on in the 1st City Clinical Hospital of Novokuznetsk. The device is convenient, efficient and allows you to perform a hernia repair operation from the lowest possible access, which reduces the patient’s hospital stay. The retractor is convenient for sterilization and this does not require special devices.

Claims (1)

 A retractor containing retractor legs associated with the possibility of rotation with a U-shaped cylindrical rod, characterized in that the retractor legs form a V-shaped plate, while one of the legs is mounted on this plate using a hinge with the ability to move in one plane relative to the other stationary paws with the formation of an angle between them, fixing in the desired position of the movable paw is carried out using a screw interacting with two eyes rigidly mounted on the inner faces of the paws, one of which mounted on a movable retractor paw, is threaded, and the screw is rotated at its other end, the plate is rigidly mounted on a semi-cylindrical sleeve mounted on a U-shaped cylindrical rod with the possibility of rotation and the inner surface of which is congruent to the outer surface of the rod, and to rotate the sleeve with the paws on top, a handle is rigidly fixed on their base, and along the generatrix of the sleeve and, accordingly, on the rod, a series of coaxial holes are made for the cotter pin for fixing the la n in a given position after raising or lowering them.

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