RU2698985C1 - Method of manual continuous combined vascular suture for eliminating an inferior vena cava defect - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, more specifically to vascular surgery. Synthetic non-absorbable monofilament suture is fixed on an atraumatic needle with a knot in the upper angle of the wound of the vessel above the edge of the defect. Inferior vena cava is closed from the top downwards through all layers with comparison of intima of the walls of the sutured vessel by the first frame continuous mattress vascular suture with width of stitches of 3.5 mm, having deviated 2 mm from the edge of the vascular wall, to the lower angle of the wound of the vessel. Points of needle sticking and removal from both sides of the wound are arranged symmetrically. Each stitched seizure is tightened in the direction of the wound downwards. Last seam stitch is applied on the unchanged wall of the inferior vena cava downstream the edge of the defect. Second continuous heaving haemostatic vessel suture is closed from the bottom upwards. Needle is brought from the outside to the inside; the vessel wall is pierced through all layers with a stitch width of 3 mm, 2 mm from the edge of the vascular wall, to the upper angle of the wound of the vessel. Each suture stitch is tightened, the last seam stitch is applied on the unchanged wall of the inferior vena cava abode beyond the defect edge. First and second sutures are tied together.

EFFECT: method makes it possible to simplify technique of suturing, to improve reliability of suture, to reduce number of postoperative complications, to avoid corrugation and deformation of vascular wall, to not disturb laminar flow of blood.

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Description

The invention relates to medicine, specifically to vascular surgery, and may find application in the surgical treatment of malignant tumors of the kidneys with the presence of a tumor thrombus of the renal vein and / or inferior vena cava.

A known method of applying a continuous twisting vascular suture according to Carrell, which is the prototype of all the numerous modifications of the vascular suture [Surgery of the aorta and major vessels / A.A. Shalimov, N.F. Druck. - Health: Kiev, 1979. - 385 p. ]. As suture material, braided or monolithic synthetic threads are used, which minimally injure the vascular wall, while having high strength and biological inertness. To date, atraumatic needles are considered the best, in which the thread is soldered into the needle and is its continuation [Bontsevich, D.N. Surgical suture material / D.N. Bontsevich. - M., 2005. - 118 p.]. An important condition for performing a vascular suture is sufficient mobilization of the vessel and thorough bleeding of the surgical field with temporary compression when applying vascular clamps and / or turnstiles to the proximal and distal sections of the vessel. Three (3) U-shaped holders are placed through all layers with thread on an atraumatic needle to invert the vessel and tightly match the intima of the stitched vessels. The tension of the holders prevents the needle from capturing the opposite wall of the blood vessel. The defect in the vessel wall is sutured with a continuous upside down suture, i.e. “on yourself”, passing the needle from the outside to the inside, piercing the vessel wall through all layers in the most gentle way. The needle is injected about 2-3 mm from the edge of the vessel. The interval between the stitches depends on the thickness of the vessel wall and varies from 0.5 to 2 mm. Each stitch of the seam is tightly tightened, preventing suture material from entering the lumen of the blood vessel. Having tied the last knot, they restore blood circulation by completely removing the vascular clamps and / or turnstiles. In 8.4% -21.7% of cases, there is a loss of blood through the imposed vascular suture, which primarily depends on the experience of the surgeon. The bleeding sections of the vascular suture are pressed with a finger, after which the bleeding, as a rule, stops. Continued bleeding in 3.6% of patients requires the addition of separate nodal sutures on an atraumatic needle. The advantages of this seam include:

- the possibility of stitching vessels of any diameter, regardless of the state of the walls of the connected vessels,

- high level of tightness,

- relatively high speed of execution.

The disadvantages of the seam are:

- when tying the last stitch, a high risk of corrugation of the vessel,

- narrowing of the lumen of the vessel,

- violation of laminar blood flow,

- postoperative bleeding,

- the formation of a parietal thrombus along the suture line and / or in the lumen of a blood vessel,

- the formation of aneurysm.

