RU2833924C1 - Method for mobilizing supra-aortic vessels from upper ministernotomy approach - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to cardiovascular surgery, and can be used for mobilization of supra-aortic vessels. Pericardium is opened transversally above the middle portion of the ascending aorta. Dissected pericardium is sutured. Filament is tractioned in the caudal direction, displacing the ascending aorta and the aortic arch downwards. Proximal portions of the supra-aortic vessels are brought into the wound.

EFFECT: method enables higher precision of manipulations on supra-aortic vessels, which reduces risks of unintentional injuries of organs and tissues due to improved vascular imaging.

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Description

The invention relates to medicine, in particular to cardiovascular surgery, and can be used for the purpose of safe precision mobilization of supra-aortic vessels, which reduces the risk of unintentional injury to organs and tissues.

The standard access in cardiac surgery is a full median sternotomy. In recent years, an increasingly relevant and popular access in surgical interventions on the aortic valve, aortic root, as well as the ascending section and arch of the aorta is the upper ministernotomy. The main positive aspects of this access are the preservation of the frame function of the chest, a decrease in intraoperative blood loss and, as a result, a reduction in the volume of blood transfusion. Such a reduction in surgical trauma allows for early activation of patients, which has a positive effect on the economic side of inpatient treatment [1, 2].

In open surgical intervention on the aortic arch, mobilization of the proximal parts of the supra-aortic vessels is a necessary condition for performing the operation. With rare exceptions, mobilization of the supra-aortic vessels is not accompanied by difficulties from a complete median sternotomy. Meanwhile, mobilization of the arch vessels, especially the left common carotid and left subclavian arteries, from the upper ministernotomy approach is technically more difficult due to unsatisfactory exposure caused by a small wound (skin incision less than 10 cm). In turn, unsatisfactory exposure can lead to unintentional trauma to the arterial and aortic wall during surgical manipulations, which can lead to difficult-to-control bleeding with the need to expand the surgical approach, which entails aggravation of the intraoperative stage and the postoperative period. In summary, the upper ministernotomy approach does not allow for adequate precision when working with supra-aortic vessels, and the difficult-to-overcome conflict of instruments in the wound due to the limited surgical field forces us to abandon the standard surgical technique and requires a different approach to performing some stages of the operation.

No adequate prototype was found in the analyzed patent and scientific-medical literature.

The objective of the invention is to create a method for mobilizing supra-aortic vessels from the upper ministernotomy approach, which allows for increasing the precision of manipulations on supra-aortic vessels, which is accompanied by a reduction in the risks of unintentional trauma to organs and tissues.

The task at hand is solved by placing a suture on the transversely opened pericardium above the middle portion of the ascending aorta with manual traction in the caudal direction, which allows the ascending section and the aortic arch to be displaced in the same direction, bringing the proximal sections of the supra-aortic vessels into the wound.

What is new in the proposed method is the implementation of surgical manipulations that improve the visualization of the supra-aortic vessels during operations on the aortic arch performed from the upper ministernotomy approach.

The technical result is a precise, non-traumatic mobilization of the proximal sections of the supra-aortic vessels, which allows minimizing the risk of trauma.

The new essential features have demonstrated in the claimed set new properties that do not clearly follow from the state of the art in this area and are not obvious to a specialist. An identical set of features has not been found in the patent and scientific medical literature.

The proposed method can be used in healthcare to improve the quality of treatment.

Based on the above, the proposed invention should be considered as meeting the patentability conditions of “novelty”, “inventive step”, “industrial applicability”.

The invention will be clear from the following description and the accompanying figures.

Fig. 1 shows a view of the surgical wound with the upper ministernotomy approach, where

1 - ascending aorta

2 – proximal parts of the supraaortic vessels

3 – aortic arch.

Fig. 2 shows the method of mobilization of supraaortic vessels from the upper ministernotomy approach, where

1 - ascending aorta

2 – proximal parts of the supraaortic vessels

3 – aortic arch.

4 – transversely opened pericardium

5 – lavsan thread 1/0.

