RU2786828C1 - Method for videoscopic necrosequestrectomy for necrotic parapancreatitis without exudative lesions of the retroperitoneal space - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to minimally invasive surgery, gastroenterology. Percutaneous puncture of the retroperitoneal space is performed along the middle or posterior axillary line at the lowest point to the pathological zone by retroperitoneal access. A rigid conductor is passed through the needle into the retroperitoneal space. Departing 4-6 cm above and parallel to the place of the first injection along the middle or posterior axillary line, a second access is made, a rigid conductor is inserted and the puncture channels are bougienage. Two 10 mm trocars are inserted along the bougie. Necrotic tissue is removed. A cavity is formed in the retroperitoneal space, a laparoscope is inserted into it and a pneumorethroperitoneum is created. Sequesters are removed under visual control of the laparoscope. Saline solution is supplied, the washing solution with small fragments of the remaining sequesters is sucked off in the vacuum aspiration mode, after which double-lumen drains are installed and fixed to the skin through each trocar. With negative clinical and laboratory dynamics of the patient's condition, the drains are removed and necrosequestrectomy is repeated along the formed channels. With positive dynamics, the drains are replaced and washing is continued every 4-6 hours until the output of clean washing water is reached.

EFFECT: method allows, in the absence of a liquid component, to create accesses to the retroperitoneal space on the right and left for subsequent videoscopic necrosequestrectomy, reduces the risk of intraoperative complications, minimizes surgical trauma, and also stops the purulent-necrotic process in the retroperitoneal space without using open methods for surgical treatment and achieves a decrease in mortality in patients with infected pancreatic necrosis.

1 cl, 2 ex

Description

The present invention relates to the field of medicine, namely to surgery, and can be used in the treatment of patients with pancreatic necrosis without exudative lesions of the retroperitoneal space.

Necrotizing pancreatitis (pancreatic necrosis, "pancreatic necrosis") is a condition characterized by the development of necrosis of the pancreatic tissue or parapancreatic tissue, which develops in the first 48-72 hours from the onset of the disease (R. Isenmann et all., 1993; B.W. Spanier et all. , 2010; P.A. Banks et all., 2012; R. F. Thoeni et all., 2012). Pancreatic necrosis can be: parenchymal, peripancreatic and combined (M. Larvin et all., 1990; CD. Johnson et all., 1991; E.J. Balthazar et all., 1994; V. S. Sainio et all., 1997; A. Zaheer et all. , 2013; J.Y. Shyu et al., 2014). Isolated parenchymal necrosis occurs in less than 5% of cases (R. Isenmann et all., 1993), the prevalence of peripancreatic necrosis reaches almost 20% (G.H. Sakorafas et all., 1999), and combined necrosis is observed in 75-80% of cases (R.F. Thoeni et al., 2012). Foci of necrotic destruction go through 4 stages in their development. The first stage - true pancreatic necrosis, is characterized by the formation of necrotic foci with minimal delimitation of non-viable tissues and the predominance of the tissue ("solid") component over the liquid, as well as the formation of acute liquid or necrotic accumulations; acute fluid collection is usually self-limiting and does not require specialized treatment; an acute necrotic accumulation exists for a long time, contains a liquid and tissue (“solid”) component in various proportions, and often requires surgical treatment. The second stage is transient pancreatic necrosis, the third stage is "organized" pancreatic necrosis, in which there is a complete rejection of necrotic tissues and the formation of cavities with predominantly liquid contents; this stage is optimal for surgical interventions. The fourth stage - pancreatic pseudocyst, is characterized by the predominance of the liquid component, limited by the fibrous capsule (E. L. 3rd. Bradley et al., 2008; R. Carter et al., 2007).

The main indication for surgical treatment of pancreatic necrosis is infection, and the type of surgical intervention largely depends on the predominance of the tissue or fluid "component" (R. Carter et al., 2007). When the retroperitoneal tissue is affected with a predominance of the exudative component, preference is given to minimally invasive puncture-draining methods of treatment, while the predominance of the tissue ("solid") component leads to the use of open surgical methods, which is characterized by a large number of perioperative complications (W. Uhl et al. , 2002).

