Cholecisectomy

Points introduction trocars:

· Manipulation trocar 10 mm.

· Trocar 5 mm. midclavicular line.

· Trocar 5 mm. anterior axillary line

Video trocar

Stages operations:

· Introduction of trocars into the abdominal cavity at the points indicated above after preliminary imposition of CO 2 of the peritoneum up to 8 mm Hg. Art.

Total examination of the abdominal cavity with the exclusion of concomitant diseases

Introduction of manipulators into the abdominal cavity for the actual cholecystectomy

Isolation of the cystic artery and cystic duct

Clipping and transection of the cystic duct and cystic artery

Excretion of the bile duct

Removal of the gallbladder from the abdominal cavity

Drainage of the abdominal cavity and suturing of the wounds of the anterior abdominal wall

On the 2-3 day after the operation, ultrasound control about the presence of fluid formations in the area of ​​the operation performed, the drains are removed.

· Auxiliary endoscopic equipment: loops, needles, biapsy forceps, Dormia baskets, sphincterotomes, cannulas, probes for diathermocoagulation.

Laparoscopy

This is an endoscopic examination of the abdominal cavity using an optical device - a laparoscope.

In 1901, the Russian obstetrician - gynecologist D.O. Ott was the first to use endoscopic examination of the abdominal cavity using a frontal reflector, an electric lamp and a mirror inserted into the incision of the fornix during vaginal belly-section. This method was called ventroscopy. In 1910, the Stockholm associate professor Jacobeus published an article outlining the possibilities of endoscopic examination of three large serous cavities: abdominal, pleural and pericardial. Jacobeus called the first method laparoscopy.

Equipment with help which produced laparoscopy :

Apparatus for applying pneumoperitoneum

Laparoscope

Equipment for manipulation and surgical interventions

Equipment for superimposing pneumoperitoneum:

To puncture the abdominal wall and introduce air into the abdominal cavity, you need:

Needle for applying pneumoperitoneum

Insufflator for introducing gas into the abdominal cavity and for controlling

By pressure

rules:

The needle should be long enough so that, in the presence of well-defined fiber of the anterior abdominal wall, it is possible to get into the abdominal cavity

Tension of the abdominal muscles, breathing movements of the patient should not cause the formation of emphysema

A Veress needle is used to apply pneumoperitoneum. The principle of the Veress needle is that when the needle passes the anterior abdominal wall, its sharp part changes to a blunt cylinder. This happens with the help of a spring, which is triggered at the moment the tissue resistance ceases.

Laparoscope:

The laparoscope consists of three parts:

Trocar

Trocar case

Optics of the same diameter as the trocar, which is also the carrier of illumination

Methodology laparoscopy:

Superposition of pneumoperitoneum

Insertion of a trocar into the abdominal cavity

· Examination of the abdominal cavity.

The abdominal wall can be punctured at various points. Previously, most often for a puncture, a place was chosen on the border of the outer and middle third of the line, connecting the navel and the upper iliac spine. The most convenient point of insertion of the needle is in the midline above the navel by 0.5 - 1.0 cm.

When a needle is inserted into the abdominal cavity to apply a pneumoperitoneum at a point, the risk of injury to the abdominal organs is the smallest. With a puncture, there can be complications, especially if there is a swelling of the intestine or a pathologically enlarged organ is located, or the loop of the small intestine is soldered to the parietal peritoneum.

Introduction trocar endoscope:

The designer of the classic laparoscope Kalka proposed 4 points of insertion of the endoscope trocar:

3 cm above the navel, 0.5 cm to the right of the midline

3 cm above the navel, 0.5 cm to the left of the midline

3 cm below the navel, 0.5 cm to the right of the midline

3 cm below the navel, 0.5 cm to the left of the midline

Another place for the introduction of the needle and the endoscope trocar is used to examine the abdominal cavity of a patient who has ever undergone surgery on the abdominal organs with a median laparotomy. In this case, a place in the mesogastrium is used on the left at the level of the navel along the midclavicular line. If the abdominal cavity of a patient with a median scar and sigmostomy is examined, the point of introduction of the laparoscope is located on the line to the left of the median scar or wound by 2.0 - 3.0 cm and 5.0 - 7.0 cm above the navel. the places for the introduction of the trocar with the novocaine solution infiltrate successively all layers of the abdominal wall from the skin to the peritoneum. The layers of the abdominal wall are infiltrated, the passage of the needle through the peritoneum is felt, and then suction is performed with a syringe. If the needle actually passes through the peritoneum, the syringe will aspirate air. This means that the site for the insertion of the endoscope is correct. If air does not enter the syringe, it means that the needle did not pass into the abdominal cavity during the introduction and is in a blood vessel and it is necessary to insert the needle in another place. After control with a needle, the endoscope trocar is inserted into the wound made with a lance-shaped scalpel 0.7 cm in size and asked to contract the abdominal press. A trocar with a sharp end easily passes the muscle tissue and the peritoneum. The felt * notch * can be used to determine when the trocar has passed through the layers of the abdominal wall. After puncture of the abdominal wall, the trocar is removed from the endoscope and into the abdominal cavity, the endoscope optics is inserted. The optics must first be heated. At the same time, the gas pressure in the abdominal cavity is automatically maintained by the insufflator. After the introduction of the optics, the abdominal cavity is examined.

Laparoscope maybe move v three directions:

The optics in the abdominal cavity can be rotated around the circumference of the base of an imaginary cone, the apex of which is located in the abdominal wall

The optics can be moved forward and backward

The optics can be rotated around its axis

A physician with sufficient experience can combine and combine all three movements and easily examine the entire abdominal cavity. To expand the boundaries of the examination of the abdominal cavity, it is necessary to change the position of the patient on the table, turning the patient left and right, lifting the leg end and the head end of the table. By changing the position of the patient's body, thereby, deeply located pathologically altered organs, such as the appendix, are achieved in the examination.

Inspection abdominal cavities:

During the examination, it is advisable to divide the abdominal cavity into six sectors and carefully examine these sectors.

Description sectors:

· The right upper square of the abdomen. Here you can see the right lobe of the liver, the gallbladder, the right half of the diaphragm, part of the greater omentum. This area is limited to the left by the sickle and round ligaments of the liver.

· Left upper square of the abdomen. Here, the left lobe of the liver, the anterior surface of the stomach, the left half of the lower surface of the diaphragm, part of the greater omentum, and the spleen are examined.

· The peritoneum of the left half of the abdomen.

· Small pelvis and its organs. Research is carried out in the Trededeburg state. Examination of the female genital organs is facilitated by lifting the uterus up through the vagina. This is done with a finger or a tool. In men, examining the bladder, it is enough to raise the pelvis onto the roller.

Peritoneum of the right half of the abdomen

· Base of the abdominal cavity. This part of the abdominal cavity is located between the lower edge of the liver and the pelvis. Here you can examine the greater omentum, the bulk of the small and large intestines, the cecum and the appendix.

After a methodical examination of the abdominal cavity, thoroughly examine the devices used during the study, rinse them, perform pre-sterilization treatment and put them in for sterilization. Immediately after the end of the study, the laparoscopic findings should be described. One cannot postpone the description of what he saw, because even the most capable people can change memory, and not everything that is necessary will be recorded.

Indications To laparoscopy:

They are subdivided into general and local. In general, the indications for laparoscopy can be formulated as follows: the patient is sent for laparoscopic studies, who failed to establish a diagnosis based on the data of clinical and laboratory studies and who, with the help of laparoscopy, have the opportunity to examine the affected organ. In addition, there must be confidence that the study will not harm the patient.

Laparoscopy is indicated not only in cases where clinical, radiological, laboratory studies do not establish a diagnosis of the disease, but also in cases where it is required to resolve the problem of differential diagnosis of two or three diseases. Then laparoscopic studies will be decisive.

The most common indications for laparoscopy is the need to clarify the diagnosis of acute appendicitis, impaired or undisturbed tubal pregnancy. A very important disease in terms of indications for laparoscopy and the decision of the question of surgical intervention is acute pancreatitis with pancreatic necrosis. With the differentiation of acute pancreatitis with pancreatic necrosis and peritonitis, there is a possibility of conservative management of patients with pancreatic necrosis, and recently endoscopic operations - and surgical treatment with laparotomy for various kinds of peritonitis. The number of laparoscopies in the diagnosis of pancreatic necrosis varies from 100 to 200 on average per year.

Often, research is carried out in connection with the inflammatory process of the gallbladder, and there are no particular difficulties in this case.

The contingent of elderly patients with chronic heart disease leading to arrhythmias is very difficult and rather rare. These patients come with severe abdominal pain and laparoscopic examination is designed to differentiate a formidable complication of atrial fibrillation - mesenteric vessel thrombosis, accompanied by intestinal necrosis, from acute myocardial infarction or other diseases.