A known method of continuous mattress seam [Beitinger, V.F. Vascular suture / V.F. Baitinger // Tomsk: ANO Research Institute of Microsurgery, TSC SB RAMS, 2005. - 106 p.]. The use of suture material and the mobilization of a vessel to perform a vascular suture are traditional for vascular surgery. The defect of the vessel wall is sutured with a continuous mattress suture, securing the thread with a knot at the edge of the vessel wound. The needle is injected at an angle at a distance of 2-3 mm from the edge of the vessel, and then carried out in the direction of the wound. The wound is stitched and the needle is removed through its other edge symmetrically to the puncture site. Intima, stitched edges of the vessel should be adjacent to the intima, while in the lumen of the vessel should be a minimum of suture material. The puncture and withdrawal points of the needle are placed at the same distance from the wound. The needle is again injected on the side where it was withdrawn. The surface part of the stitch is made so that the distance of the puncture and needle points on both sides of the wound is the same and ranges from 1 to 2 mm. Each seam stitch is tightened. Having tied the last knot, they restore blood circulation, completely removing the vascular clamps. The advantages of this seam include:

- the possibility of stitching vessels of any diameter, regardless of the state of the walls of the connected vessels,

- relatively high execution speed,

- the absence of a deforming effect on the vessel wall, causing a violation of the laminar blood flow.

The disadvantages of the seam are:

- low level of tightness,

- high risk of eruption of the sutures of the vessel,

- the need for additional nodal hemostatic sutures,

- when tying the last stitch of the seam, a high risk of corrugation of the vessel with the possibility of narrowing its lumen and a violation of the laminar blood flow,

- postoperative bleeding,

- an obstacle to the growth and increase in the lumen of the vessel.

The above disadvantages are eliminated in the claimed invention.

The objective of the invention is to develop a method of forming a structurally simple manual continuous continuous combined vascular suture that eliminates the defect of the inferior vena cava after its resection.

The invention consists in the following. The defect in the wall of the inferior vena cava is eliminated by applying a continuous manual combined vascular suture. The combined suture combines the first frame continuous mattress vascular suture and the second continuous upholstered hemostatic suture, applied in opposite directions with one thread on an atraumatic needle. A manual continuous combined vascular suture combines the advantages of two sutures, leveling each other's shortcomings, namely: it prevents corrugation and deformation of the wall of the inferior vena cava due to the first row of the suture and provides high tightness of the vascular suture due to the second row of sutures, does not lead to a significant change in the clearance of the lower vena cava and minimizes the risk of developing a violation of the laminar blood flow, turbulence and the formation of parietal thrombi.

A modern constructively simple method of forming a manual continuous combined vascular suture is proposed, which simplifies the technique of applying a vascular suture and increases its reliability, helping to reduce the number of postoperative complications and improving the quality of life of the operated patients. The formation of a manual continuous combined vascular suture by the proposed method, in contrast to the prototype:

- performed by one thread on an atraumatic needle superimposed in opposite directions,

- provides a minimum distance from the edge of the defect of the vascular wall when applying a vascular suture and the maximum distance between the stitches of the vascular suture,

- does not lead to corrugation and deformation of the vascular wall and disruption of the laminar blood flow.

The invention is illustrated by the figures:

figure 1. - the suture thread on the atraumatic needle is fixed by a knot in the upper corner of the vessel wound above the edge of the defect;

FIG. 2. - the formation of the first frame continuous mattress vascular suture through all layers with the obligatory comparison of the puncture and removal points of the needle, as well as the intima of the walls of the stitched vessel;

figure 3. - the first frame continuous mattress vascular suture is formed on the defect of the vessel wall, the last stitch of the seam is superimposed on the unchanged vessel wall below the edge of the defect;

FIG. 4. - the formation of a second continuous entwined hemostatic vascular suture, without speaking for the previously completed first frame continuous mattress vascular suture;

FIG. 5. - the formation of a second continuous twisting hemostatic vascular suture with an interval between stitches of 3 mm;

Fig.6. - tight tightening the stitches of the second continuous twisting hemostatic vascular suture;

FIG. 7. - the formation of a node between the threads of the first and second vascular sutures tied together in the upper corner of the wound of the vessel above the edge of the defect;

FIG. 8. - restoration of blood circulation with the complete removal of temporary hemostatic clamps and turnstiles.

