RU2472454C1 - Method of preparing to intracardiac stage of surgical operation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to cardiac surgery. Right anterolateral minithoracotomy is performed. First, pericardium is cut parallel to diaphragmatic nerve from orifice of superior vena cava to orifice of inferior vena cava. After that, cut is continued from orifice of superior vena cava toward aorta to transitional fold of pericardium, and from orifice of inferior vena cava cut is continued to apex of right ventricle. Points for fixation of pericardium to skin wound are selected on time of conventional clock face. Point, lying on the edge of skin wound on the straight line, passing through the centre of conventional circumference of skin wound, perpendicularly to diaphragmatic nerve in distal direction from it, is taken for 12 o'clock. Distal from diaphragmatic nerve pericardium layer is moved upward and fixed with three sutures. Edge of transitional fold of pericardium above aorta is fixed on 11 o'clock. Middle of edge of cut parallel to diaphragmatic nerve is fixed on 12 o'clock. Edge of pericardium above apex of right ventricle is fixed in point of 1 o'clock. After that proximal layer of pericardium is fixed to edges of skin wound with four sutures: from transitional fold of pericardium - on 8 o'clock, from orifice of SVC - on 7 o'clock, middle of edge of cut parallel to diaphragmatic nerve - on 6 o'clock, from orifice of IVC - on 5 o'clock. After that ascending aorta, SBC and IVC are cannulated directly through wound.

EFFECT: invention is aimed at reduction of operation space depth with reliable fixation of heart position, increase of operation action angle, optimal visualisation of aorta, SVC and IVC.

2 dwg, 2 ex

Description

The invention relates to medicine, namely to cardiac surgery, and can be used to treat congenital and acquired heart defects in conditions of cardiopulmonary bypass.

For standard access to the heart, sterno- or thoracotomy is often used, opening the chest widely, while the angle of the operative action and the depth of the operating space allow confident manipulation of the heart, use standard surgical instruments, and connect the heart-lung machine (AIK) directly through the wound, cannulating aorta and vena cava (Burakovsky V.I., Bockeria L.A. "Cardiovascular Surgery", ed. "Medicine", Moscow, 1989). An incision is made in most cases through large arrays of muscles richly equipped with blood vessels, which is associated with great trauma and laborious access, as well as a high risk of postoperative complications.

Mini-accesses, in particular mini-thoracotomy access (S.Däbritz, J. Sachweh, M.Walter, BJMessmer. Closure of atrial septal defects via limited right anterolateral thoracotomy as a minimal invasive approach in female patients, reduce the morbidity of heart surgery). . Eur J Cardiothorac Surg 1999; 15: 18-23), in which the size of the skin incision and the incision of the underlying tissue is 5-8 cm, but there is a limitation of the surgical space and the angle of surgical action, there is a need to use additional tools (special retractors , retractors, special set of surgeons tools, additional illuminators), equipment or techniques.

Closest to the claimed is a method of preparing for the intracardiac phase of the surgical operation, including the right anterolateral mini-thoracotomy, opening the pericardium parallel to the phrenic nerve and fixing the edges of the pericardial incision to the skin wound, cannulation of the ascending aorta, superior vena cava (ERV) and inferior vena cava (NP) ) to connect the AIK (Giamberti, E. Mazzera, L. Di Chiara, E. Ferretti, L. Passquini, RM Di Donate. Right submammary minithoractomy for repair of congenital heart defects. Eur J Cardiothorac Surg 2000; 18: 678-682) . In this method, when fixing the edges of the pericardial incision with three sutures to the skin wound, the right lung is held. But a linear incision of the pericardium and fixation of the pericardium at arbitrary points on the edges of the skin wound does not lead to the removal of the heart from the depth of the surgical wound. Due to the large depth of the surgical wound, optimal visualization of the vessels for connecting the AIC is not provided, which makes their cannulation difficult. The IVC cannula in this method cannot be installed from the surgical wound, therefore, the cannula is inserted through an additional chest incision 2 cm below the edge of the mini-thoracotomy, which lengthens and complicates the method, increases its invasiveness. A small angle of surgical action with such a mini-thoracic approach leads to the need to use special tools, while the complexity and duration of the operation increase.

The task is to simplify and reduce the cost of the method, reduce the morbidity, reduce the preparation time for the main stage of the operation.

