RU2749939C1 - Method for suturing the liver - Google Patents

Abstract

FIELD: medicine; abdominal surgery.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery, it can be used in performing surgical operations on the liver. The first suture is applied to the lower edge of the wound surface using a bilateral surgical atraumatic needle, threading one of the working ends of the needle. The needle is passed through the parenchyma thickness from the visceral surface of the organ to the diaphragmatic one, retreating from the edge of the liver wound surface by 10 mm. After that, the thread is removed from the working end of the needle and tied, and the needle remains in the thickness of the organ parenchyma. Then, each working end of the needle is threaded. The needle is passed through by reverse traction for the second working end in the liver parenchyma thickness until the first working end reaches the ½ of the plane of the wound surface of the liver stump. After that, the needle is tilted towards the non-sutured part of the organ and the first threaded working end of the needle is output at the formed angle of inclination on the diaphragmatic surface of the liver, retreating from the edge of the wound by 10 mm. The thread is removed, tied, and the needle is threaded again. In this case, the second working end with the thread is located at least on the ½ of the plane of the wound surface of the liver stump, but is not completely removed from the liver. Then, the second working end of the needle is tilted in the direction of the non-sutured liver parenchyma, and the needle is passed through the visceral surface of the organ perpendicular to it, retreating from the edge of the wound by 10 mm, so that the first working end is on the ½ of the plane of the wound surface of the liver stump. From the second working end of the needle, the thread is removed, tied, and the needle is threaded again. The first working end of the needle is tilted towards the non-sutured part of the organ and the needle is passed by the first working end over the diaphragmatic surface of the liver at the formed angle, retreating from the edge of the wound by 10 mm. The thread is removed, tied, and the needle is threaded again. Sutures are applied until the posterior edge of the liver wound surface is reached. The last suture is applied by inserting a thread into one of the working ends of the needle and stitching it over the entire thickness of the remaining parenchyma of the liver wound surface. The thread is tied.

EFFECT: method ensures the achievement of hemostasis and cholestasis, shortening the operation time, facilitating the work of the surgeon, preventing postoperative complications by suturing in both directions, relatively to the ½ of the plane of the wound surface of the liver stump, without capturing the parenchyma of adjacent sutures.

1 cl, 3 dwg

Description

The invention relates to medicine, namely to the field of abdominal surgery, and can be used when performing surgical operations on parenchymal organs, in particular on the liver.

The search for the optimal suture of parenchymal organs remains relevant for a long time. There are many variations of the liver suture, each with its own advantages and disadvantages. An important requirement for the liver suture is the speed of its application and effectiveness in relation to hemostasis of the wound surface of the liver and the prevention of bile leakage in the postoperative period. For example, during emergency surgical interventions, surgeons need to apply an effective suture to the damaged parenchymal organ with minimal time costs in order to avoid large blood loss, minimize the time of surgery and minimize intra- and postoperative complications. An important feature when performing operations on this organ is that surgeons have to work in a limited space of the right subphrenic space.

There is a surgical suture (patent RU No. 2 566 213 (13) C1 / application 2014152368/14, 23.12.2014; published 20.10.2015. Perkov AA, Lazarenko VA, Lazarenko SV), analogue. The method consists in applying a double spiral continuous hemostatic hepatic suture and covering the wound surface of the liver stump with a section of the greater omentum on the vascular pedicle. The disadvantages of this technique is the additional covering of the wound surface of the liver stump with a section of the greater omentum on the vascular pedicle, which implies certain risks of the formation of a residual cavity between the wound surface of the liver and the omentum. Also, this technique includes a certain amount of time spent on the isolation of the omentum strand on the vascular pedicle and its fixation. With the use of a strand of the omentum, some difficulties may also arise, and, as a result, the impossibility of applying this method: its involvement in an inflammatory or adhesions process, swelling, a short omentum or its absence due to previous operations, etc.

