RU2843923C1 - Method for transluminal icg topographic diagnosis when performing reconstructive plastic surgeries on ureters - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to surgery. A laparoscope is inserted into the abdominal cavity under endotracheal anaesthesia; enteric loops are mobilized and displaced from the anterior abdominal wall to insert trocars; a ureter brought to the anterior abdominal wall in the form of ureterocutaneous stoma or a renal pelvis with an upper one-third of the ureter is visualised. In bottle with indocyanine green dosage 25 mg is added 10 ml of water for injection, ready solution in amount of 5 ml is repeatedly diluted with 5 ml of water for injection and the resulting solution in volume of 10 ml is administered through 10Ch Nelaton catheter, introduced through the ureterocutaneostoma into the ureter or through the nephrostoma into the renal pelvis under the control of laparoscopic optics. In the ICG mode, the ureter is visualized and mobilised, separated from the adjacent small intestinal wall, or from adjacent tissues for the following reconstructive operation.

EFFECT: method allows to clearly and quickly determine "area of interest", to determine topographic anatomy of ureter and pelvis, not to damage them and adjacent organs and tissues in process of performing reconstructive operations.

1 cl, 2 ex

Description

The invention relates to medicine, namely to the field of surgery.

The indocyanine green (ICG) fluorescent test has become a standard test in surgical interventions, including in the field of surgical urology.

ICG imaging is an imaging technique based on the administration of ICG and determination of tissue perfusion (areas of interest) based on fluorescence intensity.

The main difficulties faced by the surgeon are differentiation of vital structures with difficult visualization after repeated operations due to the cicatricial-adhesive process and sclerolipomatous changes.

The ICG visualization method allows to improve the quality of tissue blood supply assessment during intravenous administration and to obtain clear visualization of tubular structures and hollow organs during endoluminal administration into them during the intraoperative period.

Transluminal ICG topographic diagnostics involves the introduction of ICG into the lumen of hollow organs (into the ureter (antegrade and retrograde), into the urethra).

Known (RU, patent 2080814, published 10.06.1997) is a method for diagnosing diseases of the prostate gland, which includes introducing into the prostatic section of the urethra a means for visually examining the seminal tubercle, introducing into the prostatic section of the urethra a means for collecting prostatic secretion, mechanical action on the seminal tubercle to extract prostatic secretion and assess the condition of the prostate gland by examining its secretion and appearance, wherein all diagnostic manipulations are performed during one procedure, and the surface of the seminal tubercle is affected for 2-5 s, with mechanical vibrations with a frequency of 8 and 16 Hz and an amplitude not exceeding 0.5 mm.

Also known (RU, patent 2200455, published 20.03.2003) is a method for comprehensive diagnostics of diseases of the genitourinary system of men, including the collection and microscopic analysis of urethral discharge and prostate secretion, while in addition, in one go, a microscopic examination of urine, as well as electropuncture and ultrasound examination are carried out in parallel and in turn, while the microscopic examination of urethral discharge is carried out for 8-10 minutes, and urine and prostate secretion - for 5-7 minutes, each smear is prepared for microscopic examination for 2-30 s at a temperature of 40-80 ° C, and the entire study is carried out for 40-60 minutes.

Also known (RU, patent 2624517, published 04.07.2017) is a method for topographic identification of the organs of the scrotum and spermatic cord during ultrasound examination, characterized in that the ultrasound examination of the organs of the scrotum and spermatic cord is carried out with a linear sensor in grayscale mode in combination with power Dopplerography, the sensor is installed on the anterior surface of the scrotum and sequential transverse scans of the testicle are performed, the one is selected on which the mediastinum of the testicle is visualized in the form of a cone; and if on the transverse scan of the testicle the base of the mediastinal cone faces the posterior edge of the testicle, and the apex faces the anterior edge of the testicle, while at the base of the mediastinal cone, starting from the corner of the base of the cone located closer to the upper pole of the testicle, in the direction to the opposite corner of the base of the mediastinal cone, in order are located the epididymal part of the vas deferens in the form of a rounded tubular and layered structure with a pronounced hypoechoic middle layer, the vascular bundle in the form of a pulsating tubular structure with a hyperechoic wall surrounded by small anechoic and hypoechoic rounded structures, and the body of the epididymis, and at the apex of the mediastinal cone closer to the upper pole of the testicle is the head of the epididymis, then this is the normoposition of the testicle; if on the transverse scan of the testicle the base of the mediastinal cone faces the anterior edge of the testicle, and the apex of the cone faces the posterior edge of the testicle, while at the base of the mediastinal cone, starting from the corner of the base of the cone located closer to the upper pole of the testicle, in the direction of the opposite corner of the base of the mediastinal cone, the body of the epididymis, the vascular bundle and the epididymal part of the vas deferens are located in order, and at the apex of the mediastinal cone closer to the upper pole of the testicle, the head of the epididymis is located, then this is a longitudinal inversion of the testicle.

