RU2609254C1 - Method of laparoscopic small intestinal intubation and device for its implementation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: group of inventions relates to medicine, surgery. Into stomach through nose probe is introduced with conductor, which is equipped with magnet. In abdominal cavity through trocar laparoscopic magnetic tool is inserted in form of tube with magnet. Magnet attracts laparoscopic tool distal magnet probe through wall of hollow organ. Probe is supplied simultaneously from outside and with help of magnetic tool advancing it behind duodenal bend.

EFFECT: method and device for its realization make it possible to avoid complications by laparoscopic monitoring of position of probe during intubation.

2 cl, 6 dwg, 1 ex

Description

The group of inventions relates to medicine, namely to laparoscopic surgery, and can be used for intubation of the small intestine with peritonitis and intestinal obstruction.

In the surgical treatment of peritonitis and intestinal obstruction, intubation of the small intestine is one of the important stages of the operation. Decompression of the gastrointestinal tract (GIT) performs the following functions: unloading, detoxification, scaffold, restoration of peristalsis, nutritional, prevention of inconsistency of the sutures of hollow organs, drug exposure of the intestinal mucosa, as well as improving the visibility of organs and allows for an adequate audit during surgery (Eryukhin I.A. Intestinal obstruction / I.A. Eryukhin et al. - St. Petersburg: Peter, 1999. - 443 p.).

Currently, in the surgical treatment of peritonitis and acute intestinal obstruction, the possibilities of laparoscopy are increasingly being used, the differences of which are: the operation is performed under the control of a laparoscope with displaying the image of the surgical field on a video monitor in a two-dimensional image, organ palpation is possible only with tools, the need to use special equipment and instruments (Fedorov I.V. Endoscopic surgery / I.V. Fedorov, E.I. et al. - M.: GEOTAR-Media, 2009. - 544 p. Fedorov I.V. La aroskopicheskaya surgery, gynecology and urology / IV Fedorov et al -. M .: Book House, 2013. - 436 s).. The advantages of laparoscopic interventions in comparison with traditional ones are: reduction of the invasiveness of the operation, postoperative pain, the number of days the patient is in the hospital, postoperative hernias, early activation of patients, good cosmetic result and others. However, this treatment method is limited by the pronounced bloating and the need for intubation of the small intestine (Khubutia M.Sh. Endosurgery for emergency diseases and trauma: a guide / M.Sh. Khubutiya, P.A. Yartseva. - M.: GEOTAR-Media, 2014. - 240 s.).

A traditional method of conducting a probe into the small intestine in the process of abdominal intervention is known. During a laparotomy, the anesthetist, at the command of the surgeon, passes a pre-lubricated probe into the stomach through the mouth. Having felt the probe in the stomach, the surgeon moves the olive through the pylorus, placing the probe along a large curvature. Corrugating the stomach, advance the probe into the small intestine. The direction of advancement of the probe in the duodenum is corrected with the left hand. When the duodenojejunal angle is acute and the probe begins to abut, a Treytz ligament is incised, increasing the angle. Further intubation is achieved by crimping and stringing the small intestine onto the probe. Care must be taken to ensure that the probe does not collapse in the digestive tube. The final step is the removal of the probe through the nasopharynx. It is possible to use a conductor. A metal string - a conductor gives the probe elasticity, does not allow it to curl up in the oropharynx cavity, and due to the increase in pressure along the axis it promotes fast and unhindered tube advancement (I. Yerukhin. Intestinal obstruction / I. A. Yerukhin and others - St. Petersburg: Peter, 1999 .-- 443 p.).

Significant disadvantages of the traditional method are:

- impossible during laparoscopic intervention due to the impossibility of manual correction and advancement of the probe;

- there is a significant injury to the walls of the digestive tract with the formation of ruptures of the mucosa, hematomas, ulcerations, perforations.

In abdominal surgery, intubation intestinal probes of various designs are used: Abbott-Miller, Cantor, Harris, Wydle, Smith, Dederer and others (Dederer Yu.M. Pathogenesis and treatment of acute intestinal obstruction / Yu.M. Dederer. - M .: Medicine, 1971. - 271 p., Yuryukhin I.A. Intestinal obstruction / I.A. Yeryukhin et al. - St. Petersburg: Peter, 1999. - 443 p.). The advancement of such probes is accompanied by massive trauma to the walls of the hollow organ, their use is limited to cavity surgery, and therefore impossible in laparoscopic surgery.

