RU2844260C1 - Method for a differential approach to the selection of a trocar arrangement pattern in patients with malignant gastric growths depending on the constituent type - Google Patents

Abstract

FIELD: medical science.

SUBSTANCE: invention refers to medicine, namely to surgery and oncology, and can be used in robot-assisted subtotal gastrectomy in the patients with gastric malignancies. For all constituent types, an optical trocar is inserted in the upper umbilical point. Remaining four trocars are placed depending on the constitution type – dolichomorphic, mesomorphic or brachymorphic.

EFFECT: method provides the optimum position of the trocars, reduces the length of the operation, requires no intraoperative rearrangement and correction of the trocar position by taking into account the patient’s somatotype.

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Description

A method of differential approach to the choice of trocar placement scheme in patients with malignant neoplasms of the stomach depending on the constitutional type

The invention relates to medicine, in particular to surgery and oncology, and can be used in performing robot-assisted subtotal gastric resection in patients with malignant neoplasms of the stomach.

The technique of robot-assisted surgical interventions is largely determined by the trocar placement option, which is important for the surgical intervention as a whole. M. Mranda (2022) argues that the most popular trocar placement schemes are not universal, since they do not take into account the individual features of the body structure of a particular patient [Feasibility of robotic radical gastrectomy using a monopolar device for gastric cancer / H. Okabe, K. Obama, S. Tsunoda [et al.] // Surgery Today. - 2019. - Vol. 49. - No. 10. - P. 820-827] [Kim M.-C. Robotic gastrectomy for gastric cancer: surgical techniques and clinical merits / M.-C. Kim, G.-U. Heo, G.-J. Jung // Surgical Endoscopy. - 2010. - Vol. 24. - Robotic gastrectomy for gastric cancer. - No. 3. - P. 610-615].

It is proposed to solve this problem by using a differential approach to choosing one or another scheme for placing robotic trocars, depending on the patient’s body type (Table 1).

Table 1. Correspondence of trocar placement technique to the patient’s constitutional type

Constitutional type Technique of trocar placement "high fan" "low fan" "linear" Dolichomorphic + Mesomorphic + Brachymorphic +

The invention is based on the task of creating a method for a differential approach to selecting a trocar placement scheme in patients with malignant neoplasms of the stomach depending on the constitutional type, which ensures the optimal placement of trocars in patients of different body types.

The solution to the set problem is ensured by the fact that in the method of differential approach to the choice of the trocar arrangement scheme in patients with malignant neoplasms of the stomach depending on the constitutional type, when determining the dolichomorphic constitutional type of body build in a patient, a high fan-shaped arrangement of trocars is used; when determining the mesomorphic constitutional type of body build in a patient, a low fan-shaped arrangement of trocars is used; when determining the brachymorphic constitutional type of body build in a patient, a linear arrangement of trocars is used.

The invention is explained by Fig. 1 and Fig. 2, which show a diagram of a “high fan-shaped arrangement of trocars” (daVinci Si and Xi), Fig. 3 and 4, which show a diagram of a “low fan-shaped arrangement of trocars” (daVinci Si and Xi); Fig. 5, which shows a diagram of a “linear arrangement of trocars”.

When using the daVinci Si robotic system, the “high fan-shaped” technique ensures optimal trocar placement in patients with a dolichomorphic body type.

The first stage involves performing a laparocentesis at the upper umbilical point and installing a 12 mm trocar to insert the video system, as shown in Fig. 1. A pneumoperitoneum of _CO2 up to 12 mm Hg is created. Then, the points are marked on the spherical surface of the anterior abdominal wall. In the left mesogastric region, 3-4 cm above the umbilicus at the level of the left anterior axillary line, there is a point for installing an 8 mm trocar with the connection of the R1 manipulator. Also, in the left mesogastric region, 1-2 cm above the umbilicus at the level of the left midclavicular line, an assistant port/trocar with a diameter of 12 mm is installed. In the right mesogastric region, 3-4 cm above the umbilicus along the midclavicular line, an 8 mm trocar with a diameter of R2 is installed. In the right hypochondrium, closer to the anterior axillary line, a trocar with a diameter of 8 mm R3 is installed (see Fig. 1).

When using the daVinci Xi robotic system, the first stage is laparocentesis at the upper umbilical point and an 8 mm diameter trocar is installed to insert the video system, as shown in Fig. 2, subsequently connected to the R3 manipulator. A pneumoperitoneum of _CO2 up to 12 mm Hg is created.

Then, on the spherical surface of the anterior abdominal wall, navigation points are marked. In the left mesogastric region, 3-4 cm above the navel at the level of the left anterior axillary line, is the point for installing a trocar with a diameter of 8 mm with the connection of the R4 manipulator. Also, in the left mesogastric region, 1-2 cm above the navel at the level of the left midclavicular line, is installed an assistant port/trocar with a diameter of 12 mm.

In the right mesogastric region, 3-4 cm above the level of the navel, a trocar with a diameter of 8 mm R2 is installed along the midclavicular line. In the right hypochondrium, at the level of the right anterior axillary line, a trocar with a diameter of 8 mm R1 is installed (see Fig. 2).

When using the daVinci Si robotic system, the “low fan-shaped” technique ensures optimal trocar placement in patients with a mesomorphic constitutional type.