In diseases of the stomach and intestines, valuable laparoscopic data can be obtained only if the pathological changes are located directly under the abdominal wall. Malignant formations of these organs can be determined by other methods. Liver metastases are easily detected laparoscopically, which can prevent unnecessary surgery.

Internal hernia holes are determined on the diaphragm and abdominal wall. Sometimes on the external abdominal wall of the hernia is still determined, and on laparoscopy you can see the inner ring of the hernial orifice.

Laparoscopy produced with aim permissions following problems:

Diagnosis of acute diseases of the abdominal organs

· Examination of the abdominal cavity for damage to its organs in case of penetrating wounds of the abdominal wall with the establishment of the presence of injuries of the peritoneum and organs, with blunt injuries of the abdomen with the establishment of injuries to organs and their complications - bleeding and effusion of the contents into the lumen of the abdominal cavity.

If laparoscopy is performed in order to identify any disease, which facilitates the treatment of the patient, and followed by an endoscopic therapeutic measure, which makes life easier for the patient, then such laparoscopy is justified.

Contraindications To laparoscopy:

Contraindications will be all those cases when laparoscopy is dangerous for the patient, and when the organ that needs examination is not available for laparoscopic examination.

To the first group contraindications - relative - include the following diseases:

All serious illnesses

Peritonitis

Encapsulated abdominal abscess

Blood clotting disorder

Hernias, including diaphragmatic

To the second group- absolute - include:

Postoperative adhesive disease of the abdominal cavity with symptoms of intestinal obstruction and possible fixation of the loops of the small intestine and the anterior abdominal wall.

Dangers and complications at laparoscopy:

Complications of pneumoperitoneum

Puncture complications

Complications associated with additional manipulators

General complications

Complication pneumoperitoneum:

Currently, pneumoperitoneum or oxygenopneumoperitoneum during laparoscopy and CO 2 - peritoneum during operations on the abdominal organs is performed by a special apparatus - an insufflator, which regulates the rate of gas supply to the abdominal cavity, the volume of gas and pressure in the abdominal cavity. In the event that the gas pressure in the abdominal cavity exceeds 12 - 16 mm. rt. pillar, the patient may develop such a formidable complication as * inferior vena cava syndrome * or, as it is also called, * inferior vena cava compression syndrome *. When gas is insufflated into the abdominal cavity above the specified parameters, high and low pressure systems are compressed. Basically, venous plexus and trunks are affected, especially the inferior vena cava. The blood flow to the right heart is sharply reduced, and it is deposited in the lower extremities. This promotes the formation of aggregates with the possible development of blood clots, and can lead to pulmonary embolism or cardiac arrest. Prevention of this complication is the strictest control over the injection of gas into the abdominal cavity and the pressure of this gas in the abdominal cavity.

Not so serious, but also unpleasant, is the complication of the imposition of pneumoperitoneum - subcutaneous emphysema. Emphysema appears when the needle for applying pneumoperitoneum does not reach the abdominal cavity or when the patient moves out of the abdominal cavity. Prevention of these complications, on the one hand, is the control over the introduction of the needle, various tests, including a ball with a solution, on the other hand, the assistant's control over the position of the needle.

Puncture complications:

They can be, both with the introduction of a needle for the imposition of a pneumoperitoneum, and with the introduction of a trocar. The difference is that the trocar is significantly larger in diameter than the needle. The endoscope trocar causes significantly more damage, but the trocar damage occurs much less frequently than the needle. This phenomenon is explained by the fact that the endoscope trocar, no matter how sharp it is, because of its thickness, passes the abdominal wall with less acceleration and, as a rule, moves the obstacle away.

When the endoscope moves in the abdominal cavity, there may be damage due to direct contact of optics or auxiliary instruments with organs. The most common complication is bleeding when biopsies are taken from various organs, especially from the liver. But there are also such casuistic complications as optics perforation of the necrotic small intestine with mesenterithrombosis.

General complications:

They can be in any patient in a state of heart, respiratory, renal, liver failure. Cases of sudden death were observed in patients with renal failure and a high content of Ca in the blood when a gastroscope was inserted into them. There have also been cases of acute myocardial infarction in patients who underwent laparoscopy. Research in such cases is immediately stopped, patients are given painkillers and transferred to the intensive care unit of the hospital.

Special part

Normal abdomen:

After the introduction of the endoscope into the abdominal cavity, the right lobe of the liver and its dimensions are examined. At normal size, the hepatic end of the falciform ligament barely reaches its edge at the site of attachment. To determine the size of the liver with the edge of the costal arch. Normally, the color is permanent: it can be brick-red, red-brown. The surface of the liver is smooth. The liver capsule is glossy, transparent. The edges of the liver are dull and rounded.

The gallbladder is determined either completely or only part of it. A bubble of different filling and tension. Its wall is smooth, the surface is shiny. The sickle ligament can be different in shape and location. Usually its color is yellow-white. The lower surface of the diaphragm covers sector 1.

2 sector.

Behind the crescent ligament on the left, the second sector begins. Here, the following organs are examined: the left lobe of the liver, the gastric diaphragm, part of the greater omentum and the uppermost part of the parietal peritoneum. The lesser curvature is visible when the liver does not cover it. The wall of the stomach is covered with a yellowish-white serous membrane. The spleen is visible only when enlarged. A part of the omentum is visible below the stomach. It leaves all or part of the transverse colon.

3 sector.

Examined: the parietal peritoneum, lining the inside of the left abdominal wall. The parietal peritoneum is smooth, glossy. The peritoneum is penetrated by a thin network of capillaries. In the area of ​​the navel, the outer and inner are visible - the lateral umbilical folds.

The pelvis can only be viewed in the Trendenlenburg position. Thanks to this, the omentum, the small and large intestines move in the direction of the diaphragm and free the entrance to the small pelvis. Women are examined: uterus, tubes, ovaries. In men, the bladder and large intestine. In women, a laparoscope can be used to examine the patency of the fallopian tubes.

5 sector.

The laparoscope is pointing up again. The horizontal table pivots to the left. Inspection is performed on the right parietal peritoneum. The laparoscopic picture of this sector completely coincides with the picture of sector 3. In this sector, the place of attachment of the falciform ligament is usually examined.

Examination of the base of the peritoneal cavity from the edge of the liver to the entrance to the small pelvis. Here you can see: the greater omentum, the small and large intestine, the appendix, sometimes part of the mesentery. It is very difficult to remove the appendix for inspection. For this, the technique of "tilting" is used, proposed by the endoscopists of the city hospital No. 67 in Moscow.

For a long time it was not widespread: there was not enough good special equipment, only cysto and thoracoscopes were used for this purpose. The imperfection of the methodology led to numerous errors, complications, and often to discredit the method itself. The rapid development of physics and the optical industry contributed to the improvement of laparoscopes. Laparoscopy has only been widely used since the 1960s.

Laparoscopy are currently successfully used in the diagnosis of closed trauma to the abdominal organs and injuries of the anterior abdominal wall. Laparoscopy with a closed abdominal trauma contributes to the early detection of this diagnostically difficult pathology and the timely provision of an operative aid, which scientists note.

It is indicated for patients with associated injuries, in whom, due to a lack of consciousness, on the basis of clinical data, it is impossible to establish the cause of a severe condition (cerebral coma, post-hemorrhagic collapse, alcohol intoxication). Under these conditions, laparoscopy is a less traumatic method of objective diagnosis than diagnostic laparotomy. Shock is not a reason for refusing laparoscopy, as the study helps to find out the source of the bleeding. In patients with severe concomitant trauma, the study should be carried out under anesthesia, using a minimum amount of gas to apply pneumoperitoneum.

Laparoscopy can provide very important additional information for establishing the correct diagnosis and choice of treatment. Naturally, it does not need to be used if the diagnosis of intra-abdominal catastrophe is clinically obvious, and with positive results of laparocentesis. In doubtful cases, laparoscopy, on the contrary, is extremely necessary, since it allows you to identify damage to the abdominal organs or makes it possible to refuse the operation. Laparoscopy is more complex, requiring well-known skills, but more reliable diagnostic method than laparocentesis.

Laparoscopy should be carried out in medical institutions by specially trained persons. For a surgeon who masters the technique of laparoscopy, the main difficulties lie not only in its implementation, but also in the correct assessment of the laparoscopic picture. With a certain skill and subject to constant readiness of tools for work, the study takes no more than 10-20 minutes. Laparoscopy is contraindicated in case of multiple scars of the anterior abdominal wall, pronounced intestinal distention and the terminal state of the patient.

The choice of the type of optimal pain relief contributes to the successful conduct of laparoscopy in patients with concomitant trauma. Laparoscopy for closed abdominal trauma is performed both under local anesthesia and under general anesthesia. Advances in modern anesthesiology have generally improved its results. Our observations indicate that in case of combined trauma, the use of only local anesthesia with its potentiation with analgesics and drugs of the phenothiazine series is not always effective (pain, poor relaxation, stress) and complicates the study. In this regard, if possible, it is necessary to apply anesthesia. However, it should be remembered that patients with concomitant closed abdominal trauma come mainly with symptoms of hypoxia and hemodynamic disturbances, which become more pronounced, sometimes threatening, after the introduction of gas into the abdominal cavity (restriction of the mobility of the diaphragm, decrease in the volume of the chest cavity). In this regard, when choosing the optimal type of pain relief, it is recommended to approach each case individually, taking into account the severity of the patient's condition.