The disadvantage of all the above sources of information is the fact that they all do not allow visualization of tubular structures and hollow organs during endoluminal administration of drugs and biologically active fluids into them during the intraoperative period, which allows improving the quality of assessment of tissue blood supply during intravenous administration and obtaining clear visualization.

The technical problem solved using the developed method consists of differentiating vital structures in the case of difficult visualization after repeated operations due to the cicatricial-adhesive process and sclerolipomatous changes.

The technical result achieved by implementing the method consists in improving the quality of assessing the blood supply to tissues during intravenous administration of drugs and obtaining visualization of tubular structures and hollow organs during endoluminal administration into them during the intraoperative period.

In order to achieve the specified technical result, it is proposed to use the developed method of transluminal ICG topographic diagnostics when performing reconstructive and plastic surgeries on the ureters, according to which, under endotracheal anesthesia, a laparoscope is inserted into the abdominal cavity, the loops of the small intestine are mobilized with their displacement from the anterior abdominal wall for the insertion of trocars, the ureter is visualized, brought out to the anterior abdominal wall in the form of a ureterocutaneostomy or the renal pelvis with the upper third of the ureter; 10 ml of water for injection is added to a vial with 25 mg of indocyanine green, the prepared solution in a volume of 5 ml is re-diluted with 5 ml of water for injection and the resulting solution in a volume of 10 ml is administered through a Nelaton 10Ch catheter inserted through a ureterocutaneostomy into the ureter or through a nephrostomy into the renal pelvis under the control of laparoscopic optics, in the ICG mode, visualization is performed and the ureter is mobilized, separated from the wall of the small intestine adjacent to it, or from adjacent tissues for subsequent reconstructive surgery.

Preferably, the tissue adjacent to the ureter is scar tissue.

Examples of implementation of the invention

Example #1

Patient M., 35, received a mine blast wound to the abdomen, pelvis, upper and lower extremities, with damage to the lower third of the left ureter. At the evacuation stages, laparotomy and ureterocutaneostomy were performed. After rehabilitation treatment, he was hospitalized for an operation to restore ureteral patency.

Under endotracheal anesthesia, in the right lateral position, the surgical field is treated twice with antiseptic solutions. Carbon dioxide is insufflated into the abdominal cavity to P = 12 mm Hg. A laparoscope is inserted into the abdominal cavity using an optical trocar. Laparoscopy reveals an extreme adhesive process in the abdominal cavity. The small intestinal loops are mobilized with their displacement from the anterior abdominal wall, trocars No. 12, No. 12 and No. 5 are alternately inserted into the abdominal cavity to the right and left of the midline in the hypogastrium, mesogastrium and epigastrium, respectively, and No. 10 in the left hypochondrium. The left ureter is visualized, brought out to the anterior abdominal wall in the form of a ureterocutaneostomy, which is intimately adjacent to the small intestinal loop. In a vial with indocyanine green (JCG), dosage 25 mg, 10 ml of water for injection were added. The ready solution was taken in a volume of 5 ml (12.5 mg of indocyanine green), again diluted with 5 ml of water for injection, and in a volume of 10 ml was injected through a Nelaton 10Ch catheter into the ureterocutaneostomy and the left ureter under the control of laparoscopic optics. In the ICG mode (in the near infrared fluorescence range), which allows to see the boundaries of the ureter and intestinal loops due to the bright green glow of the ureter, the ureter was mobilized, disconnected from the wall of the small intestine.

This technique made it possible to visualize and mobilize the ureter, separating it from the intestinal wall without damaging them.

The distal end of the ureter is spatulated without cutting off the peritoneum, then cut off from the anterior abdominal wall. The urinary bladder is filled to 500 ml.

