RU2781343C1 - Method for anesthesia of the hemorrhoidal node with laser coagulation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine, namely, anesthesiology, general surgery, coloproctology, and can be used to anesthetize a hemorrhoid during laser coagulation. The method includes the introduction of a prepared solution for analgesia, including Sol. Ultracaini 1.0% 4 ml Sol. Natrii Chloridi 0.9% 30.0 ml Sol. Sodium bicarbonate 4% 2 ml sterile. In the projection of the anus and perianal skin at points at 3, 7 and 11 o'clock on the dial, a skin puncture is performed with a slow introduction of the prepared anesthetic solution, at a rate of 0.1 ml per second, with a synchronous injection of the syringe needle through the intradermal, subcutaneous layers until the lemon peel effect is obtained, then with the advancement of the needle to a depth in the tissue and muscle layer of the anal sphincter with exposure time after the full introduction of the anesthetic for 4-5 minutes.

EFFECT: use of the invention makes it possible to achieve adequate anesthesia during laser coagulation of the hemorrhoid on an outpatient basis, to reduce the number of anesthetic complications during and after laser coagulation of the hemorrhoid, to improve the visualization of the surgical field due to the relatively smaller volume of injected anesthetic, to reduce the level of thermal effects on surrounding tissues during laser operation.

1 cl, 2 ex

Description

The invention relates to the fields of medicine, and in particular anesthesiology, minimally invasive and hospital replacement methods of anesthesia, general surgery, coloproctology.

The most well-known method of anesthesia during operations on hemorrhoids in outpatient practice, such as according to A.V. Vishnevsky (“Operational surgery and topographic anatomy / O 60 Ed. V.V. Kovanov. - 4th ed., 2001”). This type of anesthesia according to A.V. Vishnevsky is the anesthesia of choice for the vast majority of "small" proctological operations, and in particular for operations on the hemorrhoid.

However, this method has several disadvantages:

- a large amount of solution leads to mechanical ischemia of the tissues of the perianal region, which increases the risk of purulent - necrotic complications;

- low effect of analgesia due to a weak anesthetic (Novocain), which does not stop the pain syndrome and pain sensations at the proper level according to the VAS pain scale;

- high risk of burns of surrounding tissues during laser vaporization of the hemorrhoid, due to the release of kinetic energy (J/mm ² ).

- reduced visualization of the surgical field, which increases the risk of iatrogenic complications in the form of sphincter injury and heavy bleeding, as well as the adequacy of the volume of surgical treatment.

The objective of the proposed method is:

- achievement of adequate anesthesia during laser coagulation of the hemorrhoidal node on an outpatient basis;

- reduction in the number and exclusion of anesthetic complications during and after laser coagulation of the hemorrhoid;

- improved visualization of the surgical field due to the relatively smaller volume of injected anesthetic;

- reduction of the level of thermal impact on the surrounding tissues during the operation of the laser;

- exclusion of the hospital stage of finding and monitoring the patient in the hospital.

The problem is solved by preparing a solution for analgesia, including: Sol. Ultracaini 1.0% 4ml, analgesic, + Sol. Natrii Chloridi 0.9% 30.0ml, Sol is added to absorb kinetic energy. Sodium bicarbonate 4%-2 ml. sterile, then, in the projection of the anus and perianal skin at points at 3, 7, and 11 o'clock on the dial, a skin puncture is performed with a slow introduction of the prepared anesthetic solution, at a rate of 0.1 ml per second, with synchronous drawing of the syringe needle through the intradermal, subcutaneous layers to obtaining the effect of a lemon peel, then with the advancement of the needle to a depth in the fiber and muscle layer of the anal sphincter with an exposure time after the full introduction of the anesthetic for 4-5 minutes.

Clinical example No. 1.