When starting instrumental research methods, it is advisable to start with laparocentesis, always performed under local anesthesia, and only after obtaining insufficiently accurate results to carry out laparoscopy.

The technique of laparoscopy is simple and consists of the following main points:

1. imposition of pneumoperitoneum;
2. insertion of a trocar and then an optical tube into the abdominal cavity;
3. examination of the abdominal organs.

The imposition of a pneumoperitoneum before laparoscopy is a crucial moment, since this creates a kind of "air bubble" in the abdominal cavity. When the position of the patient's body changes, the location of the "air bubble" also changes.

For the imposition of pneumoperitoneum, the scientist proposed a special needle with a blunt end and a side hole.

The needle is usually inserted from the left at a point on the border of the middle and outer third of the line connecting the navel and the anterior superior axis of the ilium.

In this case, it is necessary to remember about the most frequent complication of laparoscopy - omentum emphysema, which occurs in 4.1%. Without significantly affecting the patient's condition, it significantly complicates the study. Therefore, many modern laparoscopes have an additional channel in the trocar for the additional introduction of gas into the abdominal cavity during the examination. Using laparoscopic trocars for laparocentesis, it is advisable to apply pneumoperitoneum through the mentioned trocar canal. Due to the larger diameter of the trocar than that of the needle, the trocar pushes the omentum, the intestine, without violating their integrity.

As for other complications, according to scientists, laparoscopy is complicated by preperitoneal emphysema in 0.43% of cases and subcutaneous emphysema in 0.57%. Preperitoneal emphysema occurs when an incomplete puncture of the abdominal wall and gas insufflation through the trocar casing. Subcutaneous emphysema can occur as a result of the "retrograde" flow of air residues from the abdominal cavity into the subcutaneous fatty tissue. We have not observed such complications, they can be avoided with a thorough operation.

Until now, there is no consensus as to what gas and in what amount should be injected into the abdominal cavity, what equipment is best used to apply pneumoperitoneum. In principle, most authors believe that the more gas is introduced into the abdominal cavity, the better the conditions for examining the internal organs. The question of determining the volume of gas introduced into the abdominal cavity, according to scientists, is of no practical importance, since during the procedure constant leakage and resorption of gas is inevitable, therefore it is necessary to periodically insufflate the gas during the study.

Various gases are used, including ordinary air filtered through cotton wool, which is injected with a Janet syringe.

For pneumoperitoneum, we used oxygen, nitrous oxide, carbon dioxide, but we did not observe any advantages over the introduction of air. In this regard, in recent years, with the help of a Richardson balloon, we inject air filtered through a furacilin solution.

The question of the amount of injected gas should be decided individually, depending on the choice of the method of anesthesia, the subjective feelings of the victim, the external shape and degree of elasticity of the abdomen.

Before insufflation of the bulk of the gas, a test portion should be introduced into the abdominal cavity - up to 500 ml. If the specified dose does not cause symptoms of respiratory failure or a sharp deterioration in the patient's condition, then the required (2-5 l) amount of gas is injected for laparoscopy. When the above threatening symptoms appear, further gas injection into the abdominal cavity and laparoscopy in general should be abandoned, since a sharp deterioration in the patient's condition may be associated with the flow of gas into the chest through a diaphragm rupture.

Trocar and optical tube insertion. The choice of the trocar insertion site on the anterior abdominal wall depends on the purpose of the study, the need to examine a particular organ, and the presence of postoperative scars.

However, due to the need to examine all the organs of the abdominal cavity, the most convenient place is chosen - near the navel.

After puncture of the abdominal wall, removal of the trocar stylet and application of pneumoperitoneum, the optical tube of the laparoscope is introduced into the abdominal cavity through the casing. The trocar casing and the end of the optical tube of the laparoscope are oriented parallel to the abdominal wall, advancing the tube in the direction of the xiphoid process.

After the introduction of the optical tube of the laparoscope into the abdominal cavity, due to fogging of the optical systems due to the difference between room temperature and body temperature, the image of organs is indistinct and blurred. After 1-2 minutes, the optical system heats up and a clear image appears.

It is important to examine the abdominal organs in sequence. We first examine the liver and continue in a clockwise direction.

There are such injuries of internal organs that by localization cannot be detected during laparoscopy, since there are so-called blind zones in the abdominal cavity - places that are not accessible for examination through a laparoscope.

In order to expand the boundaries of the view of the abdominal cavity, a laparoscopic manipulator can be used, which is inserted into the abdominal cavity through a manipulation trocar.

The manipulator helps to examine the "blind" zones in the abdominal cavity through the laparoscope, raise the edge of the liver, remove the great omentum covering the loops of the small intestine, liver, gallbladder, spleen, stomach, displace or press down the loops of the small intestine, uterus, appendages, as well as various pathological education. In addition to expanding the examination area, the manipulator can be used to detect violations of the integrity of parenchymal organs and temporary compression of bleeding sites.

A hollow metal rod with a bulbous working end ending in a cannula or a handle is used as a manipulator. The manipulator diameter is 3.5 mm and the length is 450 mm. This length allows detailed examination of internal organs from any point on the abdominal wall.

The use of a manipulator during laparoscopy in patients with closed abdominal trauma is especially necessary in case of combined injuries, when any change in body position to expand the boundaries of the examination of the abdominal cavity is fraught with serious consequences (shock, hemodynamic disturbance).

Scientists in experiments on cadavers obtained the following data on the visibility of various organs during laparoscopy: parietal peritoneum - 100%, liver - 94%, greater omentum - 93%, diaphragm - 90%, small intestine - 82%, sigmoid colon - 81%, blind intestine 80%, ascending colon 72%, bottom of the bladder 67%, descending colon 56%, gallbladder 55%, spleen 11%, appendix 5%.

The most frequent and reliable sign of damage to the abdominal organs, detected during laparoscopy, is hemoperitoneum.

With massive bleeding (750 ml - 3 l), blood spreads throughout the abdominal cavity, with less (500-750 ml) it collects in the sloping places of the abdomen (lateral canals, small pelvis).

Blood in the abdominal cavity (less than 500 ml) accumulates mainly in the pelvic cavity or in one of the interintestinal spaces. Sometimes traces of blood are found on the intestinal loops, the diaphragmatic surface of the liver, and the parietal peritoneum. Even a minimal accumulation of blood in the sloping places of the abdomen indicates bleeding into the abdominal cavity. Unfortunately, sometimes when a large amount of blood accumulates in the abdominal cavity, it is not possible to identify the source of the bleeding.

When the hollow organs rupture, the contents of the damaged organ are mixed with the blood, which affects the color and smell of the blood. So, if the small intestine is damaged, the blood often acquires a yellowish tint and a characteristic odor of intestinal contents.

During laparoscopy in patients with suspected bladder damage, when other diagnostic methods have already been used, the introduction of methylene blue through a catheter into the bladder makes it possible to diagnose not only bladder damage, but also localization. The appearance of methylene blue in the free abdominal cavity indicates intraperitoneal damage to the urinary bladder, and staining of the near - vesical and preperitoneal tissue - extraperitoneal.

A similar technique is possible if there is a suspicion of damage to the stomach, into which methylene blue is injected, at the same time performing laparoscopy. The appearance of methylene blue in the free abdominal cavity makes it possible to establish a ruptured stomach.

With various kidney injuries, the posterior parietal peritoneum in the area of ​​the lateral canals exfoliates with blood for a considerable length, while clear boundaries of a dark red color in the center of the hematoma and scarlet along the periphery are revealed. If the hematoma contains liquid blood, then when the position of the patient's body changes through the optical tube, its movement is clearly visible.

When a retroperitoneal hematoma is detected by laparoscopy, it is possible to determine the level of its spread relative to the spinal column and the bony protrusions of the pelvis.

Small hematomas of the liver located under the capsule are determined by a darker color (up to slate).

Laparoscopy makes it possible to diagnose intramural hematomas on the intestinal wall, which cannot be clinically determined due to poor symptoms in the first hours after injury.

Having discovered during laparoscopy signs indicating damage to the abdominal organs and dictating the need for an emergency operation, it is not necessary to establish a topical diagnosis, since this increases the study time and does not significantly affect the treatment tactics.

If laparoscopy does not reveal signs of damage to the abdominal organs (with an appropriate clinical picture), we can conclude that there is no pathology and refuse diagnostic laparotomy.