When using the daVinci Si robotic system:

- the point for installing a trocar with a diameter of 8 mm with connection of the R1 manipulator - in the left mesogastric region 1.5-2 cm above the level of the optical trocar at the level of the left anterior axillary line;

- the point of installation of the assistant port/trocar with a diameter of 12 mm - in the left mesogastric region above the level of the optical trocar by 0.5-1 cm at the level of the left midclavicular line in the middle of the distance between the optical trocar and trocar R1;

- the point for installing the trocar with a diameter of 8 mm R2 - in the right mesogastric region above the level of installation of the optical trocar by 1.5-2 cm along the right midclavicular line;

- the installation point of the trocar with a diameter of 8 mm R3 in the right mesogastric region 3-4 cm above the level of the optical trocar, at the level of the anterior axillary line (see Fig. 3).

When using the daVinci Xi robotic system:

- the point for installing a trocar with a diameter of 8 mm with connection of the R4 manipulator - in the left mesogastric region 1.5-2 cm above the level of the optical trocar at the level of the left anterior axillary line;

- the point of installation of the assistant port/trocar with a diameter of 12 mm - in the left mesogastric region above the level of the optical trocar by 0.5-1 cm at the level of the left midclavicular line in the middle of the distance between the optical trocar and trocar R4;

- the point of installation of the trocar with a diameter of 8 mm R2 - in the right mesogastric region above the level of the optical trocar by 1.5-2 cm along the midclavicular line;

- the point for installing the trocar with a diameter of 8 mm R1 - in the right mesogastric region, 3-4 cm above the level of the optical trocar, at the level of the anterior axillary line (see Fig. 4).

When using the daVinci Si robotic system, the “linear trocar placement” technique ensures optimal trocar placement in patients with a brachymorphic constitutional type.

- the point for installing a trocar with a diameter of 8 mm with connection of the R4 manipulator - in the left mesogastric region on the same horizontal line with the level of installation of the optical trocar along the border of the left anterior axillary line;

- the point of installation of the assistant port/trocar with a diameter of 12 mm is in the left mesogastric region on the same horizontal line with the level of installation of the optical trocar along the left midclavicular line;

- the point of installation of the trocar with a diameter of 8 mm R2 - in the right mesogastric region on the same horizontal line with the level of installation of the optical trocar along the right midclavicular line;

- the point of installation of the trocar with a diameter of 8 mm R1 - in the right mesogastric region 2-3 cm above the level of the optical trocar along the right anterior axillary line. Such a slightly elevated position of the trocar R1 ensures the most optimal distance and angle of action (see Fig. 5).

Clinical examples:

1. Patient K. was admitted to the abdominal oncology department with a diagnosed malignant tumor of the antral part of the stomach. During anthropometry, it was established that the patient has a dolichomorphic body type. A decision was made to use a high fan-shaped arrangement of trocars during robot-assisted subtotal gastrectomy. No intraoperative complications or conflicts of robotic manipulators were observed during the operation. Rearrangement of trocars and correction of the position of instruments were not required.

2. Patient L. was admitted to the abdominal oncology department with a diagnosed malignant tumor of the lower third of the stomach body. During anthropometry, it was established that the patient has a mesomorphic body type. A decision was made to use a low fan-shaped arrangement of trocars during robot-assisted distal subtotal gastrectomy. No intraoperative complications or conflicts of robotic manipulators were observed during the operation. Rearrangement of trocars and correction of the position of instruments were not required.

3. Patient S. was admitted to the abdominal oncology department with a diagnosed malignant tumor of the antral part of the stomach. During anthropometry, it was established that the patient has a brachymorphic body type. A decision was made to use a linear arrangement of trocars during robot-assisted distal subtotal gastrectomy. No intraoperative complications or conflicts of robotic manipulators were observed during the operation. Rearrangement of trocars and correction of the position of instruments were not required.

Claims (4)

A method for trocar placement in robot-assisted surgeries in patients with malignant neoplasms of the stomach depending on the constitutional type, characterized by the fact that for all constitutional types an optical trocar is installed at the upper umbilical point; then - with the dolichomorphic type, trocars are installed in the left mesogastric region 3-4 cm above the navel along the anterior axillary line, in the left mesogastric region 1-2 cm above the navel along the midclavicular line, in the right mesogastric region 3-4 cm above the navel along the midclavicular line, in the right hypochondrium along the anterior axillary line; - with the mesomorphic type, trocars are installed in the left mesogastric region 1.5-2 cm above the level of the optical trocar along the anterior axillary line, in the left mesogastric region 0.5-1 cm above the level of the optical trocar in the middle of the distance between the optical trocar and the trocar located along the anterior axillary line, in the right mesogastric region 1.5-2 cm above the level of the optical trocar along the midclavicular line, in the right mesogastric region 3-4 cm above the level of the optical trocar along the anterior axillary line; - with the brachymorphic type, trocars are installed on the same horizontal line with the level of installation of the optical trocar in the left mesogastric region along the anterior axillary line, in the left mesogastric region along the midclavicular line, in the right mesogastric region along the midclavicular line, in the right mesogastric region 2-3 cm above the optical trocar along the anterior axillary line.