Patient K., 37 years old, turned to the medical center for a consultation on 08/08/20 with a diagnosis of Chronic internal hemorrhoids of the 2nd stage. The diagnosis was confirmed by anamnesis, clinically, sigmoidoscopy data, visual examination. Suffering from this disease for 20 years, when he first began to notice periodic discharge of blood from the anus during defecation, discomfort in the anus, feeling of a foreign body. He was treated independently with candles and ointments with a temporary positive effect. So far, I have not contacted a proctologist. At the time of examination noted complaints of bleeding from the anus after defecation. During the examination, RRS was performed at 18 cm: pink mucosa, vascular pattern is not enhanced, the lumen is not narrowed, we pass, no neoplasms were detected, at the exit, internal hemorrhoids are determined at 3, 7 and 11 hours up to 1.0 cm, hyperemic, bluish in color, fixed in anal canal, the hemorrhoid at 7 o'clock has an erosive defect up to 0.3 mm, does not bleed. Conservative therapy was prescribed: hemostatic suppositories, venotonics. At the control examination after 14 days, positive dynamics is not observed. The patient was asked to perform laser coagulation of the hemorrhoid. The patient's consent was obtained. In the medical center, in the dressing room, the patient is located on the proctology chair. Sol solution is being prepared. Ultracaini 1.0% 4 ml, analgesic, + Sol. Natrii Chloridi 0.9% 30.0 ml, Sol is added to absorb kinetic energy. Sodium bicarbonate 4%-2 ml, sterile. Then, after processing the surgeon's hands and the surgical field in the projection of the anus and perianal skin at the points at 3, 7 and 11 o'clock on the dial, the skin is punctured, with a slow introduction of an anesthetic solution at a rate of 0.1 ml per second, with synchronous passage of the syringe needle through the intradermal, subcutaneous layers, until the effect of a lemon peel is obtained, then with the advancement of the needle to a depth in the fiber, the muscle layer of the sphincter, the outer and inner portions of the latter. The exposure time after the complete introduction of the anesthetic is 4-5 minutes. Then the divulsion of the anus begins, with a disposable rectal speculum. During which there are no signs of pain and discomfort caused by excessive tension, which is regarded as satisfactory anesthesia according to the VAS scale. Distinguished internal hemorrhoids, in the projection of which, near the anoderm, a puncture was made up to 0.2-0.3 mm, there is no pain on the VAS scale, which is regarded as satisfactory anesthesia. A metal conductor with a movable cone laser light guide from Biolitec AG was inserted through the puncture: Ceralas in the form of a peak, with a gap from the edge of the conductor to the top of the light guide 1.5-2.0 cm, passed through the thickness of the tissue of the hemorrhoid in the submucosal layer, to the base of the latter , there is no pain on the VAS scale, this is regarded as satisfactory anesthesia. The intervention was carried out under visual control, due to the absence of a dense infiltrate, but with adequate anesthesia, using a red, pulsating beam, which makes it possible to determine the position of the light guide through the thickness of the tissues. After installing the laser light guide at the base of the hemorrhoid, in continuous mode, with a wavelength of 1470 nm, a power of 8 W, laser vaporization of the hemorrhoid tissue is performed, followed by displacement of the laser light guide within the hemorrhoid with traction to the dentate line and subsequent removal of the laser light guide, There is no pain on the VAS scale, which is regarded as satisfactory anesthesia. Control for hemostasis, postoperative edema, and signs of burns, the latter were not recorded. After that, the patient is placed on the couch, observed for 1-2 hours. Then, the patient was asked about the intensity and strength of the pain syndrome. According to the VAS scale, there is no pain. Then the patient is re-examined for the presence or absence of bleeding and burns. We release the patient, with a recommendation to come for a second examination after 2, 7 and 30 days.

On examination on the 2nd day: The perianal area is slightly edematous closer to the puncture sites, the latter are covered with fibrin. P.R.: the sphincter tone is sufficient, the ampoule is empty, the study is painless according to the VAS pain scale 0-1 points. External hemorrhoids are not detected, with anoscopy of 6 cm, internal hemorrhoids at 3, 7 and 11 hours had a pale shade, significantly decreased in size. During the act of defecation, the patient notes discomfort.