Laparoscopy is a minimally invasive operation without a layer-by-layer incision of the anterior abdominal wall, which is performed using special optical (endoscopic) equipment in order to examine the abdominal organs. Its introduction into practice has significantly expanded the capabilities of general surgical, gynecological and urological doctors. The vast experience accumulated to date has shown that rehabilitation after laparoscopy, in comparison with traditional laparotomy access, is much easier and shorter in duration.

Application of the method in the gynecological area

Laparoscopy in gynecology has become especially important. It is used both for the diagnosis of many pathological conditions and for the purpose of surgical treatment. According to various sources, in many gynecological departments, about 90% of all operations are performed by laparoscopic access.

Indications and contraindications

Diagnostic laparoscopy can be planned or emergency.

Indications

Scheduled diagnostics include:

1. Formations of a tumor-like nature of unknown origin in the area of ​​the ovaries (you can read more about ovarian laparoscopy in ours).
2. The need for differential diagnosis of tumor formation of internal genital organs with that of the intestine.
3. The need for a biopsy for the syndrome or other tumors.
4. Suspected undisturbed ectopic pregnancy.
5. Diagnostics of the patency of the fallopian tubes, performed in order to establish the cause of infertility (in cases of impossibility of its implementation through more gentle methods).
6. Clarification of the presence and nature of anomalies in the development of internal genital organs.
7. The need to determine the stage of the malignant process to resolve the issue of the possibility and scope of surgical treatment.
8. Differential diagnosis of chronic pelvic pain with other pains of unclear etiology.
9. Dynamic control of the effectiveness of the treatment of inflammatory processes in the pelvic organs.
10. The need to control the preservation of the integrity of the uterine wall during hysteroresectoscopic operations.

Emergency laparoscopic diagnostics is carried out in the following cases:

1. Assumptions about possible perforation of the uterine wall with a curette during diagnostic curettage or instrumental abortion.
2. Suspicions of:

- ovarian apoplexy or rupture of its cyst;

- progressive tubal pregnancy or impaired ectopic pregnancy such as tubal abortion;

- inflammatory tubo-ovarian formation, pyosalpinx, especially with destruction of the fallopian tube and the development of pelvioperitonitis;

- necrosis of the myomatous node.

1. An increase in symptoms for 12 hours or the absence of positive dynamics within 2 days in the treatment of an acute inflammatory process in the uterine appendages.
2. Acute pain syndrome in the lower abdomen of unclear etiology and the need for differential diagnosis with acute appendicitis, perforation of the ileal diverticulum, with terminal ileitis, acute necrosis of the fat suspension.

After clarifying the diagnosis, diagnostic laparoscopy often turns into therapeutic, that is, it is carried out, the ovary, suturing the uterus during its perforation, emergency with necrosis of the myomatous node, dissection of abdominal adhesions, restoration of patency of the fallopian tubes, etc.

Planned surgeries, in addition to some of those already mentioned, are plastic or ligation of the fallopian tubes, planned myomectomy, treatment of endometriosis and polycystic ovaries (you will find in the article about the features of treatment and removal of ovarian cysts), hysterectomy and some others.

Contraindications

Contraindications can be absolute or relative.

The main absolute contraindications:

1. The presence of hemorrhagic shock, which often occurs with rupture of the fallopian tube or, much less often, with ovarian apoplexy, and other pathology.
2. Uncorrectable blood clotting disorders.
3. Chronic diseases of the cardiovascular or respiratory systems in the stage of decompensation.
4. Inadmissibility of giving the patient the Trendelenburg position, which consists in tilting (during the procedure) the operating table so that its head end is lower than the leg. This cannot be done if a woman has a pathology associated with cerebral vessels, residual consequences of trauma to the latter, sliding hernia of the diaphragm or esophageal opening and some other diseases.
5. Established malignant tumor of the ovary and fallopian tube, unless it is necessary to monitor the effectiveness of radiation or chemotherapy.
6. Acute renal-hepatic failure.

Relative contraindications:

1. Hypersensitivity to several types of allergens at the same time (polyvalent allergy).
2. Assumption of the presence of a malignant tumor of the uterine appendages.
3. Spilled peritonitis.
4. Significant, which has developed as a result of inflammation or previous surgery.
5. Ovarian tumor with a diameter greater than 14 cm.
6. Pregnancy exceeding 16-18 weeks.
7. over 16 weeks in size.

Preparation for laparoscopy and the principle of its implementation

The operation is performed under general anesthesia, therefore, in the preparatory period, the patient is examined by the operating gynecologist and anesthesiologist, and, if necessary, by other specialists, depending on the presence of concomitant diseases or questionable issues in terms of diagnosing the underlying pathology (surgeon, urologist, therapist, etc.) ...

In addition, laboratory and instrumental studies are additionally assigned. Mandatory tests before laparoscopy are the same as for any surgical intervention - general blood and urine tests, biochemical blood tests, including the content of glucose, electrolytes, prothrombin and some other indicators in the blood, coagulogram, determination of the group and Rh factor, hepatitis and HIV ...

Chest fluorography, electrocardiography and pelvic organs are repeated (if necessary). In the evening before the operation, food is not allowed, and in the morning on the day of the operation, food and liquids are not allowed. In addition, a cleansing enema is prescribed in the evening and in the morning.

If laparoscopy is carried out on an emergency basis, the number of examinations is limited by general blood and urine tests, coagulogram, determination of blood group and Rh factor, electrocardiogram. The rest of the tests (glucose and electrolyte levels) are performed only if necessary.

It is forbidden to take food and liquids 2 hours before an emergency operation, a cleansing enema is prescribed and, if possible, a gastric lavage is performed through a tube in order to prevent vomiting and regurgitation of gastric contents into the respiratory tract during induction of anesthesia.

On what day of the cycle is laparoscopy done? During menstruation, tissue bleeding is increased. In this regard, a planned operation, as a rule, is appointed on any day after the 5-7th day from the beginning of the last menstruation. If laparoscopy is performed on an emergency basis, then the presence of menstruation is not a contraindication for it, but is taken into account by the surgeon and anesthesiologist.

Direct preparation

General anesthesia for laparoscopy can be intravenous, but as a rule it is endotracheal anesthesia, which can be combined with intravenous anesthesia.

Further preparation for the operation is carried out in stages.

• An hour before the transfer of the patient to the operating room, while still in the ward, premedication is carried out as prescribed by the anesthesiologist - the introduction of the necessary drugs that help prevent some complications at the time of introduction into anesthesia and improve its course.
• In the operating room, a woman is given a dropper for intravenous administration of the necessary drugs, and monitor electrodes, in order to constantly monitor the function of cardiac activity and blood saturation with hemoglobin during anesthesia and surgery.
• Intravenous anesthesia followed by intravenous administration of relaxants for total relaxation of all muscles, which makes it possible to insert an endotracheal tube into the trachea and increases the ability to view the abdominal cavity during laparoscopy.
• The introduction of an endotracheal tube and its connection to the anesthesia machine, with the help of which artificial ventilation of the lungs is carried out and the supply of inhalation anesthetics to maintain anesthesia. The latter can be carried out in combination with intravenous drugs for anesthesia or without them.

This completes the preparation for the operation.

How laparoscopy is done in gynecology

The very principle of the technique is as follows:

1. The imposition of pneumoperitoneum is the injection of gas into the abdominal cavity. This allows you to increase the volume of the latter by creating free space in the abdomen, which provides visibility and makes it possible to freely manipulate instruments without a significant risk of damage to adjacent organs.
2. The introduction of tubes into the abdominal cavity - hollow tubes designed to pass endoscopic instruments through them.

Superimposition of pneumoperitoneum

In the navel, a skin incision is made with a length of 0.5 to 1.0 cm (depending on the diameter of the tube), the anterior abdominal wall is lifted behind the skin fold, and a special needle (Veress needle) is inserted into the abdominal cavity at a slight slope towards the small pelvis. About 3-4 liters of carbon dioxide is pumped through it under pressure control, which should not exceed 12-14 mm Hg.

Higher pressure in the abdominal cavity compresses the venous vessels and disrupts the return of venous blood, increases the level of the diaphragm, which "compresses" the lungs. The decrease in lung volume creates significant difficulties for the anesthesiologist in terms of adequate ventilation and maintenance of cardiac function.

Introduction of tubes

The Veress needle is removed after reaching the required pressure, and through the same skin incision, the main tube is inserted into the abdominal cavity at an angle of up to 60 ° using a trocar placed in it (an instrument for puncturing the abdominal wall while maintaining the hermeticity of the latter). The trocar is removed, and a laparoscope with a light guide connected to it (for illumination) and a video camera is passed through the tube into the abdominal cavity, through which the enlarged image is transmitted to the monitor screen through a fiber-optic connection. Then, at two more corresponding points, skin dimensions of the same length are made and additional tubes intended for manipulation instruments are introduced in the same way.

Various manipulation instruments for laparoscopy

After that, an audit (general panoramic examination) of the entire abdominal cavity is carried out, which makes it possible to identify the presence in the abdomen of purulent, serous or hemorrhagic contents, tumors, adhesions, fibrin layers, the state of the intestines and liver.

