Start of section Production, amateur Radio amateurs Aircraft model, rocket-model Useful, entertaining	Stealth Master Electronics Physics Technologies Inventions	Secrets of the cosmos Secrets of the Earth Secrets of the Ocean Tricks Map of section
Use of the site materials is allowed subject to the link (for websites - hyperlinks)

INVENTION
Patent of the Russian Federation RU2158548

METHOD OF SELECTING OPERATIONAL ACCESS AT CHOLECYSTECTOMY IN PATIENTS WITH ACUTE DESTRUCTIVE CHOLECYSTITIS

The name of the inventor: Vasiliev VE; Misyura OS
The name of the patent holder: Russian State Medical University
Address for correspondence: 117869, Moscow, ul. Ostrovityanova 1, Russian State Medical University, Patent Department, Pyzhev S.V.
Date of commencement of the patent: 1998.07.09

The invention relates to medicine, namely to surgical treatment of acute destructive cholecystitis. Measure the predominant echo-intensity of the peripuzular infiltrate zone and the left lobe of the liver. By their ratio, they judge the need for appropriate operational access. At a ratio of 1 to 2, low-invasive approaches to the gallbladder are used. At a ratio above 2, a wide laparotomy is used. The method allows obtaining objective criteria for the selection of adequate surgical access for cholecystectomy.

DESCRIPTION OF THE INVENTION

The present invention relates to surgery, in particular to the field of surgical treatment of acute destructive cholecystitis, namely to the removal of the gallbladder from sparing access.

It is known that at present surgery is proceeding along the path of reducing the patient's stay in the hospital by reducing the volume of surgical trauma (MI Prudkov, AG Beburishvili, AM Shulutko.) Minilaparotomy with elements of open laparoscopy in the surgical treatment of calculous cholecystitis Endoscopic surgery, 1996, N 2, pp. 12-16).

Thus, with cholecystectomy, this is achieved by reducing the injury of the anterior abdominal wall by using sparing surgical incisions, which directly affects the duration and severity of the postoperative period. However, minimizing the injury of the anterior abdominal wall is not always possible, since inflammatory changes in the tissues around the gallbladder dramatically complicate the technique of cholecystectomy and require an adequate wide laparotomy access. Errors in the selection of adequate surgical access always lead to intraoperative technical complications, changes in technique and principles of the initially selected surgical intervention. Similar errors, in turn, are transformed into postoperative complications in different severity. Such situations are very painful for both operating surgeons and their patients. The right choice of access so far remains a difficult surgical task. Of course, the high qualification and personal experience of the surgeon greatly contribute to solving this complex issue, but the criteria for selecting patients for performing a particular surgical intervention are very subjective and individual, which does not allow them to be used in wide surgical practice. Therefore, it is necessary to develop objective criteria for the choice of operative access in patients with destructive cholecystitis, which allow to avoid intraoperative complications developing in connection with unsuccessfully selected surgical access, subjectively.

Known attempts to use ultrasonic studies for objectifying the process of selecting surgical access in cholecystectomy failed (Kartakov, V. V. Ultrasound diagnosis of cholelithiasis, thesis for the degree of candidate of medical sciences, Moscow, 1984).

The main reason for the failure here is the great variability in the information obtained, since the data obtained on the echo-intensity of the zones of interest depend not only on the state of the tissues studied, but also on the echo-intensity of the tissues through which the ultrasonic wave passes. In conditions of a large difference in the thickness of the abdominal wall, this makes information on the echo intensity of the studied tissues useless (Vasiliev VE, Zubarev AR, Starkov Yu.G. Ultrasound examination of the density of bile and gallbladder walls in various forms of acute cholecystitis. N 7. Page 66 - 69).

The aim of the invention is to obtain objective criteria that could be correlated with the nature of the morphological changes around the gallbladder and would allow selection of adequate surgical access.

This goal is achieved by the fact that the amount of surgical intervention in the anterior abdominal wall is commensurate with the ultrasonic density of the inflammatory peripuzular infiltrate, and for the objectification of the data, the ultrasound density of the peripuzular infiltrate is compared with the ultrasound density of the patient's liver.

