RU2607919C1 - Method of crossectomy with ligation of great saphenous vein trunk above and below tributaries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to vascular surgery. Allocation of shaft of great saphenous vein is made 5–7 cm from anastomosis. Near-mouth tributaries are additionally extracted in amount from two to seven. After complete bypass with ligature of great saphenous vein trunk at mouths of tributaries at level of its natural neck first loop of figure in form of eight is made. Vein trunk is ligated with one node and suture ends are delivered to both sides from under great saphenous vein trunk and tied above trunk with surgical node distal to tributaries, forming complete figure in form of eight.

EFFECT: method enables reducing risk of complications, simplifying technique of crossectomy.

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Description

The invention relates to medicine, namely to vascular surgery, and can be used to treat varicose veins of the lower extremities and ascending thrombophlebitis.

The operation of crossectomy (cutting off, removal of the intersection) is widely used in vascular surgery in the treatment of varicose veins of the lower extremities and ascending thrombophlebitis. It is aimed at eliminating safeno-femoral anastomosis. It is noteworthy that in the treatment of ascending thrombophlebitis of the great saphenous vein, there is no alternative to this operation.

The prototype of the invention is the operation of classical crossectomy, the main principle of which is the ligation and excision of a large saphenous vein (vena saphena magna) at the place of its entry into the femoral. The intersection of the great saphenous vein is performed 5-10 mm from the place of its inflow into the femoral vein after ligation of all estuarine tributaries [Topographic anatomy and surgical surgery. Edited by academician of RAMS Yu.M. Lopukhina. Volume 1, 3rd edition, revised. Moscow 2009, p. 294].

The disadvantages of the prototype are the complexity associated with the need for ligation of many thin-walled narrow venous estuarine inflows using a large number of ligatures, the risk of bleeding, lymphorrhea, the likelihood of damage to the deep femoral vein. Often during the formation of the vena saphena magna stump, technical difficulties arise with determining the level of its ligation and cutting off [Clinical Angiology: Manual / Ed. A.V. Pokrovsky. T. 2. - M .: OJSC "Publishing house" Medicine ", 2004. - 888 c.].

The objective of the invention is to simplify the technique of performing the operation of crossectomy, reducing complications.

The technical result when using the invention is to simplify the technique of performing a crossectomy operation, reducing complications.

The invention is illustrated by the following figures illustrating the stages of crossectomy according to the proposed method: in FIG. 1 depicts safeno-femoral anastomosis normal, where: 1 - femoral vein; 2 - a large saphenous vein; 3 - venous tributaries of the safeno-femoral anastomosis; 4 - the natural neck of the trunk of a large saphenous vein; in FIG. 2 - at the level of the natural neck, the trunk of the saphenous vein is circumvented by the ligature under the tributaries; the ends of the ligature through a single node are allotted in different directions; in FIG. 3 - the vein trunk at the level of the natural neck is tied up with one knot; in FIG. 4 - the ligature after bypassing the trunk of a large saphenous vein distal to the tributaries form the second node; in FIG. 5 - the vein trunk is ligated a second time with a surgical site distal to the tributaries; in FIG. 6 - tributaries bypassed at one end of the ligature and formed an additional node; in FIG. 7 - tributaries tied up; in FIG. 8 - final view: the trunk of a large saphenous vein is cut off with the formation of a stump.

The proposed method of crossectomy is as follows. Using the odorless access, a skin incision is made in the projection of the bisector of the triangle between the femoral vessels and the inguinal ligament. In the region of the oval fossa, the trunk of vena saphena magna is isolated for up to 5-7 cm from the anastomosis, and the mouth inflows in the amount, as a rule, are from 2 to 7 (Fig. 1). The most permanent of these is vena epigastrica superficialis, which flows from above. Each inflow is mobilized separately at a distance of up to 10-20 mm. Last of all, the safeno-femoral anastomosis is mobilized. Then, under the tributaries, the trunk of the saphenous vein is bypassed with a ligature, starting from the medial edge. To do this, capturing the tip of the thread by the dissector, spend it under the mouth of the tributary. After passing under the inflow, the end of the ligature is intercepted with tweezers from the opposite side, then the thread is held under the adjacent inflow and then stepwise along the circumference of the trunk to the last inflow (Fig. 2). After a complete detour of the trunk of vena saphena magna under the mouths of the tributaries, at the level of its natural neck, the ligature forms the first loop of the eight-shaped figure.