The method is performed as follows (Fig. 2). After performing the upper ministernotomy approach, the pericardium 4 is transversely opened above the middle portion of the ascending aorta 1 to exclude trauma to the aortic adventitia. A suture of 1/0 3 lavsan thread is applied to the dissected pericardial layer without forming a knot. The thread 5 is pulled in the caudal direction, thereby displacing the ascending aorta 1 and the aortic arch 3 in the same direction, bringing the proximal sections of the supra-aortic vessels 2 into the wound, which facilitates their precise mobilization.

After these manipulations, the further operation is carried out according to the standard protocol.

Example.

Patient P., 62 years old, was admitted to the cardiac surgery department with a diagnosis of: Aneurysm of the ascending and proximal aortic arch.

Upon admission, the patient complained of headaches and increased blood pressure to 200/120 mm Hg.

Spiral computed tomography of the aorta confirmed the diagnosis of aneurysm of the ascending aorta and proximal aortic arch.

The patient is scheduled for surgical treatment in the amount of prosthetics of the ascending aorta and aortic arch (hemiarch) under conditions of artificial circulation, cardioplegia, circulatory arrest, antegrade perfusion of the brain and moderate hypothermia from the upper ministernotomy approach.

After induction of anesthesia and preparation of the surgical field, a 9 cm skin incision was made. The anterior surface of the sternum was exposed from the jugular notch to the 4th intercostal space on the right. An upper ministernotomy approach was performed - J-shaped ministernotomy in the 4th intercostal space. A pericardial leaflet (15 mm) was opened transversely with an electrocautery above the middle portion of the ascending aorta. A suture was applied to the incised pericardial leaflet. The thread was pulled caudally, thereby shifting the ascending aorta and aortic arch downwards, and the proximal parts of the supra-aortic vessels were brought out into the wound. The supra-aortic vessels were mobilized. Artificial circulation was connected according to the scheme: brachiocephalic trunk - right atrium. Artificial circulation was started with simultaneous cooling of the patient to the target temperature of 28 °C. Upon reaching the target temperature, circulatory arrest with antegrade unilateral perfusion of the brain through the brachiocephalic trunk was initiated. A distal anastomosis was formed between the aortic arch and the vascular prosthesis. Upon its completion, patient warming was initiated. Against this background, a proximal anastomosis was formed between the vascular prosthesis and the aortic root at the level of the sinotubular junction. The operation was completed in a standard manner. The duration of artificial circulation was 136 minutes, the time of cardiac arrest was 109 minutes, the time of circulatory arrest was 16 minutes. The patient was transferred to the intensive care unit.

Four hours after the end of the operation, the patient regained consciousness and was able to communicate productively. Neurological status was without focal symptoms. The patient was on artificial ventilation for 8 hours. The total time of the patient's stay in the intensive care unit was 24 hours. According to spiral computed tomography of the aorta in the postoperative period, all anastomoses were passable and hermetic.

The patient was discharged from the hospital in satisfactory condition on the 15th day after the operation.

The method proposed as an invention was tested in 18 adult patients with aneurysm of the ascending section and proximal part of the aortic arch, operated from the upper ministernotomy approach, which allows for simplified mobilization of the proximal sections of the supra-aortic vessels and minimizes the risk of unintentional trauma to tissues and organs.

References

1. Goebel N, Bonte D, Salehi-Gilani S, Nagib R, Ursulescu A, Franke UFW. Minimally Invasive Access Aortic Arch Surgery. Innovations (Phila). 2017 Sep/Oct; 12 (5): 351–355. doi: 10.1097/IM000000000000390.

3. Charchyan E.R., Skvortsov A.A., Panfilov V.A., Belov Yu.V. Surgical interventions on the root and ascending aorta from a mini-access. Cardiology and cardiovascular surgery. 2017;10(1):42-46.
Charchyan ER, Skvortsov AA, Panfilov VA, Belov YuV. Experience for aortic root and ascending aortic surgery via minimal access. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2017;10(1):42-46.(In Russ.) https://doi.org/10.17116/kardio201710142-46

Claims (1)

A method for mobilizing supraaortic vessels during operations on the aortic arch from the upper ministernotomy approach, characterized by the fact that the pericardium is transversely opened above the middle portion of the ascending aorta, a suture is placed on the dissected pericardial leaflet, the thread is pulled caudally, displacing the ascending aorta and the aortic arch downward, and the proximal sections of the supraaortic vessels are brought out into the wound.