In this case, the prevailing echo-intensity of the peripuzular infiltrate zone is measured in the area of ​​the projection of the vesicle artery and duct and the region of the left lobe of the liver, then, by their ratio, the complexity of the proposed surgical intervention and the need for appropriate operative access are judged, in particular, in the ratio from 1 to 2, minimally invasive approaches to Gallbladder, and at a ratio of more than 2 using a wide laparotomy.

The invention is illustrated by specific examples.

Example 1 . The patient received a patient Ch., 44 years old, a medical history of 8151, 1996. According to the physical examination, acute phlegmonous cholecystitis, local peritonitis was diagnosed. According to ultrasonography, acute phlegmonous cholecystitis is diagnosed, complicated by the development of peripuzular infiltrate. The obtained histogram of the infiltrate speaks about its sufficient homogeneity, but does not allow to judge its density and, as a consequence, to predict the technical complexity of the surgical intervention.

According to the proposed method, the prevailing echo intensity of the liver and infiltrate in the region of the hepatic-duodenal ligament located between the left lobe of the liver and the neck of the gallbladder is measured (Fig. 1). Fatty tissue in this area contains the bladder artery and duct. The development of a dense infiltrate in this zone does not allow to conduct a thin and visually controlled separation of tissues for isolation, bandaging and crossing of the above-mentioned arteries and ducts, which in turn excludes the application of technologies of remote surgery and, respectively, sparing sections of the anterior abdominal wall. The predominant echo intensity of the left lobe of the liver (in the photo the square marked with a cross - "x" and the letter L) was 19 db, the prevalent echo intensity of the hepatic-duodenal ligament infiltrate in the zone of the projection of the cystic artery and duct (in the photo, the square marked "+" and " The letter L) was 23 dB. The ratio of the density of the infiltrate to the density of the liver was 1.2.

With this ratio, the use of gentle gallbladder access is recommended. In other words, the infiltrate is loose and does not complicate the separation of the hepatic-duodenal ligament in the allocation of the vesicle artery and duct.

It was decided to perform cholecystectomy from the mini-access. A sparing incision is made of the anterior abdominal wall 4 cm long in the right hypochondrium. Transrectal access revealed the abdominal cavity. A moderate amount of odorless gallstone effusion was found, which was evacuated by an electric pump. Around the gallbladder is a loose infiltrate, which includes a large omentum, duodenum, hepatic-duodenal ligament. Infiltration is easily divided by a dull and sharp path. The neck of the gallbladder is isolated, after which, without technical difficulties, the vascular artery and duct are separated, crossed and bandaged. Considering the loose infiltration of tissues, including the wall of the gallbladder, a subserious removal of the phlegmonous altered gallbladder was easily done. On day 3 the patient with sutures is discharged for outpatient care. At a control examination 10 days after the operation, the wound on the anterior abdominal wall 4 cm long healed by primary tension. Thus, with the seemingly necessary use of wide laparotomic access for objective indicators, it was possible to identify the clinical situation when we were able to use sparing access to the gall bladder and thereby reduce the severity of the postoperative period.

Example 2 . Patient M. 53 years old, the history of the disease 8660, 1996, 3 weeks before admission to the hospital suffered an attack of acute phlegmonous cholecystitis.

From the proposed operation at that time refused, received conservative treatment, against which there was a short-term remission of the disease. After the error in the diet, an attack of acute phlegmonous cholecystitis again developed, with which she entered the surgical department. With ultrasound, the diagnosis of acute phlegmonous cholecystitis was confirmed and a large peripuzular infiltrate was detected. According to the method proposed by us, the ratio of prevailing echo intensity was determined: the infiltration of the hepatic-twelve-ligament ligament in the zone of the projection of the vesicle artery and duct, and the left lobe of the liver, which was 2.29 (Fig. Operative intervention from a wide laparotomy is recommended.