Then the patient is placed in the Fowler (lateral) or Trendelenburg position by tilting the operating table. This contributes to the displacement of the intestine and facilitates manipulation during a detailed targeted diagnostic examination of the pelvic organs.

After the diagnostic examination, the question of choosing further tactics is decided, which may consist in:

• implementation of laparoscopic or laparotomic surgical treatment;
• biopsy;
• drainage of the abdominal cavity;
• completion of laparoscopic diagnostics by removing gas and tubes from the abdominal cavity.

Cosmetic sutures are placed on three short incisions, which subsequently dissolve on their own. If non-absorbable sutures are applied, they are removed after 7-10 days. The scars formed at the site of the incisions become almost invisible over time.

If necessary, diagnostic laparoscopy is transferred to therapeutic, that is, surgical treatment is performed by the laparoscopic method.

Possible complications

Complications during diagnostic laparoscopy are extremely rare. The most dangerous of them arise from the introduction of trocars and the introduction of carbon dioxide. These include:

• massive bleeding as a result of injury to a large vessel of the anterior abdominal wall, mesenteric vessels, aorta or inferior vena cava, internal iliac artery or vein;
• gas embolism as a result of gas entering the damaged vessel;
• desertion (damage to the outer membrane) of the intestine or its perforation (perforation of the wall);
• pneumothorax;
• widespread subcutaneous emphysema with displacement of the mediastinum or compression of its organs.

Postoperative period

Scars after laparoscopic surgery

Long-term negative consequences

The most frequent negative consequences of laparoscopy in the immediate and late postoperative periods are adhesions, which can cause intestinal dysfunction and adhesive intestinal obstruction. Their formation can occur as a result of traumatic manipulations with insufficient experience of the surgeon or already existing pathology in the abdominal cavity. But more often it depends on the individual characteristics of the woman's body itself.

Another serious complication in the postoperative period is slow bleeding into the abdominal cavity from damaged small vessels or as a result of even a slight rupture of the liver capsule, which may occur during a panoramic revision of the abdominal cavity. Such a complication occurs only in cases where the damage was not noticed and not eliminated by the doctor during the operation, which occurs in exceptional cases.

Other consequences that do not pose a danger include hematomas and a small amount of gas in the subcutaneous tissues in the area of ​​trocar insertion, which dissolve on their own, the development of purulent inflammation (very rarely) in the area of ​​wounds, and the formation of a postoperative hernia.

Recovery period

Recovery from laparoscopy is generally quick and smooth. Active movements in bed are recommended already in the first hours, and walking - after a few (5-7) hours, depending on how you feel. This helps to prevent the development of intestinal paresis (lack of peristalsis). As a rule, after 7 hours or the next day, the patient is discharged from the department.

Relatively intense pain in the abdomen and lumbar region persists only for the first few hours after surgery and usually does not require the use of pain relievers. By the evening of the same day and the next day, a subfebrile (up to 37.5 o) temperature and blood-thinning, and subsequently mucous membranes without admixture of blood, discharge from the genital tract are possible. The latter can last on average up to one, maximum 2 weeks.

When and what can you eat after surgery?

As a result of the consequences of anesthesia, irritation of the peritoneum and abdominal organs, especially the intestines, gas and laparoscopic instruments, some women in the first hours after the procedure, and sometimes throughout the day, may experience nausea, single, rarely repeated vomiting. Intestinal paresis is also possible, which sometimes persists the next day.

In this regard, 2 hours after the operation, in the absence of nausea and vomiting, it is allowed to take only 2 - 3 sips of still water, gradually adding it to the required volume in the evening. The next day, in the absence of nausea and bloating and in the presence of active intestinal motility, as determined by the attending physician, you can use ordinary still mineral water in unlimited quantities and easily digestible food.

If the symptoms described above persist the next day, the patient continues treatment in a hospital setting. It consists in a fast diet, stimulation of bowel function and intravenous drip of solutions with electrolytes.

When will the cycle be restored?

The next menstruation after laparoscopy, if it was done in the first days after menstruation, usually appears at the usual time, but the spotting can be much more profuse than usual. In some cases, menstruation may be delayed up to 7-14 days. If the operation was performed later, then this day is considered the first day of the last menstruation.

Is it possible to sunbathe?

Staying in direct sunlight is not recommended for 2-3 weeks.

When can you get pregnant??

The timing of a possible pregnancy and attempts to implement it are not limited by anything, but only if the operation was exclusively diagnostic in nature.

Attempts to carry out pregnancy after laparoscopy, which was carried out for infertility and was accompanied by the removal of adhesions, are recommended after 1 month (after the next menstruation) throughout the year. If the fibroids were removed, no earlier than six months later.

Laparascopy is a low-traumatic, relatively safe and with a low risk of complications, a cosmetically acceptable and cost-effective method of surgical intervention.

Lecture number 6

“Characteristics of endoscopic research methods. Punctures "

Endoscopy (Greek endō inside + skopeō to examine, examine) is a method of visual examination of hollow organs and body cavities using optical instruments (endoscopes) equipped with a lighting device. If necessary, endoscopy is combined with targeted biopsy and subsequent morphological examination of the material obtained, as well as with X-ray and ultrasound examinations. The development of endoscopic methods, the improvement of endoscopic techniques and their widespread introduction into practice are important for improving the early diagnosis of precancerous diseases and tumors of various localization at the early stages of their development.

Modern medical endoscopes are complex optical-mechanical devices. They are equipped with light and image transmission systems; are completed with instruments for biopsy, foreign body extraction, electrocoagulation, drug administration and other manipulations; with the help of additional devices, they provide obtaining objective documentation (photography, filming, video recording).

Depending on the purpose, they are distinguished:

viewing;

biopsy;

operating rooms;

special endoscopes;

endoscopes designed for adults and children.

Depending on the design of the working part, endoscopes are divided:

on rigid ones, which retain their shape during the study;

flexible, the working part of which can be flexed smoothly in the anatomical canal.

The light transmission system in modern endoscopes is made in the form of a light guide consisting of thin fibers that transmit light from a special light source to the distal end of the endoscope into the cavity under study. In rigid endoscopes, the optical system that transmits the image of the object consists of lens elements.

In the optical system of flexible endoscopes (fibroscopes), flexible bundles are used, consisting of regularly laid fiberglass threads with a diameter of 7-12 microns and transmitting an image of an object to the eyepiece end of the endoscope. Fiber-optic endoscopes produce a raster image.

The variety of functional purposes of endoscopes determines the difference in their design. For example, duodenoscope with a lateral arrangement of the optical system at the end of the endoscope facilitates examination and manipulation of the duodenal papilla, esophagogastroduodenoscope with an end position of the optical system allows for examination and therapeutic interventions in the lumen of the esophagus, stomach and duodenum.

In recent years, endoscopes of small (less than 6 mm) diameter have become widespread for the study of thin anatomical canals and hard-to-reach organs, for example ureterorenoscopes, Various types bronchoscopes with fiber optics.

Promising development video endoscopes, in which instead of an optical channel with a fiber bundle, a system with a special photosensitive element - a CCD matrix is ​​used. Due to this, the optical image of the object is converted into electrical signals transmitted through an electric cable inside the endoscope into special devices that convert these signals into an image on a television screen.

Flexible two-channel operating endoscopes are widely used. The presence of two instrumental channels makes it possible to simultaneously use various endoscopic instrumentation (for capturing education and its biopsy or coagulation), which greatly facilitates surgical interventions.

After the examination, the endoscope should be thoroughly rinsed and cleaned. The instrument channel of the endoscope is cleaned with a special brush, after which it is washed and dried with compressed air using special devices.

All valves and accessory valves are disassembled, washed and dried thoroughly prior to assembly. Endoscopes are stored in special cabinets or on tables in a position that prevents deformation of the working parts or their accidental damage.

Endoscopes are sterilized in various means (glutaraldehyde solution, 6% hydrogen peroxide solution, 70% ethyl alcohol) at a temperature not exceeding 50 ° due to the danger of sticking optical elements.

The most widespread endoscopy is used in gastroenterology:

esophagoscopy;

gastroscopy;

duodenoscopy;

intestinoscopy;

colonoscopy;

sigmoidoscopy;

choledochoscopy;

laparoscopy;

pancreatocholangioscopy;

fistuloscopy.

In the diagnosis and treatment of diseases of the respiratory system, such endoscopic methods are widely used as:

laryngoscopy;

bronchoscopy;

thoracoscopy;

mediastinoscopy.

Other methods of endoscopy allow for informative studies of individual systems, for example urinary(nephroscopy, cystoscopy, ureteroscopy), nervous(ventriculoscopy, myeloscopy), some organs (for example, uterus - hysteroscopy), joints (arthroscopy), vessels(angioscopy), cardiac cavities (cardioscopy), etc.

