RU2801346C1 - Simulator for developing operational skills in biliary surgery - Google Patents

Abstract

FIELD: teaching aids in medicine.

SUBSTANCE: simulator for practicing operational skills in biliary surgery includes a rectangular platform with four silicone suction cups installed in the corners of the platform and a rectangular plastic box for storing consumables and modules placed on the platform. The first module for testing the stitching of anatomical structures in the depth of the surgical wound is a tube with a plug, on the upper edge of which a round piece of spunbond fabric is installed with the formation of a cone-shaped recess in the center of the plug, where a plastic ball with a diameter is placed. The second module for working out the suturing of the vessel in the depth of the surgical wound is a PVC pipe with a plug, in the center of which there is a hole for inserting a rubber elastic tube. The third and fourth modules each represent a PVC pipe with a rectangular hole and four clamps installed 1 cm from the tops of the rectangular hole for fixing materials imitating the anterior abdominal wall. The third module is intended for the imposition of cholecystostomy, includes foam rubber imitating the surrounding tissues in the paravesicular space of the gallbladder installed into the base of the module, and a pear-shaped rubber ball filled with water, colored with brilliant green, imitating bile. The fourth module is intended for practicing operations on the common bile duct, it includes foam rubber imitating the surrounding tissues installed on the base of the module, and an external elastic rubber tube with an opening imitating the mouth of the cystic duct, a plastic ball imitating a gallstone is installed proximal to the opening into the lumen of the tube, obturating lumen of the common bile duct.

EFFECT: ensuring the development of basic manual skills in biliary surgery.

1 cl, 16 dwg

Description

The simulator for working out operational skills in biliary surgery belongs to the field of medicine, namely, to the development of manual skills and operational techniques in biliary surgery by medical students, residents and surgeons.

When developing the proposed device, the goal was set: to create a simulator for practicing operational skills in biliary surgery, which will allow you to practice the skill of stitching tissues at the depth of the surgical wound and in difficult operating conditions, simulate the most frequent surgical interventions on the gallbladder and extrahepatic bile ducts, and will be easy to use. manufacturing, have cheap consumables and a low economic component.

The result of the implementation of the goal is a simulator for practicing operational skills in biliary surgery (Fig. 1). The simulator includes a rectangular platform 30*30 cm in size, 1 cm thick, with four silicone suction cups installed in the corners of the platform at a distance of 1 cm from the edges, on which a rectangular plastic rectangular box 12*4*8 cm is installed for storing consumables (Fig. 2 , Fig. 3) and four clinical modules for practicing surgical techniques.

The first module for suturing anatomical structures in the depth of the surgical wound is represented by a plastic PVC pipe 13 cm high, 0.3 cm thick and 5 cm in diameter with a 30 degree bend, 5 cm from the base, fixed 2 cm from the lateral edge and 2 cm from front edge to the base of the platform. A rectangular hole 4 cm wide and 4 cm long was created from the rear semicircle of the pipe. For fixation, a pipe plug with an outer diameter of 4.9 cm and a height of 3 cm is used. A round piece of spunbond fabric with an area of 130 cm ² is installed on the upper edge of the plug so that a recess in the form of a cone 2 cm deep is formed in the center of the plug. Install the pipe on the plug . A plastic ball 4 mm in diameter is placed in the center of the recess (Fig. 4).

The cadet is asked to put a purse-string suture around the plastic ball so that when the thread is tied, the ball is completely immersed in the fabric, and the knot is tightly fixed (Fig. 9).

When completing this module, the student develops skills: suturing in the depth of the surgical wound, which requires positioning the needle at different angles and directions to the plane and knitting a surgical knot at the depth of the wound.

The second module - flashing the vessel in the depth of the surgical wound is represented by a PVC plastic pipe 13 cm high, 3 mm thick and 5 cm in diameter with an inclination angle of 30 degrees, fixed 11 cm from the side face and 2 cm from the front face to the base of the platform (Fig. .6). A rectangular hole 4 cm wide and 4 cm long is created from the rear semicircle of the pipe. For fixation, a plug is used for a pipe with an outer diameter of 4.9 cm and a height of 3 cm. A 4 mm hole is formed in the center of the plug from the front semicircle for inserting a rubber elastic tube 7 cm long, with an outer diameter of 3 mm, a wall thickness of 0.5 mm and an inner diameter 2 mm. The tube is passed in foam rubber 3 cm thick so that a 1 cm long section of the tube remains in the center of the foam rubber. The outer section of the tube for an aqueous sample is 2 cm (Fig. 7).