The method is as follows. With surgical intervention in the retroperitoneal space with the involvement of the inferior vena cava section in the pathological process, the wall of the inferior vena cava is resected. To this end, mobilize and impose turnstiles, possibly vascular clamps, on the inferior vena cava distal and proximal to the pathological retroperitoneal process for temporary bleeding of the surgical field. Additionally, if necessary, mobilize and impose turnstiles, possibly vascular clamps, on the renal veins. On the site of resection of the inferior vena cava, a hemostatic elastic clamp of Satinsky is temporarily applied without violating the integrity of the vascular wall. After the preparatory stage, the pathological retroperitoneal process is removed with economical resection of the inferior vena cava with maximum preservation of the wall of the central blood vessel.

The defect in the wall of the inferior vena cava is eliminated by a continuous combined vascular suture. Holders on the wall of the inferior vena cava do not overlap, because the edges of the wound are available for visual inspection and comparison. A synthetic non-absorbable monofilament suture material with a smooth surface is used that does not contribute to bacterial contamination, soldered into the needle and provides constant tensile strength of the thread in the tissues, easy sliding of the thread through the fabric without injury, while it is possible to form a knot of minimum diameter due to plastic properties.

The defect of the vessel wall is sutured with the first frame continuous mattress vascular suture through all layers with the obligatory comparison of the intima of the walls of the stitched vessel from top to bottom, fixing the thread with a knot in the upper corner of the vessel wound above the edge of the defect (Fig. 1). A synthetic non-absorbable monofilament thread on an atraumatic needle is injected at a distance of 2 mm from the edge of the defect of the vascular wall. The wound is stitched and the needle is removed through its other edge symmetrically to the puncture site. The puncture and withdrawal points of the needle are placed at the same distance from the edge of the vascular wall defect. The needle is again injected on the side where it was withdrawn. The surface part of the stitch is made so that the distance of the puncture and needle points on both sides of the wound is the same and is 3.5 mm. Each stitch of the suture is tightened in the direction of the wound down to avoid corrugation of the vessel and the site of suture material getting into the lumen of the vessel (Fig. 2). The defect of the vessel wall is sutured when the lower angle of the wound of the vessel is reached (Fig. 3). The last stitch of the suture is applied to the unchanged wall of the inferior vena cava below the edge of the defect.

The juxtaposed edges of the inferior vena cava are sutured from the second continuous upholstered hemostatic vascular suture from the bottom up, passing the needle from the outside to the inside, piercing the vessel wall through all layers in the most gentle way. The needle is injected no more than 2 mm from the edge of the vessel without protruding onto the previously completed primary continuous frame suture (Fig. 4). The interval between the stitches is 3 mm (Fig. 5). Each stitch of the seam is tightly tightened, preventing the suture material from entering the lumen of the blood vessel (Fig. 6). After applying the last screed in the upper corner of the wound of the vessel above the edge of the defect, the threads of the first and second seams are tied together (Fig. 7).

They restore blood circulation by completely removing the Satinsky temporary styptic elastic clamp that does not violate the integrity of the vascular wall and turnstiles, possibly vascular clamps, distal and proximal to the temporarily bloodless surgical field on the inferior vena cava (Fig. 8).

Clinical example.

Patient S., 71 years old, was examined according to the clinical examination program at the place of attachment, where an ultrasound revealed a 55 mm tumor of the left kidney. When examining the MSCT of the abdominal organs, a solid volume formation of the left kidney of 49 × 48 × 52 mm with vascular invasion and germination of the left renal vein was confirmed. Upon objective examination, the condition is satisfactory, peripheral lymph nodes are not enlarged, the abdomen is soft, painless on palpation, the liver along the edge of the costal arch, tumor formations are not detected. Pasternatsky’s symptom is negative on both sides. There is no hematuria.