Due to the increased diagnostic capabilities of endoscopy, it has turned in a number of branches of clinical medicine from an auxiliary to a leading diagnostic method. The great possibilities of modern endoscopy have significantly expanded the indications and sharply narrowed contraindications to the clinical use of its methods.

Conducting a planned endoscopic examination shown :

1. to clarify the nature of the pathological process, suspected or established using other methods of clinical examination of the patient,

2. obtaining material for morphological research.

3. In addition, endoscopy makes it possible to differentiate between diseases of an inflammatory and neoplastic nature,

4. and also reliably exclude the pathological process that was suspected during the general clinical examination.

Emergency endoscopy is used as a means of emergency diagnostics and therapy for acute complications in patients with chronic diseases who are in an extremely serious condition, when it is impossible to conduct a routine study, and even more so, surgery.

Contraindication to endoscopy are:

violations of the anatomical patency of hollow organs to be examined,

severe disorders of the blood coagulation system (due to the risk of bleeding),

as well as such disorders of the activity of the cardiovascular and respiratory systems, in which endoscopy can lead to life-threatening consequences for the patient.

The possibility of endoscopy is also determined by the qualifications of the doctor performing the study and the technical level of the endoscopic equipment that he has.

Preparation patients for endoscopy depends on the objectives of the study and the patient's condition. Routine endoscopy is performed after clinical examination and psychological preparation of the patient, in which the task of the study is explained to him and the basic rules of behavior during endoscopy are introduced.

With emergency endoscopy, it is possible to carry out only the psychological preparation of the patient, as well as to clarify the main details of the anamnesis of the disease and life, to determine contraindications for the study or the prescription of drugs.

Medical preparation of the patient is primarily aimed at ensuring optimal conditions for the implementation of endoscopic examination and consists in relieving the patient's psychoemotional stress, carrying out anesthesia during manipulations, reducing the secretory activity of the mucous membranes, and preventing the occurrence of various pathological reflexes.

Technique endoscopy is determined by the anatomical and topographic features of the examined organ or cavity, the model of the endoscope used (rigid or flexible), the patient's condition and the objectives of the study.

Endoscopes are usually inserted through natural openings. When carrying out such endoscopic examinations as thoracoscopy, mediastinoscopy, laparoneoscopy, choledochoscopy, the opening for the introduction of the endoscope is created with special trocars, which are inserted through the thickness of the tissues.

A new trend in endoscopy is the use of flexible endoscopes for the study of internal and external fistulas - fistuloscopy. The indications for fistuloscopy are external intestinal fistulas with a diameter of at least 3 mm; internal intestinal fistulas, located at a distance of 20-25 cm from the anus; a high degree of narrowing of the intestinal lumen, when it is not possible to examine the narrowing itself and the overlying sections of the intestine with the help of endoscopes of other designs.

The combination of endoscopy with X-ray research methods is becoming more widespread. The combination of laparoneoscopy with puncture cholecystocholangioscopy, cystoscopy with urography, hysteroscopy with hysterosalpingography, bronchoscopy with isolated bronchography of individual lobes and segments of the lung makes it possible to fully reveal the nature of the disease and establish the localization and length of the pathological process, which is extremely important for determining the need for surgical intervention or endoscopy. ...

Research methods are being developed that use a combination of endoscopy with ultrasound methods, which facilitates the diagnosis of cavities located next to the investigated organ, and the detection of calculi in the biliary or urinary tract. The ultrasonic probe-probe introduced through the manipulation channel of the endoscope also makes it possible to determine the tissue density, the size of the pathological formation, i.e. to obtain information that is extremely important for the diagnosis of the tumor process. Since the probe is positioned in close proximity to the object under examination with the help of the endoscope, the accuracy of the ultrasound examination is increased and the interference possible during the examination in the usual way is eliminated.

Endoscopic diagnosis can be difficult due to local causes (pronounced deformation of the examined organ, the presence of adhesions) or the general serious condition of the patient. Various complications of endoscopy can be associated with the preparation or conduct of the study: they arise in the examined organ or other body systems, depend on the underlying or concomitant diseases and appear during the study or some time later.

Most often, complications are associated either with anesthesia (individual intolerance to drugs), or with a violation of the technique of endoscopic examination. Failure to comply with mandatory endoscopy techniques can lead to organ injury up to its perforation. Less often, other complications are possible: bleeding after a biopsy, trauma to varicose veins, aspiration of gastric contents during an emergency examination, etc.

Laparoscopy

Laparoscopy(Greek lapara belly + skopeō observe, investigate; synonym: abdominoscopy, ventroscopy, peritoneoscopy, etc.) - endoscopic examination of the abdominal cavity and pelvic organs.

It is used in cases where the cause and nature of the disease of the abdominal organs cannot be established with the help of modern clinical laboratory, X-ray and other methods.

High information content, relative technical simplicity and low invasiveness of laparoscopy have led to its widespread use in clinical practice, especially in children and elderly and old people.

Not only diagnostic laparoscopy, but also therapeutic laparoscopic techniques are widely used: drainage of the abdominal cavity, cholecystomy, gastro-, jejunostomy and colonostomy, dissection of adhesions, some gynecological operations, etc.

The indications for diagnostic laparoscopy are:

diseases of the liver and biliary tract;

tumors of the abdominal cavity;

suspicion of an acute surgical disease or damage to the abdominal organs, especially in the absence of consciousness in the victim;

ascites of unknown origin.

Indications for therapeutic laparoscopy may occur:

with obstructive jaundice;

acute cholecystitis and pancreatitis;

conditions in which the imposition of fistulas on various parts of the gastrointestinal tract is shown: (obstruction of the esophagus);

maxillofacial injury;

severe brain damage;

tumor obstruction of the pylorus;

burns to the esophagus and stomach.

Contraindications to laparoscopy are:

blood clotting disorders;

decompensated pulmonary and heart failure;

coma;

suppurative processes on the anterior abdominal wall;

extensive adhesions of the abdominal cavity;

external and internal hernia;

flatulence;

severe obesity.

For laparoscopy, special instruments are used:

a needle for imposing a pneumoperitoneum;

a trocar with a sleeve for puncturing the abdominal wall;

laparoscope;

puncture needles;

biopsy forceps;

electrodes;

electric knives and other instruments that can be passed either through the manipulation channel of the laparoscope, or through a puncture of the abdominal wall.

Laparoscopes are based on the use of rigid optics, their optical tubes have different directions of view - direct, lateral, at different angles. Are being developed fibrolaparoscopes with a controlled distal end.

Diagnostic laparoscopy in adults, it can be performed under local anesthesia; all laparoscopic operations, as well as all laparoscopic manipulations in children, are usually performed under general anesthesia. In order to prevent possible bleeding, especially with liver damage, vikasol, calcium chloride are prescribed 2-3 days before the examination. The gastrointestinal tract and the anterior abdominal wall are prepared as for abdominal surgery.

The first stage of laparoscopy is the imposition of a pneumoperitoneum... The abdominal cavity is punctured with a special needle (such as a Leriche needle) at the lower left point of the Calca (Fig. 14).

Rice. 14. Classic Calca points for the imposition of a pneumoperitoneum and the introduction of a laparoscope: the insertion sites of the laparoscope are indicated by crosses, the puncture site for the imposition of pneumoperitoneum is indicated by a circle, the projection of the round ligament of the liver is shaded.

3000-4000 cm3 of air, nitrous oxide or carbon monoxide are injected into the abdominal cavity. Depending on the task of the study, for the introduction of the laparoscope, one of the points is selected according to the Kalka scheme, most often above and to the left of the navel. A 1 cm long skin incision is made with a scalpel, the subcutaneous tissue and the aponeurosis of the rectus abdominis muscle are dissected. Then the anterior abdominal wall is pierced with a trocar with a sleeve, the trocar is removed, and a laparoscope is inserted through its sleeve.

Inspection of the abdominal cavity is carried out sequentially from right to left, examining the right lateral canal, liver, subhepatic and suprahepatic space, subphrenic space, left lateral canal, small pelvis.

If necessary, you can change the position of the patient for a more detailed examination. By the color, nature of the surface, the shape of the organ, overlays, the type of effusion, it is possible to establish the nature of the lesion: liver cirrhosis, metastatic, acute inflammatory process (Fig.15a, b), necrotic process, etc. To confirm the diagnosis, a biopsy (usually a puncture) is performed.

Various therapeutic procedures performed during laparoscopy are widely used: drainage of the abdominal cavity, microcholecystostomy), etc. After the end of laparoscopy and removal of the laparoscope from the abdominal cavity, gas is removed, the skin wound is sutured with 1-2 sutures.

Rice. 15a). Laparoscopic picture in some diseases and pathological conditions of the abdominal organs - gangrenous cholecystitis.

Rice. 15b). The laparoscopic picture in some diseases and pathological conditions of the abdominal organs is fibrous peritonitis.