An analogue of the proposed method of necrosequestrectomy is taken as a method for the treatment of retroperitoneal pancreatogenic phlegmon, proposed by O.I. Okhotnikov, S.V. Ivanov (RU 2128949 IPC A61M 27/00; A61B 17/00). The method of treatment is as follows: according to the results of a sonographic study, signs of an exudative lesion of the retroperitoneal space in pancreatic necrosis are revealed. After that, under sonographic control, a targeted puncture of the retroperitoneal space is carried out with a large diameter needle, for example, 17.5 G, with verification of the pathological discharge. Further manipulations are carried out under combined sono-fluoroscopic control. A water-soluble contrast is introduced along the needle into the destruction zone, the distribution of which specifies the volume and topography of the destruction zone. Then, through the lumen of the needle, a safe j-guide is inserted into the affected area, and sequential hermetic dilatation of the wound channel is carried out through it with telescopic bougies, for example, from K Storz, to a caliber of 30-32 Fr, followed by the installation of a double-lumen drainage of large diameter (10-11 mm) and flow-through rinsing. Similarly, the installation of additional drains (1-2) is carried out aiming at the prevalence of the destructive process.

In the post-manipulation period, not earlier than 5 days, according to clinical, radiological and sonographic indications, according to the established drainage, an amplat-thin-walled casing with a beveled working end is inserted telescopically into the retroperitoneal space, through which, after temporary removal of the drainage, an optical instrument is inserted, for example, a K Storz rigid nephroscope , through which visual control of the state of the destruction zone is carried out, and necrosequestrectomy.

The disadvantages of the method:

- the method does not provide for the possibility of drainage without exudative lesions of the retroperitoneal space;

- the use of a soft conductor at the stage of bougienage of the wound channel does not provide sufficient rigidity of the structure, as a result of which it breaks and changes the direction of the bougie in the tissues;

- the use of a nephroscope for necrosequestrectomy with a working channel diameter of 4 mm does not allow full sanitation of necrotic tissue due to its blockage by large fragments of sequesters;

- the use of one instrumental access for necrosequestrectomy increases the duration of surgery and anesthesia;

- carrying out necrosequestrectomy no earlier than 5 days after surgical treatment can lead to the development of sepsis and the progression of multiple organ failure due to the lack of timely surgical intervention aimed at removing necrotic tissue, which is a source of endogenous intoxication.

The study of Šileikis A., Beiša V., Beiša A., Samuilis A., Serpytis M., Strupas K. (Minimally invasive retroperitoneal necrosectomy in management of acute necrotizing pancreatitis. Wideochir. Inne Tech. Maloinwazyjne. 2013; 8(1): 29-35.). With this method, the patient is placed on the operating table on the right side. The first 10 mm trocar is inserted under ultrasound control into the fluid accumulation in the retroperitoneal space along the midaxillary line near the end of the 12th rib. Create a pneumorethroperitoneum with a maximum pressure of up to 14 mm Hg. Then a laparoscope with a diameter of 10 mm is inserted to assess the pathological cavity and the nature of its contents. The next two trocars are placed under the control of a laparoscope along the left anterior and posterior axillary lines, through which suction and a laparoscopic clamp are introduced. Under the visual control of the laparoscope, it sanitizes the cavity and removes necrotic tissue. Surgical treatment is completed with the installation of drains conducted into the retroperitoneal space at the puncture sites of the trocar. The next day, continuous washing of the pathological cavity begins. If necessary, repeat retroperitoneoscopic necrectomy is performed through the same holes in the places of established drainages.

The disadvantages of the method:

- the method does not provide for the possibility of application in the absence of exudative lesions of the retroperitoneal space;

- the method does not provide for use in the spread of the pathological process in the right sections of the retroperitoneal space;

- installation of additional trocars without visualization of their trajectory in the retroperitoneal space increases the risk of intraoperative complications;

- continuous postoperative lavage may contribute to fluid retention and the spread of exudate in the retroperitoneal tissue.

Tasks:

- creation of accesses to the retroperitoneal space without a liquid component on the right and left for the subsequent performance of videoscopic necrosequestrectomy;

- minimization of surgical trauma;

- carrying out manipulations under combined radiation and ultrasound control to reduce the risk of intraoperative complications due to improved visualization;

- relief of purulent-necrotic process of the retroperitoneal space without the use of open methods of surgical treatment;

- Decreased mortality.