The method of suturing the liver tissue (patent SU No. 1 818 084 A1 / application 4904512, 1991.01.22; published 1993.05.30. Ivanov S.V., Zatolokin V.D., Drimalovsky I.Ya.) is that through injections and punctures of the surgical needle are made every 1.5-2 cm from each other with the capture and removal of the thread to any convenient surface of the liver in the form of loops, and with additional compression at the ends of the thread from both surfaces, a fixation point is formed with the tops of the loops at the level of the middle the parenchyma of the liver and the threads cut through the stitches of the organ parenchyma from both surfaces, at the end of the imposition of the hepatic suture, the ends of the thread are connected with the observance of the compression similar to the above. The disadvantages of this method is the possible technical complexity of performing the suture in the limited spaces of the abdominal cavity, in particular the subdipharagmal space, in the case of performing, for example, right-sided hemihepatectomy or right-sided lateral lobectomy. The surgical needle with an atraumatic tip, proposed for this suture, also emphasizes this disadvantage in the form of a technical inconvenience for the surgeon when working in a confined space.

The technical result of the present invention: achievement of hemostasis and bile stasis, reduction of operation time, facilitation of the surgeon's work, prevention of other postoperative complications.

The technical result is achieved by:

- sutures are applied using a bilateral surgical atraumatic needle [see. patent RU 191060 U1 / application 2019108299, 2019.03.22; published on 2019.07.22. Peryakov A.A., Zaitsev O.V., Tarasenko S.V., Mokrova A.V.];

- sutures are applied in both directions, relative to ½ plane of the wound surface of the liver stump;

- in the process of suturing, complete removal of the needle from the organ parenchyma is not required, which allows them to be applied in limited spaces (subphrenic, subhepatic) of the abdominal cavity;

- the sutures are applied in such a way that each of them captures its own "portion" of the organ parenchyma, without capturing the parenchyma of adjacent stitches, which prevents unnecessary trauma to the organ tissues and reduces the risk of thread eruption;

- this suture allows you to achieve hemo- and bile stasis with minimal time costs, due to the fact that the suture is technically simple to implement, and the design of the needle allows you to simultaneously charge 4 threads and apply 4 consecutive sutures, which saves the time of the operation required both in emergency and and in planned operations.

Brief Description of Drawings:

Fig. 1. The scheme of imposing the first suture on the liver stump: 1 - indent from the edge of the wound surface 10 mm

Fig. 2. The scheme of the superimposed second suture on the liver stump

Fig. 3. Scheme of the final view of the sutures on the liver stump (2 - ½ plane of the wound surface of the liver stump)

The suture is applied as follows. After complete cutting off of the removed part of the liver, ligation or suturing of visible blood vessels and bile ducts, visualized on the wound surface of the liver stump, is performed. Then the first interrupted suture is applied to the lower (sharp) edge of the wound surface of the liver using a bilateral surgical atraumatic needle, charging one of the working ends (first working end) of the needle with a fragment of Vicryl 0 thread (or other suture material suitable for suturing the liver parenchyma), and holding the needle through the thickness of the parenchyma from the visceral surface of the organ to the diaphragmatic, stepping back from the edge of the wound surface of the liver by 10 mm (figure 1).

The thread is removed from the tip of the needle and the threads are tied. At this moment, the needle remains in the thickness of the organ parenchyma. Then, in each of the two working ends of the needle, a thread is charged (to simplify and accelerate the suturing of the wound surface of the liver, due to the advantages of the needle design, you can use from one to four threads at a time, loading one thread in both ears and wrapping one thread around the necks , so that there is no need to recharge it in cramped conditions.When such a need arises, then due to the design of the needle, it is possible to recharge its working end when the eyelet or neck of the needle protrudes above the surface of the organ). After charging the needle, the latter is carried out by reverse traction for the second working end in the thickness of the liver parenchyma until the first working end reaches ½ the plane of the wound surface of the liver stump. Then the needle is tilted towards the unstitched part of the organ. The smaller the angle of inclination of the needle, the less the parenchyma of the organ will be squeezed at the moment of tilt, but the more threads will be required, which means that more foreign tissues will remain in the parenchyma. The first working end of the needle, charged with a thread, is withdrawn at a formed angle of inclination on the diaphragmatic surface of the liver, stepping back from the edge of the wound by 10 mm (Fig. 2).