However, at the insistence of the patient, subjectively assessing her illness as easy and uncomplicated, an attempt was made to perform surgical intervention from the 4 cm mini access. During the operation, attempts to make a thin separation of the liver and duodenum tissues were not only unsuccessful, but also dangerous, as they led to intraoperative Complication - detachment of the vesicle artery from the hepatic. Attempts to perform the operation from the mini-access were stopped, a wide laparotomy was performed, after which it was possible to complete the cholecystectomy and to suture the hepatic artery defect that was formed earlier as a result of detachment of the vesicle artery. The postoperative period was complicated by the development of anemia after intraoperative bleeding and the suppuration of the postoperative wound of the anterior abdominal wall, which was caused by the duration of the operation and the technical inconveniences caused by the change in technique of operative care and infection of abdominal wall tissues. Thus, the refusal to focus on objective indicators led to a complication of surgical intervention and intraoperative complications.

Example 3 . Patient M. 69 years old, a medical history of 645, 1996, entered the clinic with a clinical picture of subsumed phlegmonous cholecystitis. Given the history and duration of the disease - 4 weeks, you can assume the presence of a dense infiltrate in the hepatic-duodenal ligament. With ultrasound, the diagnosis of destructive cholecystitis is confirmed, as well as infiltrative changes in the peripuzyr space. Such changes usually cause surgeons to prepare for a severe operation from a wide laparotomy access. The prevailing echo intensity of the left lobe of the liver and the peripuzular infiltrate was determined according to the procedure proposed by us (Fig. 3). The ratio of the prevailing echo intensity of the infiltrate and the left lobe of the liver was 1.6, which implies the absence of technical difficulties in the remote separation of elements of the hepatic-duodenal ligament. Successful cholecystectomy was made from the mini-access.

The proposed method of selecting an operative approach for cholecystectomy in patients with acute destructive cholecystitis was applied in the faculty surgery clinic in 27 patients, but there were no mistakes. Currently, the faculty surgery clinic does not perform operations without the presumed method of choosing an operative approach for cholecystectomy in patients with acute destructive cholecystitis. With apparent simplicity and overall availability, the proposed method is not obvious to a specialist surgeon specializing in biliary surgery, most of which rely on their own intuition. Moreover, among biliary surgeons there was an opinion that it is impossible to judge by the ultrasonography the nature and density of the peripuzular infiltrate. The proposed simple and affordable method disproves this opinion and at no additional cost allows improving the diagnosis of acute cholecystitis, avoiding intraoperative technical complications and thereby improving the results of surgical treatment. The method is of great socio-economic importance, since it reduces the number of complications, reduces the traumatization of patients, and leads to a reduction in the patient's stay in the hospital bed.

The choice of operative access for cholecystectomy in patients with acute destructive cholecystitis is fully ready for use without additional costs in specialized departments of biliary surgery.

CLAIM

1. Method of choosing operative access for cholecystectomy in patients with acute destructive cholecystitis, characterized by the fact that the volume of surgical intervention in the anterior abdominal wall is commensurate with the ultrasonic density of the inflammatory peripuzular infiltrate, and for the objectification of data, the ultrasound density of the peripuzular infiltrate is compared with the ultrasound density of the patient's liver.

2. The method according to claim 1, characterized in that it measures the prevalent echo-intensity of the peripuzular infiltrate zone and the left-lobe area of ​​the liver and, by their ratio, judges the complexity of the proposed surgical intervention and the need for appropriate operative access, in particular, in a ratio of 1 to 2, minimally invasive Access to the gallbladder, and at a ratio of more than 2 - use a wide laparotomy.

print version
Date of publication 28.01.2007gg

NEW ARTICLES AND PUBLICATIONS
	The technology of manufacturing universal couplings for unbreakable, threadless, flossless connection of pipe sections in high pressure pipelines (video is available )
	Technology of oil and oil products cleaning
	On the possibility of moving a closed mechanical system at the expense of internal forces
	Fluorescence in thin dielectric channels
	The relationship between quantum and classical mechanics
	Millimeter waves in medicine. A New Look. MMV therapy
	Magnetic engine
	Heat source based on pump units