Complications are rare. The most dangerous are instrumental perforation of the gastrointestinal tract, damage to the vessels of the abdominal wall with the occurrence of intra-abdominal bleeding, infringement of hernias of the anterior abdominal wall. As a rule, with the development of such complications, an emergency operation is indicated.

Colonoscopy

Colonoscopy (Greek kolon colon + skopeō observe, examine; synonym: fibrocolonoscopy, colonofibroscopy) - a method of endoscopic diagnosis of diseases of the colon. It is an informative method for early diagnosis of benign and malignant tumors of the colon, ulcerative colitis, Crohn's disease, etc. (Fig. 16,17).

During colonoscopy, it is also possible to perform various therapeutic manipulations - removal of benign tumors, stopping bleeding, extracting foreign bodies, recanalisapia of bowel stenosis, etc.

Rice. 16. Endoscopic picture of the colon in normal conditions and with various diseases: the mucous membrane of the large intestine is normal.

Rice. 17. Endoscopic picture of the colon in normal conditions and with various diseases: sigmoid colon cancer - necrotic tumor tissue is visible in the center of the visual field.

Colonoscopy is performed using special devices - colonoscopes. Colonoscopes KU-VO-1, SK-VO-4, KS-VO-1 are produced in the Russian Federation (Fig. 18). Colonoscopes of various Japanese firms are widely used.

Rice. 18. Colonoscopes special KS-VO-1 (left) and universal KU-VO-1 (right).

The indication for colonoscopy is the suspicion of any disease of the colon. The study is contraindicated in acute infectious diseases, peritonitis, as well as in the late stages of heart and pulmonary failure, severe disorders of the blood coagulation system.

Preparation for colonoscopy in the absence of persistent constipation includes taking the patients on the eve of the study in the afternoon (30-50 ml) of castor oil, after which in the evening two cleansing enemas are performed with an interval of 1-2 hours; they are repeated on the morning of the study day.

With severe constipation, 2-3 days of preparation is necessary, including an appropriate diet, laxatives and cleansing enemas.

In diseases accompanied by diarrhea, laxatives are not given, it is enough to use small-volume (up to 500 ml) cleansing enemas.

Emergency colonoscopy for patients with intestinal obstruction and bleeding can be performed without preparation. It is effective when using special endoscopes with a wide biopsy channel and active irrigation of the optics.

Colonoscopy is usually performed without premedication. Patients with severe pain in the anus are shown local anesthesia (dicain ointment, xylocaineel). In case of severe destructive processes in the small intestine, massive adhesions in the abdominal cavity, it is advisable to carry out a colonoscopy under general anesthesia, which is mandatory for children under 10 years of age. Complications of colonoscopy, the most dangerous of which is bowel perforation, are very rare.

Ultrasound examination (ultrasound) Is a painless and safe procedure that creates an image of internal organs on a monitor due to the reflection of ultrasonic waves from them.

At the same time, media of different density (liquid, gas, bone) are displayed on the screen in different ways: liquid formations look dark, and bone structures - white.

Ultrasound allows you to determine the size and shape of many organs, such as the liver, pancreas, and see the structural changes in them.

Ultrasound is widely used in obstetric practice: to identify possible fetal malformations in early pregnancy, the state and blood supply of the uterus, and many other important details.

This method, however, is not suitable and therefore not used for examining the stomach and intestines.

THROMBOTIC COMPLICATIONS OF LAPAROSCOPIC

Thrombotic complications of laparoscopic operations mean, first of all, the development of phlebothrombosis and thrombophlebitis in the lower extremities and small pelvis with the threat of subsequent pulmonary embolism. In addition to the operational aggression itself, during laparoscopic operations, additional factors are included in the pathogenesis.

These include:

- increased intra-abdominal pressure due to pneumoperitoneum,

- the position of the patient on the table with the raised head end,

Video: Are complications possible after surgery in laparoscopic urology

- long duration of the operation.

Despite the fact that our experience and literature data do not allow us to speak about a reliably more common thromboembolism after laparoscopic operations, the existing prerequisites for venous stasis in the lower extremities force us to pay increased attention to the prevention of thrombotic complications of laparoscopic operations.

To this end, we consider it necessary:

Elastic bandaging of the lower extremities before surgery and during the entire postoperative period, regardless of the presence of varicose veins in the patient.
Use, if possible, pneumatic compression of the lower extremities during the operation.
The use of anticoagulants in small doses before and after surgery. It is now known that the administration of 5000 IU heparin before and every 12 hours after surgery (or fraxiparine every 24 hours) does not increase the risk of bleeding, but reduces the risk of thrombus formation.

Such prophylaxis can and should be carried out with all laparoscopic procedures. Appropriate appointments are made by the surgeon before the operation.

PULMONARY AND CARDIOVASCULAR COMPLICATIONS OF LAPAROSCOPIC SURGERY

The main reasons for this group of complications during endovideosurgical operations are as follows:

limitation of excursions of the lungs due to their compression by the diaphragm with pneumoperitoneum.
reflex suppression of the motor function of the diaphragm in the postoperative period due to its overstretching during laparoscopic intervention.
the negative effect of absorbed carbon dioxide on the contractile function of the myocardium, depression of the central nervous system, in particular, the respiratory center, especially with long-term carboxypneumoperitoneum.
a decrease in cardiac output due to a decrease in venous return to the heart due to the deposition of blood in the veins of the pelvis and lower extremities.
additional negative influence of the patient's body position - Trendelenburg or Fowler.
ischemic disturbances in the microvasculature of the abdominal organs due to compression in pneumoperitoneum, and also due to reflex spasm in response to developing hypotension, hypercapnia.
displacement of the mediastinum and a decrease in lung volumes during thoracoscopic interventions due to pneumothorax and lateral position of the patient.

These reasons are leading in the development of intra- or postoperative cardiopulmonary disorders, the development of which may become the basis for the transition to "open" intervention, cause respiratory arrest or the development of pneumonia, myocardial infarction or other serious complications after surgery. Their prevention is more a task of anesthetic and resuscitation support. The surgeon should be wary of this group of complications and, if necessary, expand the complex of preoperative functional examinations of the patient.

Organizationally, during endovideosurgical operation and in the early postoperative period, monitoring of blood gases, pulse, blood pressure and, if indicated, electrocardiogram should be ensured.

Video: Obstruction of pipes

In addition, it is necessary to remember about the possibility of developing pneumo- or hydrothorax after laparoscopic operations. The reason may be the penetration of gas or liquid (with massive lavages of the abdominal cavity during the operation) through physiological or pathological defects of the diaphragm. These complications can be bilateral and unilateral, combined with pneumomediastinum and subcutaneous emphysema. Their treatment is not very difficult - a puncture or, in some cases, drainage of the chest cavity should be performed. Timely diagnosis can be more difficult. In this regard, some surgeons offer a routine X-ray examination of the lungs on the operating table for prolonged (more than 1 hour) laparoscopic operations.

FAILURES AND COMPLICATIONS OF LAPAROSCOPIC SURGERY IN CREATION OF PNEUMOPERITONEUM

The creation of a pneumoperitoneum is potentially one of the most dangerous stages of any laparoscopic surgery. A large number of complications of laparoscopic operations can be directly related to the technique of performing the manipulation. They are primarily due to the lack of visual control during puncture of the abdominal cavity with a Veress needle and the introduction of the first trocar.

Complications of laparoscopic operations arising from the imposition of pneumoperitoneum can be divided into the following groups:

Associated with extraperitoneal gas injection.
Associated with direct mechanical damage to various anatomical structures.

The most common situations are when, due to various reasons (errors in testing or neglect), gas is insufflated into the subcutaneous tissue, preperitoneally, into the tissue of the greater omentum or the round ligament of the liver.

Pneumatization of the cellular spaces should be attributed to failures, and not to complications of the operation, since they can be quite easily recognized when they occur visually, as well as according to the indications of the insufflator, and even with sufficient severity, they practically do not affect the course of the postoperative period.

A great danger is posed by cases of gas entering the venous system in case of accidental puncture of a venous vessel or its injury in the presence of pneumoperitoneum. And if, as a rule, treatment is not necessary during insufflation into fiber, then gas embolism requires immediate active action.

Necessary:

Remove pneumoperitoneum.
Transfer the patient to the Durant position - on the left side with the raised leg end of the table.
Aspirate gas from the right atrium through the central vein.
Provide ventilation with pure oxygen.
Conduct resuscitation therapy.

Mechanical damage to blood vessels and intestines occurs in 0.14-2% of cases.

Damage to the vessels of the anterior abdominal wall, as a rule, does not pose an immediate threat to the patient's life, but lead to the formation of hematomas with the risk of subsequent suppuration.

Injuries of large vessels of the retroperitoneal space - the aorta, vena cava, iliac arteries and veins are more dangerous and require immediate active action to eliminate the damage. Mortality in these cases reaches 40%.