The thread from the first working end of the needle is removed and tied, and the next thread is charged. It is preferable to pass the needle through the thickness of the parenchyma of the organ so that the second working end, charged with a thread, is not less than ½ of the plane of the wound surface of the liver stump, but is not completely removed from the liver. Then, with the second working end of the needle, an inclination is made towards the unstitched liver parenchyma and the needle is withdrawn through the visceral surface of the organ, perpendicular to it and stepping back from the edge of the wound by 10 mm, with the second working end so that the first working end of the needle is on ½ of the plane of the wound surface of the liver stump. From the second working end of the needle, the thread is removed and tied, and the next thread is charged. Next, the next tilt is made by the first working end of the needle towards the unstitched part of the organ and the needle is removed by the first working end above the diaphragmatic surface of the liver at a formed angle and stepping back from the edge of the wound by 10 mm, the thread is removed, the next thread is tied and charged. In this way, suturing is repeated until we reach the posterior edge of the wound surface of the liver. The last suture is applied by introducing a thread into one of the working ends of the needle (depending on the convenience for the surgeon in the subsequent extraction of the needle from the parenchyma) and stitching it over the entire thickness of the remaining parenchyma of the wound surface of the liver, after which the thread is tied (Fig. 3).

It is permissible to tie the threads at the end of the application of all sutures, provided that there is no risk of blood loss during their application.

Thus, as a result of the use of a sequential interrupted suture of the liver with the help of a bilateral atraumatic surgical needle, reliable hemostasis along the course of the suture is ensured and the absence of bile leakage in the postoperative period, as well as between the elements of the suture inside the parenchyma, simplifies the suture technique with a reduction in the time required for this. The advantages of the suture are achieved through the technical advantages of the bilateral surgical atraumatic needle.

Claims (1)

A method of suturing the liver, including suturing the wound surface of the liver, characterized in that the first suture is applied to the lower edge of the wound surface using a bilateral surgical atraumatic needle, charging one of the working ends of the needle with a thread, passing the needle through the thickness of the parenchyma from the visceral surface of the organ to the diaphragmatic , stepping back from the edge of the wound surface of the liver by 10 mm, after which the thread is removed from the working end of the needle and tied, and the needle remains in the thickness of the parenchyma of the organ, then into each of the two working ends of the needle it is charged along the thread, after which the needle is held by reverse traction for the second working end in the thickness of the liver parenchyma until the first working end reaches ½ the plane of the wound surface of the liver stump, after which the needle is tilted towards the unstitched part of the organ, then the first working end of the needle, charged with a thread, is withdrawn at the formed angle of inclination on the diaphragmatic surface of the liver, retreating from the edge of the wound by 10 mm, n The thread is removed, the next thread is tied and charged, while the second working end with the thread is at least ½ of the plane of the wound surface of the liver stump, but is not removed completely from the liver, then the second working end of the needle is tilted towards the unstitched liver parenchyma and the needle is removed through the visceral surface of the organ perpendicular to it, stepping back from the edge of the wound by 10 mm, so that the first working end is on ½ the plane of the wound surface of the liver stump, then a thread is removed from the second working end of the needle, tied, the next thread is charged, the first working end is tilted the needle towards the unstitched part of the organ and the needle is withdrawn by the first working end above the diaphragmatic surface of the liver at a formed angle and, stepping back from the edge of the wound by 10 mm, the thread is removed, the next one is tied and charged, after which the suturing is repeated until we reach the rear the edges of the wound surface of the liver, apply the last suture by introducing a thread into one of the working ends of the needle and stitching it over the entire thickness of the remaining parenchyma of the wound surface of the liver, after the thread is tied, in the absence of the risk of blood loss, the threads can be tied after all the sutures have been applied.

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