The essence of the method is that after computed tomography, a pathological zone in the retroperitoneal space is determined: its dimensions, configuration and plane of location, using a needle for primary access under U3 control, a percutaneous puncture of the retroperitoneal space is performed along the middle or posterior axillary line at the lowest point to the pathological zone by retroperitoneal access, with the condition of bypassing vascular structures, parenchymal and hollow organs, followed by the introduction of a contrast agent and X-ray control, passing a rigid conductor through the needle into the retroperitoneal space, retreating 4-6 cm above and parallel to the first injection site along the middle or posterior axillary line a second access is made, a rigid conductor is inserted and the puncture channels are bougienage, two 10 mm trocars are inserted along the bougies, a laparoscope is inserted into one trocar, a working instrument (a laparoscopic clamp with a ribbed inner surface) is inserted into the other, under X-ray control I remove the t necrotic tissues creating a cavity in the retroperitoneal space, a laparoscope is inserted into it and pneumoretroperitoneum is created with a pressure of 10-12 mm Hg, further intervention is carried out under the visual control of the laparoscope, laparoscopic clamp with a ribbed inner surface is used to fragment and remove sequesters, replace the laparoscopic suction clamp and in the irrigation mode, physiological saline is supplied to the working field to visualize freely lying sequesters and flush the retroperitoneal space, in the vacuum aspiration mode, the washing solution with small fragments of the remaining sequesters is removed, after which, under X-ray control, through each trocar, they are installed and fixed to double-lumen drains on the skin for subsequent fractional washing of the retroperitoneal space, with negative clinical and laboratory dynamics of the patient's condition, the drains are removed and necrosequestrectomy is repeated along the formed channels, and with a positive clinical and laboratory changes in the patient's condition under X-ray control, the drains are replaced and every 4-6 hours the lavage is continued until the release of clean rinsing water is reached. The method has been tested for 5 years on 46 patients.

EFFECT: in the absence of a liquid component, creation of accesses to the retroperitoneal space on the right and left for subsequent performance of videoscopic necrosequestrectomy. Combined radiation and ultrasound control reduces the risk of intraoperative complications, due to improved visualization, it allows minimizing surgical trauma, as well as stopping the purulent-necrotic process in the retroperitoneal space due to videoscopic necrosequestrectomy, without using open methods of surgical treatment, and achieving a decrease in mortality in patients with infected pancreatic necrosis.

Approbation of the method allowed to reduce mortality in patients with infected necrosis from 48% to 15.3%. The method is carried out as follows.

After computed tomography, the pathological zone in the retroperitoneal space, its dimensions, configuration and plane of location are determined, using a needle for primary access under V3 control, a percutaneous puncture of the retroperitoneal space is performed along the middle or posterior axillary line at the lowest point to the pathological zone by retroperitoneal access, followed by the introduction of a contrast agent and X-ray control to visualize the pathological zone and passing through the needle of a rigid conductor into the retroperitoneal space, stepping back 4-6 cm above and parallel to the place of the first injection along the middle or posterior axillary line, a second access is made, a rigid conductor is inserted and bougienage of the puncture channels is performed, two 10 mm trocars are inserted along the bougies, a laparoscope is inserted into one trocar, a working instrument is inserted into the other, a laparoscopic clamp with a ribbed inner surface, necrotic tissues are removed under X-ray control with a clamp, a cavity is formed in the retroperitoneal space, in a laparoscope is inserted into it and a pneumorethroperitoneum is created with a pressure of 10-12 mm Hg, further intervention is carried out under visual control of the laparoscope, sequesters are fragmented and removed with a laparoscopic clamp with a ribbed inner surface, the laparoscopic clamp is replaced with suction, and in the irrigation mode, the working field is served physiological solution for washing the retroperitoneal space, in the vacuum aspiration mode, the washing solution with small fragments of the remaining sequesters is sucked off, after which, under X-ray control, two-lumen drains are installed and fixed to the skin through each trocar for subsequent fractional washing of the retroperitoneal space, with negative clinical and laboratory dynamics of the patient's condition, the drains are removed and necrosquestrectomy is repeated along the formed channels, and with a positive clinical and laboratory dynamics of the patient's condition under X-ray control, the drains are replaced and every 4-6 hours continue to be washed until the output of clean wash water is reached.

