RU2612983C1 - Method for limited incision during appendectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: during acute appendicitis surgery, an incision is made in the right iliac region from a point between the outer and middle third of the line connecting the navel to the right anterior superior iliac spine, downward perpendicular to the said line, length from 2 cm to 4 cm. Next, the abdominal external oblique muscle aponeurosis is cut along the aponeurotic fibers. From the upper wound corner of the abdominal external oblique muscle aponeurosis, cut is made up parallel to the edge of the abdominal rectus muscle, length up to 3 cm. From the lower wound corner of the abdominal external oblique muscle aponeurosis, cut is made down parallel to the edge of the abdominal rectus muscle, length up to 3 cm.

EFFECT: possibility of surgical procedures on the appendix, not only in case of its default location in the right iliac fossa, but also in case of subhepatic or pelvic location, reduced the skin cosmetic defect, reduced trauma surgery, risk of postoperative hernias and other postoperative complications.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used in operations for acute appendicitis.

There is a method of surgical access to the vermiform appendix, which consists in the fact that the access is performed with a right oblique incision according to Volkovich-Dyakonov (see Surgery and topographic anatomy. / Edited by V.V. Kovanov, M: Medicine, 1978). An incision 6-10 cm long is carried out parallel to the inguinal ligament through the Mac Burney point, located between the outer and middle third lines connecting the navel to the right anterior superior iliac spine. One third of the section is located higher, two thirds - below the specified line. The cut length should be sufficient to allow wide access.

However, this method leaves a cosmetic defect, leads to tissue trauma and worsens the healing of a postoperative wound.

The closest technical solution in relation to the proposed set of essential features is oblique pararectal mini-access for appendectomy (see RF Patent No. 2346658, publ. 02.20.2009). This access is performed in the following way: The patient lies on his back horizontally, if the patient’s body mass index is greater than 30 (obesity), then his body is turned to the left at an angle of 30 °. The surgeon is located on the right, the assistant to the left of the patient.

Make a cut. The direction of the incision is from the point of Mac Burney, located between the outer and middle third lines connecting the navel to the right anterior superior iliac spine, parallel to the inguinal ligament to the right lateral edge of the rectus abdominis muscle.

A section of the anterior abdominal wall begins from linea biiliaca or 1-2 cm lower, 2 to 5 cm long, depending on the physique and body mass index of the patient.

Dissect the skin and subcutaneous tissue. The aponeurosis of the external oblique muscle of the abdomen is dissected along the aponeurotic fibers, from the border of the end of the muscle fibers with the transition to the anterior wall of the vagina of the rectus abdominis muscle. The vagina of the rectus abdominis muscle is not completely opened. A section of the aponeurosis of the external oblique muscle of the abdomen is 2-4 cm longer than the skin incision.

The internal oblique muscle of the abdomen and the transverse muscle of the abdomen are stupidly pushed apart at the border between the muscle fibers of the internal oblique muscle of the abdomen and aponeurotic, in the immediate vicinity of the lateral edge of the vagina of the rectus abdominis muscle (spigel line). The muscles are stretched with hooks along the length of the skin wound.

The reasons that impede the achievement of the technical result indicated below when using the known method adopted for the prototype include the limited availability of the appendix when it is subhepatic or pelvic.

The objective of the invention is to provide a mini-access method for appendectomy, providing a technical result consisting in the possibility of surgical procedures on the vermiform appendix, not only with its standard location in the right iliac fossa, but also with the subhepatic or pelvic location, without a pronounced skin cosmetic defect, and reducing the surgical trauma , the risk of developing postoperative hernias and other postoperative complications.

The specified technical result is achieved by the fact that the mini-approach for appendectomy involves a skin incision in the right iliac region from the point located between the outer and middle third lines connecting the navel to the right anterior superior iliac spine, down perpendicular to the downline from 2 cm to 4 cm, dissection of the aponeurosis of the external oblique muscle of the abdomen along the aponeurotic fibers.

A feature is that in the upper corner of the wound, the incision of the aponeurosis of the external oblique abdominal muscle is deflected upward parallel to the edge of the rectus abdominis muscle up to 3 cm, and in the lower corner of the wound, the incision of the aponeurosis of the external oblique muscle of the abdomen is deflected down parallel to the edge of the rectus abdominus muscle up to 3 cm

The invention is illustrated in the drawing, where

1 - skin incision in the right iliac region;

2 - point of Mac Burney;

3 - a navel;

4 - anterior superior iliac spine.

5 - section of the aponeurosis in the upper corner of the wound is rejected upward parallel to the edge of the rectus abdominis muscle;

6 - section of the aponeurosis in the lower corner of the wound is rejected down parallel to the edge of the rectus abdominis muscle.