The cadets are offered to stitch the damaged vessel in the depth of the surgical wound by applying a Z-shaped hemostatic suture, which imitates the stitching of the cystic artery when it is damaged during cholecystectomy (Fig. 8). After flashing the vessel, to check the quality of the ligation, it is proposed to inject water colored with brilliant green through the outer end of the tube, using a syringe. With high-quality ligation, there is no flow of fluid through the inner section of the tube.

The third and fourth modules are represented by a PVC plastic pipe 20 cm high, 3 mm thick with a wall thickness of 11 cm and 11 cm in diameter with an inclination angle of 30 degrees, fixed 2 cm from the side face and 2 cm from the front face to the platform base. A rectangular hole 7 cm wide and 10 cm long was created from the rear semicircle of the pipe. 4 clamps are installed 1 cm from the tops of the rectangular hole to fix materials imitating the anterior abdominal wall (Fig. 9). The layers of the anterior abdominal wall are imitated with artificial skin, subcutaneous fat - with foam rubber 1 cm thick, muscles - with a composite polymer material based on ethylene vinyl acetate 0.5 cm thick, peritoneum - with spunbond fabric 1 mm thick. Materials for imitation in structure and properties are close to the tissues of the anterior abdominal wall. For fixation, a tube plug with an outer diameter of 10.9 cm and a height of 3 cm is used. A tube diameter of 11 cm simulates an operative access to the gallbladder and extrahepatic bile ducts, for example, when performing access according to Kocher, Fedorov, transrectal or upper median laparotomy.

The third module for the imposition of cholecystostomy includes foam rubber 1 cm thick, imitating the surrounding tissues in the paravesicular space of the gallbladder, installed in the base of the module and a pear-shaped rubber ball with a volume of 100 ml, wall thickness 1.5 mm, filled with brilliant green water, which imitates bile . A rubber ball imitating the gallbladder is fixed at the base of the module 1 cm from the tube wall at 3 o'clock of the conditional dial, this simulates the position of the gallbladder from the surgical access (Fig. 10).

The cadet is invited to perform the imposition of cholecystostomy in stages: 1) with a Luer clamp, grab the bottom of the rubber ball and remove it from the depth of the wound; 2) put two ligatures on the bottom of the bubble - holders; 3) between the ligatures, make an incision for the introduction of tubular drainage; 4) insert the drainage into the rubber ball, having previously fixed the ligature on the drainage for fixation to the gallbladder; 5) sew drainage to the bladder wall; 6) put a purse-string suture around the tubular drainage; 7) immerse the drain in a rubber ball and tighten the purse-string suture around the drain; 8) make a skin incision 4 mm long to remove the drainage; 9) perform a puncture with a Billroth clamp of the anterior abdominal wall, capture the drainage and remove it from the module (Fig. 11); 10) sew drainage in the area of the skin incision and 7 cm from it, forming a loop (Fig. 12).

When working on this module, the cadet works out the skill of external drainage of the gallbladder in conditions close to real.

The fourth module for practicing operations on the common bile duct is represented by a PVC plastic pipe described above, foam rubber 2 cm thick, imitating the surrounding tissues, installed on the base of the module and an elastic rubber tube with an outer diameter of 10 mm, a wall thickness of 1 mm and an inner diameter of 8 mm. The tube mimics the common bile duct. The rubber tube is positioned so that the proximal end is fixed at 10 o'clock and the distal end at 4 o'clock of the conventional dial (Fig. 13). This position of the tube corresponds to the intraoperative location of the common bile duct when performing operative access to the extrahepatic bile ducts. The tube has a 5 mm hole imitating the orifice of the cystic duct. A plastic ball with a diameter of 9 mm is placed 1 cm proximal to the opening into the lumen of the tube. A plastic ball imitates a gallstone obturating the lumen of the common bile duct. The module simulates the clinical situation of choledocholithiasis.