A flap approximately 50 mm long and 20 mm wide was cut out of the bladder wall. The bladder wall was fixed with a thread to the lumbar muscle to reduce tension in the area of the proposed anastomosis. A stent was installed in the ureter, passed with the proximal curl of the stent in the renal pelvic floor system of the left kidney. The angle of spatulation of the ureter was fixed with a nodal suture to the cut out flap of the bladder. The distal curl of the stent was passed into the bladder. Locking sutures were applied first along the "posterior tube" of the anastomosis from the angle of spatulation between the ureter and the neoureter (flap from the bladder), then along the "anterior lip". The bladder was sutured with a locking suture with subsequent tubularization of the neoureter. The tightness of the bladder and ureter in the area of suturing and anastomoses was checked. Hemostasis. A drainage tube was installed in the small pelvis. The napkins, all instruments, trocars, wound sutures, and aseptic adhesive tapes were removed from the abdominal cavity.

Example #2

Patient M., 38 years old, received a mine blast wound to the chest and abdomen with damage to the small and large intestines, and a complete rupture of the upper third of the right ureter. Multiple surgeries on abdominal organs and a nephrostomy on the right were performed. After rehabilitation treatment, he was hospitalized for an operation to restore ureteral patency.

Under endotracheal anesthesia, in the left lateral position, the surgical field is treated twice with antiseptic solutions. Carbon dioxide is insufflated into the abdominal cavity to P = 12 mm Hg. A laparoscope is inserted into the abdominal cavity using an optical trocar. Laparoscopy reveals an extreme adhesive process in the abdominal cavity. Mobilization of the small intestinal loops with their displacement from the anterior abdominal wall is performed; trocars No. 12, No. 5 (2) are alternately inserted into the abdominal cavity to the right and left of the midline in the hypogastrium, mesogastrium and epigastrium, respectively, and No. 10 in the right hypochondrium. With significant technical difficulties due to the extreme degree of severity of the cicatricial process, the right kidney is mobilized over the entire surface.

It was not possible to visualize the renal pelvis and the upper third of the right ureter due to pronounced scars and disruption of the topographic anatomy. 10 ml of water for injection were added to a vial with indocyanine green (ICG), dosage 25 mg. The prepared solution was withdrawn in a volume of 5 ml (12.5 mg indocyanine green), diluted again with 5 ml of water for injection, and in a volume of 10 ml was injected through a nephrostomy drainage into the pelvis (renal cavity system) under laparoscopic control. In the ICG mode (in the near infrared fluorescence range), it was possible to see the pelvis and its borders in the area of the lower pole of the right kidney in the cicatricial conglomerate. The pelvis and the right ureter in the upper third were mobilized. The ureter was taken on a holder. The pelvis of the right kidney was transected obliquely, the ureter - 1 cm distal to the obliteration. No stones were found in the lumen of the renal pelvis, a curl of the nephrostomy drainage was visualized. The ureter was spatulated along the posterior surface by 15 mm. After placing guide sutures on the medial and lateral angles of the renal pelvis and ureter with 4/0 Vicryl, a circular wrap suture was made with two oncoming threads (4/0 Vicryl). The tightness of the anastomosis was confirmed by means of nephrostomy drainage. Monitoring for hemostasis, foreign bodies and anatomical integrity of organs. A 19 Ch Blake drain was placed in the retroperitoneal space behind the kidney, brought out through a trocar wound in the right iliac region. The trocars and instruments were removed under visual control. Layer-by-layer sutures on the wounds. Aseptic stickers.

As a result of the surgical interventions performed, it is obvious that this method allows us to clearly and quickly determine the “zone of interest”, determine the topographic anatomy of the genitourinary system organs (ureter, renal pelvis), and not damage them and the adjacent organs and tissues during reconstructive operations.

Claims (2)

1. A method of transluminal ICG topographic diagnostics when performing reconstructive and plastic surgeries on the ureters, characterized by the fact that under endotracheal anesthesia, a laparoscope is inserted into the abdominal cavity, the loops of the small intestine are mobilized with their displacement from the anterior abdominal wall for the insertion of trocars, the ureter is visualized, brought out to the anterior abdominal wall in the form of a ureterocutaneostomy or the renal pelvis with the upper third of the ureter; 10 ml of water for injection is added to a vial with 25 mg of indocyanine green, the prepared solution in a volume of 5 ml is re-diluted with 5 ml of water for injection and the resulting solution in a volume of 10 ml is administered through a Nelaton 10Ch catheter inserted through a ureterocutaneostomy into the ureter or through a nephrostomy into the renal pelvis under the control of laparoscopic optics, in the ICG mode, visualization is performed and the ureter is mobilized, separated from the wall of the small intestine adjacent to it, or from adjacent tissues for subsequent reconstructive surgery. 2. The method according to paragraph 1, characterized in that the tissue adjacent to the ureter is scar tissue.