The technical result is a reduction in the depth of the surgical space with reliable fixation of the position of the heart, an increase in the angle of surgical action, optimal visualization of the aorta, ERW and IVC

This result is achieved by the fact that in the method of preparing for the intracardiac phase of the surgical operation, including the right anterolateral mini-thoracotomy, opening the pericardium parallel to the phrenic nerve, fixing the edges of the pericardial incision to the skin wound and cannulation of the ascending aorta, ERW and IVC, we propose to open the pericardium of the trapezius , for which, first, the pericardium is cut parallel to the phrenic nerve from the mouth of the superior vena cava to the mouth of the inferior, then from the mouth of the superior vena cava, the incision continues along alignment to the aorta to the transitional fold of the pericardium, and from the mouth of the inferior vena cava, the incision continues to the apex of the right ventricle; the points for fixing the pericardium to the skin wound should be selected by the clock of the conditional dial, taking in 12 hours a point lying on the edge of the skin wound on a straight line passing through the center of the conditional circumference of the skin wound, perpendicular to the phrenic nerve in the direction distal from it, while distal from the phrenic nerve take the leaf of the pericardium up and fix it with three sutures: fix the edge of the transitional fold of the pericardium over the aorta at 11 o’clock, fix the midpoint of the incision parallel to the phrenic nerve at 12 o’clock, and the ne fix the icard over the top of the right ventricle at 1 o'clock, after which the proximal leaf of the pericardium is fixed to the edges of the skin wound with four sutures: from the transitional fold of the pericardium - for 8 hours, from the mouth of the ERW - for 7 hours, the middle of the edge of the incision parallel to the phrenic nerve, - for 6 hours, from the mouth of the IVC - for 5 hours, after which the cannula of the ascending aorta, ERW and IVC cannula directly through the wound.

Fixation of the edges of the proposed trapezoidal incision of the pericardium around the entire circumference of the skin wound brings the heart closer to the surface of the wound and reliably fixes it in this position, reduces the depth of the surgical space and increases the angle of surgical action.

The pericardium is fixed to the skin in those areas of the pericardium that are in direct connection with the aorta, IVC and ERW, therefore, when the pericardium is pulled up and fixed at the points chosen by the authors, these areas are displayed in the surgical field, which ensures optimal exposure of the aorta, ERW and IVC and safe their cannulation. The fixation points, oriented according to the clock of the conditional dial, the authors selected experimentally, seeking to reduce the depth of the surgical space with optimal exposure of the vessels in the surgical field.

The shorter depth of the operating space, a larger angle of operation and reliable fixation of the position of the heart make it possible to abandon special tools for mini-accesses and use surgical tools for open access, which simplifies, cheapens and speeds up the method, increasing its safety. The optimal exposure of the aorta, ERW and IVC allows cannulation of these vessels directly through the surgical wound, avoiding additional incisions, which reduces trauma and increases the safety of the method.

The inventive method is illustrated by drawings.

Figure 1 shows schematically an operational wound.

In Fig.2 - the same with the clock conditional dial.

The inventive method is as follows.

After intubation and induction of anesthesia, the patient is placed on a roller on his left side at an angle of 45 °. A skin incision in the 4-5 intercostal space begins to retreat outward from the parasternal line by 1-2 cm, without bringing it to the front axillary line by 3-4 cm. Subcutaneous fat 1 is dissected in layers, separating the breast capsule upward if necessary, then dissect the pectoralis majoris and the serratus muscles, intercostal muscles. When breeding the intercostal space, a retractor 2 is installed. In children, the mandatory step is to remove the right lobe of the thymus gland. After that, pericardium 3 is cut longitudinally along the phrenic nerve, 1-2 cm from it, from the mouth of the superior vena cava 4 to the mouth of the inferior vena cava 5. Then the incision from the ERW is continued towards the aorta 6 to the transitional fold of the pericardium, and the incision from LEL continues towards the apex of the right ventricle - thus, the pericardium is opened with a trapezoidal incision. Then hem the pericardium to the edges of the skin wound 7. Points for fixing the pericardium to the skin wound are selected according to the clock of the conditional dial (figure 2). For optimal removal of the cannulation points and the whole heart into the wound, the corresponding pericardial regions and fixation points were selected: for excretion of the aorta, the proximal and distal pericardial sheets in the transitional fold region are sutured to the edges of the skin wound for 8 and 11 hours, respectively, to remove the pericardial ERW over its mouth fixed at the level of 7 hours, to remove the NPV, the pericardium above its mouth is fixed at 5 hours, to remove the rest of the heart, the middle part of the proximal pericardium is sutured at 6 hours, and the middle part of the distal foxes pericardial tissue and above the apex of the pancreas - at 12 and 1 hours, respectively. After fixation of the pericardium, vascular cannulation is performed directly through the wound according to the standard technique and the main stage of the operation is performed.