An additional examination was carried out to assess the prevalence of the tumor process and prepare for surgical intervention: MSCT of the chest organs, ultrasound of the peripheral lymph nodes, VVD, ECG, echocardiography, FGS, ultrasonography of the vessels of the lower extremities. Generalization of the tumor process was not detected. No abdominal surgery was performed.

The patient was diagnosed with Cancer of the left kidney St 3 T3bNoMo.

The patient underwent a laparotomy operation with a chevron-type incision. When revising the abdominal organs, the liver is not enlarged, smooth, elastic, retroperitoneal lymph nodes are not enlarged, pelvic organs without features. No carcinomatosis, ascites in the abdominal cavity. In the region of the upper and middle segments of the left kidney, a dense tumor is determined up to 8 cm in diameter, tightly mobile, with severe varicose veins of the perinephric fiber. Renal vessels on the left, lymphatic dissection on the left. In the lumen of the renal vein, a fixed thrombus is determined. The mobilization of the inferior vena cava on the right was carried out. A tumor thrombus floats in the lumen of the inferior vena cava up to 3 cm long. A nephradrenalectomy was performed on the left with separate ligation of the renal artery and resection of the wall of the inferior vena cava. A resection of the wall of the inferior vena cava was performed within healthy tissues with a site of tumor growth into the renal vein on the left and removal of the floating thrombus from its lumen. The defect in the wall of the inferior vena cava is sutured according to the original technique.

The duration of the operation is 2 hours, the volume of blood loss is 360 ml. Histological examination of the surgical material: clear cell renal cell carcinoma with cysts and hemorrhages, foci of fibrosis, without invasion per capsule; in a vessel, a tumor thrombus is represented by clear cell renal cell carcinoma; adrenal tissue of the usual structure, lymph nodes without pathology.

The diagnosis established by the results of the operation and histological conclusion: Cancer of the left kidney St 3 T3bNoMo.

The patient on the second day was transferred to the profile urological department. The postoperative period was uneventful. Narcotic analgesics were prescribed for 2 days, followed by the use of non-narcotic analgesics for 3 days. Drug therapy during the first 7 days: the introduction of antibiotics, infusion therapy. Prevention of thrombotic diseases in accordance with existing standards for the provision of medical care to cancer patients in the Russian Federation. Postoperative dressings are dry and clean. The drainage of the retroperitoneal space in the area of the surgical wound was removed on the third day. Postoperative wound healing by primary intention. Diuresis daily adequate. Independent bowel movements on the third day after surgery. The patient was discussed in consultation: additional antitumor treatment is not indicated, dynamic follow-up.

In this way, surgical treatment was performed in 3 patients with localization of the tumor process in the left kidney and tumor vascular invasion of the renal vein. Bleeding in the early and late postoperative period was not observed in any case. There were no other surgical complications in the postoperative period. All patients were discharged from 12 to 16 days.

Claims (1)

The method of manual continuous combined vascular suture to eliminate the defect of the inferior vena cava performed after removal of the pathological retroperitoneal process with resection of the wall of the inferior vena cava mobilized and temporarily bleached by vascular clamps distal and proximal to the vascular surgical field, characterized in that they fix a synthetic non-absorbable monofilament thread atraumatic needle with a knot in the upper corner of the wound of the vessel above the edge of the defect, suture the inferior vena cava from top to bottom through all layers with matching the intima of the walls of the stitched vessel with the first frame continuous mattress vascular suture with a stitch width of 3.5 mm, deviating 2 mm from the edge of the vascular wall, to the lower corner of the vessel’s wound, place symmetrically the puncture and needle points on both sides of the wound, tighten each stitch of the suture in the direction of the wound down, impose the last stitch of the suture on the unchanged wall of the inferior vena cava below the edge of the defect, suture the second continuous upholstered hemostatic vascular suture from the bottom up, hold the needle and inwardly, pierce the vessel wall through all layers with a stitch width of 3 mm, deviating 2 mm from the edge of the vascular wall to the upper corner of the vessel wound, tighten each stitch of the suture, impose the last stitch of the suture on the unchanged wall of the inferior vena cava above the edge of the defect, tie between themselves the threads of the first and second seams.

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