On examination on the 7th day: The perianal area is not changed, the puncture sites are covered with fibrin with a slight edging in the form of hyperemia. P.R.: the sphincter tone is sufficient, the examination is painless, the ampoule is empty, external hemorrhoids are not detected, with anoscopy at 6 cm, the largest hemorrhoid at 3 o’clock had a pale hue up to 1.0 cm in size, there is no bleeding, in the projection of the nodes at 11 and 7 hours is determined by the site of fibrosis up to 0.5 cm without defects. During the act of defecation, the patient notes discomfort.

On examination on the 30th day: on rectal examination, the examination was painless. The largest hemorrhoidal node significantly decreased at 3 o'clock, presented in the form of a fibrous area up to 1.0 cm in diameter, hemorrhoids in other projections were not detected. During the act of defecation, the patient does not notice discomfort. The course of treatment was completed in full, the patient was given recommendations.

Clinical example No. 2.

Patient K., aged 57, came to the medical center for consultation with the diagnosis: Chronic internal hemorrhoids 3 tbsp. The diagnosis was confirmed by anamnesis, clinical examination, visual examination and sigmoidoscopy data.

Suffering from this disease for 20 years, when he first began to notice periodic discharge of blood from the anus during defecation, discomfort in the anus, feeling of a foreign body. He was treated independently with candles and ointments with a temporary positive effect. So far, I have not contacted a proctologist. At the time of examination noted complaints of bleeding from the anus after defecation. During the examination, RRS was performed at 20 cm: pink mucosa, vascular pattern is not enhanced, the lumen is not narrowed, we pass, no neoplasms were detected, internal hemorrhoids are determined at 3, 7 and 11 hours from 1.0 to 1.5 cm, hyperemic, bluish in color, the hemorrhoidal node at 3 o'clock during the traction of the proctoscope falls out of the anal canal after the latter, after which it is reduced with a digital aid.

Conservative therapy was prescribed: hemostatic suppositories, high doses of venotonics. At the control examination after 14 days, positive dynamics is not observed. The patient was asked to perform laser coagulation of the hemorrhoid. The patient's consent was obtained. In the medical center, in the dressing room, the patient is located on the proctology chair. Sol solution is being prepared. Ultracaini 1.0% 4ml, analgesic, + Sol. Natrii Chloridi 0.9% 30.0ml, Sol is added to absorb kinetic energy. Sodium bicarbonate 4%-2 ml. Then, after the treatment of the surgeon's hands and the surgical field, in the projection of the anus and peri-anal skin at the points at 3, 7 and 11 o'clock on the dial, the skin is punctured, with a slow introduction of an anesthetic solution at a rate of 0.1 ml per second, with synchronous passage of the syringe needle through the intradermal , subcutaneous layers, until a lemon peel effect is obtained. Then, with the advancement of the needle to a depth in the fiber, the muscle layer of the sphincter, the outer and inner portions of the latter. The exposure time after the complete introduction of the anesthetic is 4-5 minutes. Then, devulsion of the anus begins, using a disposable rectal mirror, during which there are no signs of pain and discomfort caused by excessive tension, which is regarded as satisfactory anesthesia according to the VAS scale. Distinguished internal hemorrhoids, in the projection of which, near the anoderm, a puncture was made up to 0.2-0.3 mm, there is no pain according to the VAS scale, this is regarded as satisfactory anesthesia. Through the latter, a metal conductor with a movable cone laser light guide from Biolitec AG: Ceralas was introduced in the form of a peak, with a gap from the edge of the conductor to the top of the light guide 1.5-2.0 cm. the last one. There is no pain on the VAS scale, this is regarded as satisfactory anesthesia. The intervention was carried out under visual control, due to the absence of a dense infiltrate, but with adequate anesthesia. With the help of a red, pulsating beam, which allows you to determine the position of the light guide through the thickness of the tissues. After installing the light guide at the base of the hemorrhoid, in continuous mode, with a wavelength of 1470 nm, a power of 8 W, laser vaporization of the hemorrhoid tissue is performed, followed by displacement of the laser light guide within the hemorrhoid and traction to the dentate line, followed by extraction of the latter. There is no pain on the VAS scale, this is regarded as satisfactory anesthesia. Control for hemostasis, and postoperative edema, signs of burns, the latter were not recorded. Subsequently, the patient is placed on the couch, observed for 1-2 hours. Then, the patient was asked about the intensity and strength of the pain syndrome according to the VAS scale - there was no pain. Then the patient is re-examined for the presence or absence of bleeding and burns. The patient is released, with a recommendation to come back for a second examination after 2, 7 and 30 days.