Example 1

Patient R., 9 years old, with a diagnosis of a secondary atrial septal defect, was operated on in 2009. The operation - suturing DMPP in cardiopulmonary bypass - is performed from the right mini-thoracotomy. The skin incision was made in 4 intercostal space, departing outward from the parasternal line by 1-2 cm, continuing the incision, not bringing it to the front axillary line by 3-4 cm, the length of the skin incision was 6 cm, then the pleural cavity in 4 intercostal space was opened. The pericardium is opened by a trapezoidal incision, fixed to the edges of the skin wound. The cannulas were installed directly through the wound cavity, a standard IR device was connected, and the main stage of the operation was performed.

Before fixation of the pericardium, the angles of operational action were measured: above the aorta - 30 °, above the ERW - 35 °, above the IVC - 45 °. The depth of surgical action above the aorta is 105 mm, above the ERW - 75 mm, above the IVC - 70 mm. After fixation of the pericardium according to the closest to the claimed method, the following angles of surgical action were obtained: above the aorta 40 °, above the ERW - 35 °, above the IVC - 45 °. The depth of surgical action above the aorta is 75 mm, above the ERW 60 mm, and on the IVC 45 mm. After fixation of the pericardium to the edges of the skin wound, the angles of surgical action were measured, the following results were obtained - over the aorta 45 °, over the ERW 60 °, over the IVC 65 °. Depth of surgical action above the aorta 45 mm, above the ERW 30 mm, above the IVC 20 mm

Reducing the depth of the operation and increasing the angles of the operation more than 45 ° allows the use of standard tools, and at angles of more than 60 ° the working conditions of the surgeon become comfortable.

Example 2

Patient K., 3 years old, diagnosed with a secondary atrial septal defect, was operated on in 2009. The operation - suturing DMPP in cardiopulmonary bypass - is performed from the right mini-thoracotomy.

Operational access steps are the same as in the previous example.

Before fixation of the pericardium, the angles of surgical action were measured: above the aorta - 40 °, above the ERW - 45 °, above the IVC - 45 °. The depth of surgical action above the aorta is 45 mm, above the ERW - 50 mm, above the IVC - 70 mm. After fixation of the pericardium, by the closest to the claimed method, the following angles of surgical action were obtained: above the aorta 50 °, above the ERW - 50 °, above the IVC - 55 °. The depth of surgical action above the aorta is 40 mm, above the ERW 40 mm, above the IVC 55 mm. After fixation of the pericardium to the edges of the skin wound, the angles of surgical action were measured, the following results were obtained - over the aorta 70 °, over the ERW 95 °, over the IVC 80 °. The depth of surgical action above the aorta is 20 mm, above the ERW 30 mm, above the IVC 35 mm.

Thus, the presented examples show that the use of the proposed method allows to reduce the depth of the operative space with reliable fixation of the position of the heart, increase the angle of surgical action, optimally visualize the aorta, ERW and IVC, which leads to a simplification and cheapening of the method, reducing trauma, and shortening the preparation time for the main stage of the operation.

Claims (1)

A method of preparing for the intracardiac stage of a surgical operation, including the right anterolateral minithoracotomy, opening the pericardium parallel to the phrenic nerve, fixing the edges of the pericardial incision to the skin wound and cannulation of the ascending aorta, superior vena cava and inferior vena cava, characterized in that the pericardium is opened with a trapezoid first, the pericardium is cut parallel to the phrenic nerve from the mouth of the superior vena cava to the mouth of the inferior, then from the mouth of the superior vena cava, the incision continues in the direction ju to the aorta to the transitional fold of the pericardium, and from the mouth of the inferior vena cava, the incision continues to the apex of the right ventricle; points for fixing the pericardium to the skin wound are selected according to the clock of the conditional dial, taking 12 hours for a point lying on the edge of the skin wound on a straight line passing through the center of the conditional circumference of the skin wound, perpendicular to the phrenic nerve in the direction distal from it, while distal from the phrenic nerve the leaf of the pericardium is taken up and fixed with three sutures: the edge of the transitional fold of the pericardium over the aorta is fixed for 11 hours, the middle of the edge of the incision parallel to the phrenic nerve is fixed for 12 hours, and the edge of the pericardium is above the apex of the right ventricle is fixed at 1 h, after which the proximal leaf of the pericardium is fixed to the edges of the skin wound with four sutures: from the transitional fold of the pericardium - for 8 hours, from the mouth of the superior vena cava - for 7 hours, the middle of the cut edge parallel to the phrenic nerve, - for 6 hours, from the mouth of the inferior vena cava - for 5 hours, after which the ascending aorta, superior vena cava and inferior vena cava are cannulated directly through the wound.

Images