Clinical example 1. Patient G., 46 years old, was transferred to the clinic from the central district hospital on March 10, 2016, on the 18th day from the onset of the disease, with a diagnosis of infected pancreatic necrosis, purulent-necrotic parapancreatitis. According to computed tomography data from 03/10/2016: signs of pancreatic necrosis, widespread necrosis of the retroperitoneal tissue and aracolon on the left. Operation 03/10/2016: “Retroperitenioscopy, videoscopic necrosequestrectomy.

Drainage of the retroperitoneal space on the left. According to the results of computed tomography of the abdominal cavity and retroperitoneal space, a lesion zone in the retroperitoneal space on the left was 15 by 28 cm in size, spreading along paracolic tissue to the left of the tail of the pancreas to the left iliac region without an exudative component. Under U3 control, a puncture trajectory is planned along the shortest distance to the pathological zone. In the left lateral region along the midaxillary line, a percutaneous puncture of the pathological zone was performed with a needle for primary access by retroperitoneal access. A contrast was introduced through the needle, an R-study was performed: the pathological zone in the retroperitoneal space was contrasted, a rigid conductor was inserted through the needle into the retroperitoneal space. 4 cm above and parallel to the first access, the second access was made, under combined U3- and X-ray control, bougienage of the injunction channels was performed, two 10 mm trocars were inserted along the bougies, a laparoscope was inserted into one trocar, and a laparoscopic clamp with a ribbed inner surface was inserted into the other working instrument . Under X-ray control with a clamp, after removal of necrotic tissues, a minimally necessary cavity was created in the retroperitoneal space, a laparoscope was inserted into it and pneumorethroperitoneum was created with a pressure of up to 12 mm Hg. Under the visual control of the laparoscope, clamp, sequesters were removed within healthy tissues by phragmentation. Then, instead of a clamp, suction was introduced, sanitation of the retroperitoneal space was performed with washing of the cavity every 6 hours to visually clear waters. Under x-ray control, 10 mm double-lumen drainage tubes were installed through each trocar and fixed to the skin.

In the postoperative period, drainage was continued to be washed with an aqueous solution of chlorhexidine every 6 hours. Achieved output of clean wash water.

In the future, the patient's condition showed moderate positive dynamics. On March 17, 2016, a programmed replacement of retroperitoneal drains on the left was performed along a guidewire under X-ray control with contrasting.

On March 23, 2016, a moderate negative clinical and laboratory dynamics of the patient's condition was observed. On March 24, 2016, a second operation was performed: “Retroperithenioscopy, videoscopic necrosequestrectomy. Replacement of retroperitoneal drains on the left"; in the course of the intervention according to the method described above, the rehabilitation of the retroperitoneal space on the left was performed. In the postoperative period, there was a positive clinical and laboratory dynamics.

On March 30, 04, 7, 2016, April 14, 2016, and April 21, 2016, programmed replacements of retroperitoneal tissue drains along a conductor under X-ray control with contrast were performed. Due to the positive dynamics, normalization of indicators, on April 29, 2016, the patient was discharged in a satisfactory condition for further treatment at the Central District Hospital at the place of residence with drains.

On May 3, 2016, the patient was hospitalized for a follow-up examination. There is no discharge through the drains; produced fistulography, which shows obliteration of the pathological cavity; drains removed.

After 1 month, the control examination, complaints of pain, discomfort in the abdominal cavity, the patient does not present. Notes a satisfactory condition in compliance with all recommendations after discharge.

Clinical example 2. Patient A., 47 years old, was transferred to the clinic on 05/03/2016 from the central district hospital with a diagnosis of "Infected pancreatic necrosis, purulent-necrotic parapancreatitis" due to negative dynamics and intractable febrile temperature. Upon admission, the patient was in a serious condition due to sepsis and was hospitalized in the intensive care unit. According to CT data from 05/03/2016, CT-signs of pancreatic necrosis, widespread necrosis of retroperitoneal tissue paracolon on the right. On May 4, 2016, after the necessary preoperative preparation, the patient underwent the following operation:

“Retroperithenioscopy, videoscopic necrosequestrectomy.

Drainage of the retroperitoneal space on the right.