The cadet is invited to perform choledochotomy and lithoextraction in stages: 1) apply two ligatures - holders opposite each other in the area of the proposed choledochotomy; 2) perform a longitudinal choledochotomy; 3) mechanically using a clamp to capture the calculus and perform lithoextraction, or use the Dormia basket to capture and remove the calculus; 4) suturing the incision with single interrupted sutures, or draining the common bile duct according to Vishnevsky, Kocher, Halsted (Fig. 14), Kerr or Kertle, followed by removal of the drainage through a hole that imitates the anterior abdominal wall and its fixation to the skin (Fig. 15, Fig. 16).

The tightness test is carried out with water dyed with brilliant green, introduced into the lumen of the tube with a Janet syringe into its distal end, a clamp is preliminarily applied to the proximal end of the tube. The consistency of the sutures and installed drainage shows the absence of leakage of colored water imitating bile.

The proposed simulator for practicing operational skills in biliary surgery can be widely used in teaching and training manual skills, as it has the following advantages:

• allows you to practice a number of manual skills and operational techniques, such as: stitching anatomical structures at the depth of the surgical wound; imposition of external cholecystostomy; performing choledochotomy and lithoextraction; drainage of the common bile duct by known methods; removal and proper fixation of drainage;

• available consumables that mimic anatomical structures;

• simple manufacturing technology;

• low cost of components and parts of simulators makes it cost-effective for educational institutions and for personal use.

Claims (7)

Simulator for practicing operational skills in biliary surgery, including: a rectangular platform 30*30 cm in size, 1 cm thick, with four silicone suction cups 3 cm in diameter installed in the corners of the platform at a distance of 1 cm from the edges, and a rectangular plastic box 12*4*8 cm for storing consumables; and the modules placed on it: the first module for testing the stitching of anatomical structures in the depth of the surgical wound, which is a polyvinyl chloride (PVC) pipe 13 cm high, 0.3 cm wall thick and 5 cm in diameter with a 30-degree bend 5 cm from the base, with a plug, on the upper edge in which a round flap of spunbond fabric is installed with the formation of a recess in the form of a cone in the center of the plug, where a plastic ball with a diameter of 4 mm is placed; the second module for testing the suture of the vessel in the depth of the surgical wound, which is a PVC pipe 13 cm high, 3 mm thick and 5 cm in diameter with an inclination angle of 30 degrees with a plug for the pipe with an outer diameter of 4.9 cm and a height of 3 cm, in the center plugs, a hole 4 mm in diameter was formed for inserting a rubber elastic tube 7 cm long, with an outer diameter of 3 mm, a wall thickness of 0.5 mm and an inner diameter of 2 mm, the tube was inserted into the foam rubber 3 cm thick so that in the center of the foam rubber there was a section of the tube with a length of 1 cm; the third and fourth modules, each consisting of a PVC pipe 20 cm high, 3 mm thick and 11 cm in diameter with an angle of inclination of 30 degrees, with a rectangular hole 7 cm wide and 10 cm long, and installed 1 cm from the tops of the rectangular hole four clamps for fixing materials imitating the anterior abdominal wall; at the same time, the third module for applying cholecystostomy includes foam rubber 1 cm thick, imitating the surrounding tissues in the paravesicular space of the gallbladder, installed at the base of the module, and a pear-shaped rubber ball with a volume of 100 ml, a wall thickness of 1.5 mm, filled with water, colored with brilliant green, imitating bile, fixed in the base of the module 1 cm from the wall of the tube at 3 o'clock of the conditional dial to simulate the position of the gallbladder from the surgical access; and the fourth module for practicing operations on the common bile duct includes foam rubber 2 cm thick, imitating the surrounding tissues, installed on the base of the module, and an elastic rubber tube with an outer diameter of 10 mm, a wall thickness of 1 mm and an inner diameter of 8 mm, a hole of 5 mm is formed in the tube , imitating the mouth of the cystic duct, 1 cm proximal to the hole in the lumen of the tube, a plastic ball with a diameter of 9 mm is installed, imitating a bile calculus obturating the lumen of the common bile duct.