The method is as follows.

The patient lies horizontally on his back, if the patient’s body mass index is greater than 30 (obesity), then his body is turned to the left at an angle of 30 °. The surgeon is located on the right, the assistant to the left of the patient.

An incision is made 1 of the skin and subcutaneous tissue in the right iliac region, with incision 1 starting from the point of Mac Burney 2, located between the outer and middle third lines connecting the navel 3 to the right anterior superior iliac spine 4. Next, the incision 1 is carried out perpendicular to the mentioned line down to a length of 2 cm to 4 cm. The aponeurosis of the external oblique muscle of the abdomen is dissected along the incision 1 of the skin and aponeurotic fibers. In the upper corner of the wound, section 5 of the aponeurosis of the external oblique abdominal muscle is deflected upward parallel to the edge of the rectus abdominis muscle up to 3 cm, and in the lower corner of the wound, section 5 of the aponeurosis of the external oblique muscle of the abdomen is deflected down parallel to the edge of the rectus abdominis muscle up to 3 cm long.

The internal oblique muscle of the abdomen and the transverse abdominal muscle are bluntly stratified along the muscle fibers. The muscles are stretched with hooks along the length of the wound, then the peritoneum is opened and an appendectomy is performed.

Clinical example.

Patient M., 24 years old, was admitted to the 6th Department of Surgery at the Municipal Clinical Hospital of the Ulyanovsk State Medical Pedagogical University in Ulyanovsk with a diagnosis of Acute appendicitis.

Upon admission, the patient complained of pain in the right iliac region, lower abdomen, nausea. Sick for 8 hours

Inspection: general state of moderate severity; the skin is moist, pale; pulse of weak filling and tension - 92 beats per minute; blood pressure - 120/60 mm Hg

The tongue is dry, coated with a white coating. The abdomen is of the correct form, not swollen, symmetrical, does not participate evenly in the act of breathing, the right half lags behind in the act of breathing. On palpation, tense and sharply painful in the right iliac region. Hepatic dullness is present. There is no dullness. Intestinal motility preserved. Symptom Shchetkin-Blumberg negative

Diagnosed with acute appendicitis.

Operation. Appendectomy, debridement and drainage of the abdominal cavity. Completed mini access by the proposed method. An incision was made in the skin and subcutaneous tissue in the right iliac region, the beginning of the incision is the point of Mac Burney, located between the outer and middle third lines connecting the navel to the right anterior superior iliac spine, the incision is made down and perpendicular to this line 3 cm long. Aponeurosis of the external oblique muscle the abdomen was cut along the skin incision and aponeurotic fibers, in the upper corner of the wound, the aponeurosis section of the external oblique abdominal muscle was rejected upward parallel to the edge of the rectus abdominis muscle 2 cm long, and in the lower corner of the wound s incision aponeurosis of the external oblique abdominal muscle declined downwards parallel to the edge rectus length of 1 cm.

The internal oblique muscle of the abdomen and the transverse muscle of the abdomen stupidly stratified along the muscle fibers. The muscles were stretched with hooks along the length of the wound, then the peritoneum was opened. During the audit, a tense, hyperemic, fibrin-covered appendix with a size of 8.0 × 2.0 cm located in the subhepatic space was found, without appendectomy, appendectomy, rehabilitation and drainage of the abdominal cavity were performed.

The postoperative period was uneventful. In satisfactory condition on the 6th day the patient was discharged from the hospital under the supervision of a surgeon in the clinic at the place of residence.

Examined after six months. No complaints, the result of the operation is rated as good.

Thus, the proposed method allows to provide an adequate amount of surgical manipulations on the vermiform appendix, not only with its standard location in the right iliac fossa, but also with the subhepatic or pelvic location, without a pronounced skin cosmetic defect, reducing the surgical trauma, the risk of developing postoperative hernias and other postoperative complications.

Claims (1)

A mini-approach for appendectomy, including a skin incision in the right iliac region from the point located between the outer and middle third lines connecting the navel to the right anterior superior iliac spine, downward perpendicular to said downline from 2 cm to 4 cm long, dissection of the external aponeurosis oblique muscle of the abdomen along the aponeurotic fibers, characterized in that in the upper corner of the wound, a section of the aponeurosis of the external oblique abdominal muscle is deflected upward parallel to the edge of the rectus abdominis muscle up to 3 cm long, and in the lower of the lumen of the wound, the aponeurosis incision of the external oblique abdominal muscle is deflected parallel to the edge of the rectus abdominis muscle up to 3 cm long.

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