According to the results of computed tomography of the retroperitoneal space, a lesion zone in the retroperitoneal space on the right was revealed, measuring 14 by 23 cm, extending along the paracolic tissue to the right from the head of the pancreas to the right iliac region, without an exudative component. Under U3 control, a puncture trajectory is planned along the shortest distance to the pathological zone. In the right lateral region along the posterior axillary line, a percutaneous puncture of the pathological zone was made with a needle for primary access by retroperitoneal access. A contrast was introduced through the needle, an X-ray examination was performed: the pathological zone in the retroperitoneal space was contrasted, a rigid conductor was introduced through the needle into the retroperitoneal space. 6 cm above and parallel to the first access, the second access was performed, under combined U3- and X-ray control, puncture canals were bougienage, two 10 mm trocars were inserted along the bougies, a laparoscope was inserted into one trocar, and a working instrument (a laparoscopic clamp with a ribbed inner surface) was inserted into the other trocar. ). Necrotic tissues were removed under x-ray control with a clamp and a minimally necessary cavity was created in the retroperitoneal space, a laparoscope was inserted into it and pneumorethroperitoneum was created with a pressure of up to 10 mm Hg. Under visual control of the laparoscope, sequesters within healthy tissues were removed by fragmentation with a clamp. Instead of a clamp, suction was introduced, sanitation of the retroperitoneal space was performed with washing of the cavity every 4 hours to visually clear waters. Under x-ray control, two-lumen drainage tubes with a diameter of 10 mm were installed through each trocar and fixed to the skin.

In the postoperative period, the drainage was continued to be washed with an aqueous solution of chlorhexidine every 4 hours, until the output of clean washing water was reached.

On May 11, 2016, May 18, 2016, May 25, 2016, June 2, 2016, June 7, 2016, and June 14, 2016, programmed replacements of retroperitoneal drains under X-ray control were performed. Due to the positive dynamics, normalization of indicators, on June 30, 2016, the patient was discharged with drains for further treatment at the Central District Hospital at the place of residence in a satisfactory condition.

On July 28, 2016, the patient was hospitalized for a follow-up examination. There is no discharge through the drains; produced fistulography, which shows obliteration of the pathological cavity; drains removed.

After 1 month, the control examination, complaints of pain, discomfort in the abdominal cavity, the patient does not present. Notes a satisfactory condition in compliance with all recommendations after discharge.

Claims (1)

A method for videoscopic necrosequestrectomy in necrotic parapancreatitis without exudative lesions of the retroperitoneal space, including providing access to the pathological zone, forming a puncture channel with a needle for primary access under the control of radiation and ultrasound methods of examination, characterized in that after computed tomography, the pathological zone in the retroperitoneal space is determined, its dimensions, configuration and plane of location, using a needle for primary access under U3 control, a percutaneous puncture of the retroperitoneal space is performed along the middle or posterior axillary line at the lowest point to the pathological zone by retroperitoneal access, followed by the introduction of a contrast agent and X-ray control to visualize the pathological zone and passing through the needle of a rigid conductor into the retroperitoneal space, stepping back 4-6 cm above and parallel to the place of the first injection along the middle or posterior axillary line, the second access is carried out a rigid conductor is inserted and the puncture channels are bougienage, two 10 mm trocars are inserted along the bougie, a laparoscope is inserted into one trocar, a working instrument is inserted into the other, a laparoscopic clamp with a ribbed inner surface, necrotic tissues are removed under X-ray control with a clamp, a cavity is formed in retroperitoneal space, a laparoscope is inserted into it and a pneumorethroperitoneum is created with a pressure of 10-12 mm Hg, further intervention is carried out under visual control of the laparoscope, sequesters are fragmented and removed with a laparoscopic clamp with a ribbed inner surface, the laparoscopic clamp is replaced with suction and in irrigation mode physiological solution is supplied to the working field, in the vacuum aspiration mode, the washing solution with small fragments of the remaining sequesters is sucked off, after which, under X-ray control, double-lumen drains are installed and fixed to the skin through each trocar, with negative clinical and laboratory dynamics of the patient's condition the drains are removed and necrosequestrectomy is repeated along the formed channels, and with a positive clinical and laboratory dynamics of the patient's condition under X-ray control, the drains are replaced and every 4-6 hours the lavage is continued until the release of clean rinsing water is reached.