Most often, such complications of laparoscopic operations occur with the introduction of the first trocar - in 66-100% of cases, less often - with the introduction of the Veress needle. K. Bett (1996) and some other authors point to the likelihood of damage to large vessels during the paraumbilical incision with a scalpel.

In addition, in the literature, you can find examples of failures in the performance of pneumoperitoneum, manifested long after the operation. For example, there is a description of a case of infringement of a transmesosigmoid hernia 5 months after injury to the mesentery of the sigmoid colon during laparoscopic intervention.

A large number of various complications in the imposition of pneumoperitoneum, which poses an immediate threat to the patient's life, dictate the need for mandatory compliance with a number of rules for this procedure. Strict implementation of each of them allows you to maximize the safety of the patient and the surgeon.

In order to reduce the risk of possible unrecognized damage to internal organs and blood vessels during the creation of pneumoperitoneum, it is necessary to examine the abdominal cavity at the beginning of each laparoscopic operation. In all difficult and doubtful cases, preference should be given to the method of open laparoscopy. If any complication occurs, in case of insufficient control over the situation, you should go to an open operation with the involvement, if necessary and possible, of specialists of the appropriate profile (for example, vascular surgeons).

THERMAL AND COAGULATION DAMAGE

The use of equipment, especially monopolar coagulation, has its own specificity in the conditions of endovideosurgical operations.

The latter is defined as follows:

restriction of visual control
the presence of several instruments in the operation area, the working part of almost each of which can be a conductor of electric current.
longer instrument, the presence of constant additional contact through the trocar with the abdominal wall -
the use of irrigation during surgery, which can lead to electrical conduction along the dielectric surfaces of the instruments or the appearance of abnormal flow paths through the fluid.

The main mechanisms of electrocautery damage:

direct damaging effect of the working part of the instrument in case of untimely pressing the pedal or in case of incorrect orientation in tissues, or in case of “blind” coagulation -
direct damaging effect of an instrument with an elongated metal working part (some types of dissectors), which is out of sight at the time of coagulation;
direct damaging effect due to insulation failure or its capacitive breakdown -
mediated (through touching another instrument, including a laparoscope) damage -
direct damage due to the instrument touching any organ immediately after coagulation, when the working part still retains an elevated temperature -
coagulation near clips or a mechanical suture - in this case, the clips become electrical conductors, which causes tissue necrosis -
prolonged coagulation of fine structures, causing abnormal current movement, for example, during electrocoaulation of the fallopian tube - through its fimbrial end, which can damage the organs presenting to it;
prolonged use of coagulation in conditions of insufficient visibility near tubular structures (common bile duct) - leads to the development of their delayed
burn injury to internal organs with a laparoscope left in the abdominal cavity without pneumoperitoneum during any manipulations (for example, removing an organ from the abdominal cavity) -
burns in the area of ​​the plate (passive electrode) due to a decrease in the area of ​​its contact with the body surface.

INFECTIOUS COMPLICATIONS OF LAPAROSCOPIC SURGERY

Trocar wound infections are quite rare in endovideosurgery; according to numerous literature data, the incidence of this complication does not exceed 1%. The rules for preventing infection are well known: careful handling of tissues, removal of an organ in a container through an incision in the area of ​​the smallest thickness of the abdominal wall, antibiotic prophylaxis.

At the same time, we would like to draw attention to the possible difficulties in the timely recognition of infectious complications of laparoscopic operations. In our practice, we observed a subgaleal abscess of the epigastric puncture area after cholecystectomy. The pain syndrome in the epigastrium that arose on the 3rd day after the operation was at first mistakenly regarded as a manifestation of postoperative pancreatitis. The correct diagnosis was made only at the time of perforation of the abscess into the abdominal cavity. The reasons for the late diagnosis were: the absence of external manifestations due to the small size of the skin incision, lack of alertness. The latter is the main condition for the timely prevention and treatment of any complications.

POSTOPERATIVE HERNIA

They are quite rare. A preventive measure is suturing of all trocar defects in the aponeurosis with a diameter of more than 1 cm, which can be easily controlled by palpation at the end of the operation.

METHODS FOR CORRECTION OF COMPLICATIONS OF LAPAROSCOPIC SURGERY

Effective actions to eliminate the complication of laparoscopic surgery begin with the timeliness of its recognition. Therefore, any endovideosurgical operation should begin with a survey laparoscopy, one of the tasks of which is the timely diagnosis of complications at the initial stage of the operation.

If an injury is found to any organ (for example, the intestine), it must be sutured. At the same time, we believe that if the intestine is damaged with a Veress needle, it is safer to immediately impose an immersed serous-serous suture than to give preference to expectant tactics, as some surgeons recommend. If the use of laparoscopic technique is not possible, you should switch to a microlaparotomy or a full-fledged one, which will ensure maximum reliability of manipulations.

Vascular injuries during the operation pose an immediate danger both for the normal course of the operation and, sometimes, for the patient's life. Surgical tactics depends on the nature of the damage to the vessel and the intensity of bleeding.

With minor bleeding, you can choose a wait and see tactic - if the bleeding intensity spontaneously decreases, no additional action is required. With an increase in the intensity or initially moderately severe bleeding, it is necessary to achieve temporary hemostasis, for example, by tamponade with the presenting organ (gallbladder, intestine). We often use a gauze swab inserted through a 10 mm trocar for this. Sometimes temporary hemostasis can be achieved by grasping the vessel with a dissector or atraumatic clamp. After assessing the situation, vessels up to one, sometimes 2 mm in diameter can be coagulated, if at the same time there is confidence that there is no threat of damage to surrounding organs, or clipped. Clipping should also be done under visual control.

For the safe performance of these manipulations, we consider it necessary to have a confident mastery of the bimanual operating technique. In this case, we consider the work as optimal with a dissector or atraumatic clamp - in the left hand and an electric aspirator - in the right. The technique for stopping bleeding is as follows: with constant irrigation and aspiration of fluid and blood, removing the surrounding tissue with a dissector if necessary, the vessel is clearly visualized. A situation is achieved when the outflowing blood is aspirated directly from the vessel. The latter is captured by an atraumatic instrument, the tip of the electric aspirator is removed, a clip-applicator is inserted through this trocar, and the vessel is clamped with clips under strict visual control.

With severe bleeding, with unsuccessful attempts to stop bleeding, if it is impossible to achieve 100% visualization and the danger, as a result, of additional damage, it is necessary to perform an adequate laparotomy.

The surgeon's tactics for injuring the vessels of the retroperitoneal space has its own specifics. If there is a reasonable suspicion of injury to the aorta, inferior vena cava or their branches, it is necessary to perform immediate laparotomy and suturing of the vessel defect.

If small vessels in this area are injured, expectant tactics are possible. We believe that the detection, after the imposition of pneumoperitoneum, of a retroperitoneal hematoma without obvious signs of enlargement, allows us to adhere to the following algorithm of actions: remove the pneumoperitoneum for 1-5 minutes, then, after re-creating it, assess the size of the hematoma. If they have not increased, perform the operation. At the end of it, assess the size of the hematoma after removal and reapplication of pneumoperitoneum. In the absence of signs of enlargement, additional surgical actions are not required. It is advisable to carry out antibiotic therapy in the postoperative period.

I would like to emphasize that any doubts about the stability of surgical hemostasis, especially with damage to large vessels, must end in conversion.

Stopping bleeding from damaged vessels of the anterior abdominal wall is not an easy task. Experience shows that percutaneous stitching of epigastric arteries or their large branches is usually ineffective and leads to a deterioration in cosmetic results. In the event of such complications, we consider it optimal to use a furrier's needle, which makes it possible to capture a sufficient array of deep tissues of the abdominal wall with a thread from practically one external injection. This allows for guaranteed flashing of the vessel without disturbing the cosmetics.

Minor bleeding from trocar injections often stop spontaneously by the end of the operation. If this does not happen, or the outflowing blood creates difficulties for the main stage of the operation, such bleeding can be stopped by electrocautery. One of these successfully used methods: at the end of the operation, a coagulation instrument (for example, a dissector) is inserted through the trocar, the trocar is pulled out of the abdominal cavity, and the instrument is installed in such a way that its working part is in the thickness of the abdominal wall. Coagulation of the walls of the wound trocar canal is performed.

To achieve reliable hemostasis, always at the end of the operation, it is necessary to inspect possible bleeding sites at a temperature lower than 7-8 mm Hg. Art. intra-abdominal pressure. This eliminates the tampon effect of pneumoperitoneum.

Endovideosurgery cannot be absolutely safe and without failures and complications. We believe that every surgeon performing endoscopic interventions should not neglect any trifles in the preoperative examination and preparation of the patient for the operation, as well as the preparation and adjustment of the equipment. In addition, the operating surgeon must have a clear algorithm of actions in cases of certain complications. All this is a fundamental point that allows you to prevent or, if necessary, quickly and safely eliminate the complication of laparoscopic surgery.