Next, the vein trunk is ligated with one knot, while locating the knot at the lower edge of the trunk, the ends of the threads are brought out from under the lower edge of the trunk vena saphena magna in both directions (Fig. 3) and tied over the trunk distal to the tributaries (Fig. 4), forming a complete figure in the form of a figure eight (Fig. 5). Thus, vena saphena magna is ligated in two places - before and after the tributaries. In this case, the confluence of the tributaries is turned off between the two ligatures. To exclude blood flow between the inflows through the cavity of the switched off segment of the vena saphena magna trunk, one end of the thread bypasses all the tributaries (Fig. 6) and bandages (Fig. 7) with the second end of the thread. Technically, this manipulation is performed, as a rule, without noticeable tension of the tributaries and the threat of their tear.

In patients with ascending thrombophlebitis, in the presence of blood clots in the anastomosis, before the first node is tightened, the vena saphena magna lumen is opened, blood clots are removed, and only then the trunk is ligated according to the proposed method.

Before the completion of the vascular stage of the operation, the trunk of vena saphena magna is crossed distally to the site before clamping, leaving a stump 15-20 mm long (Fig. 8). It does not require additional ligation of the vena saphena magna stump. The distal end of the trunk is bandaged, the clamp is removed.

The proposed method allows to prevent the development of specific complications inherent in classical crossectomy. Bandaging vena saphena magna at the level of the natural neck under the mouths of the tributaries eliminates the possibility of leaving a long stump, as well as the possibility of narrowing or deformation of a deep vein in the region of the vena saphena magna. At the same time, there is no crossing of the tributaries, which simplifies the technique, reduces the risk of bleeding, the invasiveness of the intervention and reduces its duration.

The proposed method of crossectomy was tested on corpses, subsequently introduced into the clinic. In the clinic, the proposed crossectomy method was used in 27 patients. Of these, in surgical treatment of varicose veins of the lower extremities - in 20, and ascending thrombophlebitis - in 7. Men were 9, women 18. The age of patients ranged from 19 to 71 years, on average 40.0 ± 3.1.

During combined phlebectomy operations with varicose veins of the lower extremities, a crossectomy according to the proposed technique was performed at the first stage of the intervention; in patients with ascending thrombophlebitis - as the main stage. In all operated patients in the postoperative period no complications were noted, they were discharged with primary wound healing.

Example

Patient F., 57 years old, was hospitalized for surgical treatment with a diagnosis of Varicose veins of the saphenous veins of the right lower limb in the saphenous vein system, CVI 2. Class C 2-3. 01/20/15, the operation was performed: phlebectomy of the right large saphenous vein and tributaries by the combined method. Anesthesia: spinal anesthesia.

The skin incision was made in the projection of the bisector of the triangle, the sides of which are the femoral vessels and the inguinal ligament. After dissection of the surface leaf of the broad fascia of the thigh in the oval fossa, the trunk of vena saphena magna is identified to the anastomosis with the femoral vein. At the same time, 4 estuarine tributaries-collaterals were mobilized for up to 15 mm. According to the proposed method, the trunk of a large saphenous vein under the tributaries is circumvented by a ligature (kapron No. 2), starting from the lower edge. To do this, the end of the ligature was captured by the dissector and stepwise carried it under the mouths of the tributaries around the circumference of the trunk, intercepting with forceps from the opposite side. Initially, they passed under the medial and then passed under the lateral inflows with the output of both ends of the thread in the region of the lower edge of the trunk, and the ligature was tied with one knot. Then the stretched ends of the threads were diverted from under the trunk of vena saphena magna in different directions and again tied over it immediately behind the mouths of the tributaries with a surgical unit. To exclude blood flow between inflows through the cavity of the switched off segment of vena saphena magna, one end of the thread bypassed the mouth of the tributary and tied the second end of the thread, thereby tying the inflows above the trunk without noticeable tension.

After that, the trunk of vena saphena magna was crossed before clamping distal to the site, leaving a stump 15 mm long without additional ligation.

The distal end of the trunk was subsequently removed during phlebectomy in a combined manner. Hemostasis. Wound closure. Bandaging the lower leg and thigh. Aseptic dressing. Elastic limb compression.

Claims (2)

1. The method of crossectomy by ligation and excision of a large saphenous vein at the place of its inflow into the femoral, including the allocation of the trunk of a large saphenous vein for 5-7 cm from the anastomosis, characterized in that it additionally allocate estuarine inflows in an amount of two to seven, large ligation saphenous vein is carried out after a complete bypass of the large saphenous vein under the mouth of the tributaries with a ligature at the level of the natural neck of the trunk, thereby forming the first loop of the figure in the form of a figure eight, then the ends of the threads are brought out on both sides od trunk of the great saphenous vein, the vein trunk tie up the second time a surgical knot distal tributaries, forming a ligature full figure eight-shaped. 2. The method according to p. 1, characterized in that in addition all the tributaries bypass one of the ends of the thread and bandage the second end of the thread.

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