On examination on the 2nd day: The peri-anal area is slightly swollen closer to the puncture sites, the latter are covered with fibrin. P.R.: the sphincter tone is sufficient, the ampoule is empty, the study is painless according to the VAS pain scale 0-1 points. External hemorrhoids are not detected, with anoscopy of 6 cm, internal hemorrhoids at 3, 7 and 11 hours had a pale shade, significantly decreased in size. During the act of defecation, the patient notes discomfort. No bleeding data.

On examination on the 7th day: The perianal area is not changed, the puncture sites are covered with fibrin with a slight edging in the form of hyperemia. P.R.: the sphincter tone is sufficient, the examination is painless according to the VAS pain scale 0-1 points, the ampoule is empty, external hemorrhoids are not detected, with anoscopy at 6 cm, the largest hemorrhoid at 3 hours had a pale hue up to 1.0 cm in size, bleeding was not noted , in the projection of the nodes at 11 and 7 o'clock, a fibrosis area up to 0.5 cm without defects is determined. During the act of defecation, the patient notes discomfort. No bleeding data.

On examination on the 30th day: during rectal examination and through anoscopy, the study showed that the study was painless on a VAS pain scale of 0 points, that the largest hemorrhoid at 3 hours significantly decreased and was presented in the form of a fibrous area up to 1.0 cm in diameter, hemorrhoids in other projections were not determined. During the act of defecation, the patient does not notice discomfort. No bleeding data. The course of treatment was completed in full, the patient was given recommendations.

The method is carried out by introducing the prepared Sol solution. Ultracaini 1.0% 4ml, analgesic, + Sol. Natrii Chloridi 0.9% 30.0ml, Sol is added to absorb kinetic energy. Sodium bicarbonate 4% - 2 ml; after processing the surgeon's hands and the surgical field in the projection of the anus and perianal skin, at the points at 3, 7 and 11 o'clock on the dial, a skin puncture is performed with a slow introduction of the prepared anesthetic solution at a rate of 0.1 ml per second, with synchronous passing of the syringe needle through the intradermal, subcutaneous layers until a lemon peel effect is obtained. Then, with the advancement of the needle to a depth in the fiber and the muscle layer of the sphincter. The exposure time after the complete introduction of the anesthetic is 4-5 minutes. During the operation, the effectiveness of analgesia is evaluated according to the VAS pain rating scale, the proposed method of pain relief during laser coagulation of the hemorrhoid in the absence of pain during anus divulsion, with a rectal mirror.

The absence of pain during the puncture of the anal skin. The absence of pain during the laser light guide, below the dentate line.

The proposed method of anesthesia of the hemorrhoid during laser coagulation allows:

- exclude or reduce to a minimum the likelihood of pain during laser coagulation of the hemorrhoid on the VAS pain scale;

- improve the visualization of the surgical field by reducing the level of infiltration of surrounding tissues with an anesthetic solution;

- reduce the level of thermal impact on surrounding tissues during laser operation;

- minimize or eliminate the number of complications during and after surgery;

- to exclude the hospital stage of finding and monitoring the patient in the hospital.

Claims (1)

A method for pain relief of a hemorrhoid during laser coagulation, characterized by the introduction of a solution for analgesia, including: Sol. Ultracaini 1.0% 4 ml Sol. Natrii Chloridi 0.9% 30.0 ml Sol. Sodium bicarbonate 4% 2 ml sterile, for which, in the projection of the anus and perianal skin at points at 3, 7 and 11 o'clock on the dial, a skin puncture is performed with a slow introduction of the prepared anesthetic solution, at a rate of 0.1 ml per second, with synchronous holding of the syringe needle through intradermal, subcutaneous layers until the effect of a lemon peel is obtained, then with the advancement of the needle to a depth in the fiber and muscle layer of the anal sphincter with an exposure time after the full introduction of the anesthetic for 4-5 minutes.