A silicone probe with permanent magnets mounted in its distal end with a diameter of 0.3 0.2 cm thick was developed (a method for treating intestinal insufficiency in the postoperative period is RF patent No. 2340367, publ. 10.12.2008). However, the advancement of such a probe leads to injury to the mucosa, it is carried out during a cavity intervention, and therefore it is impossible to carry out laparoscopically: with axial pressure on the outer end, such a probe collapses, its olive rests against the bends of the walls of the digestive tract, it cannot be advanced and controlled, its tip is brought only in the oscillatory motion, practically in the blind, since the exact location of the magnets is unknown, which can lead to perforation of the hollow organ, the tip of the probe can use atsya only magneto-mechanical stimulation of intestinal motility, increasing the distance between the magnets, the oscillations are reduced, become uncontrollable at a distance greater than 4 cm, especially if the intestine is deep in the pelvis, or obesity, the probe becoming ineffective.

Abroad, for the purpose of enteral nutrition, in resuscitation patients, probes for various pyloric pulses are carried out in various designs using external large permanent magnets or electromagnetic sensors (Parkman N.R., McCallum RW Gastroparesis. Pathophysiology, presentation, treatment. - NY: Humana press, 2012 .-- P. 342). Disadvantages: difficult to use, training of medical personnel for working with these devices is necessary, high cost of equipment and probes, can cause interference in electronic devices, unsuitable for laparoscopy.

Izosimov A.N. et al. proposed a method of laparoscopic decompression of the small intestine with intestinal obstruction and peritonitis in children: during laparoscopy, a purse string suture is placed on the intestine, the wall of the latter is punctured with an endoscopic needle and connected to aspiration, then the needle is removed after the contents have been evacuated, the puncture site is treated with iodine and a purse string suture. delayed (Method of laparoscopic decompression of the small intestine with intestinal obstruction and peritonitis in children / A.N. Izosimov, A.A. Gumerov, V.V. Plechev, etc. // Medical Bulletin of Bashkortostan. - 2012. - No. 2. - p. 97-99). The method has a number of significant drawbacks: firstly, it is traumatic - to unload the entire small intestine, it is necessary to puncture various sections of the intestine repeatedly, thereby increasing the risk of inconsistency of the joints, secondly, not all contents are evacuated due to the small diameter of the needle, and thirdly, contamination of the abdominal cavity occurs, which can lead to postoperative peritonitis, wound complications, fourthly, there is no decompression of the small intestine in the postoperative period.

The prior art method for intubation of the small intestine and a device for its implementation (application for the invention of the Russian Federation No. 98110402/14, publ. 02.20.2000), the essence of which is as follows. During a traditional cavitary intervention, an intestinal tube is inserted into the stomach lumen, through which a flexible conductor with olive at the end is passed, the olive is captured through the wall of the hollow organ with the help of a tool, which is a magnet placed on the body of a non-magnetically conducting material, and it is advanced with a flexible conductor to the required level of intubation of the small intestine, where they hold the olive, and then a probe is passed through the conductor to the place of fixation of the olive.

The disadvantages of the method and device for its implementation are:

- due to the design, the advancement of such a probe into the intestine is difficult, there is no possibility of monitoring and correcting the position of the tip of the probe, especially when it rests against the wall of a hollow organ, its use leads to trauma to the walls of the gastrointestinal tract, it is unsuitable for laparoscopic intubation;

- on the tool, the fixation of the magnet is unreliable;

- due to the material, shape and size of the tool nodes, it cannot be entered safely and without loss of tightness through the laparoscopic trocar;

- the tool does not allow you to safely, unhindered, quickly get to the operation area and hold the probe into the small intestine during laparoscopy;

- the instrument is non-ergonomic, bulky, uncomfortable, complicated in design, sterilization, expensive to manufacture, can cause interference in electronic devices, injures the gastrointestinal wall;

- friction between the conductor and the probe prevents the olive from moving to the required level of intubation, which is also accompanied by trauma to the intestinal wall;

- promotion of olive alone with a guide through the gastrointestinal tract leads to significant mucosal injury due to the “sawing” effect;

- due to the bending of the conductor in the lumen of the digestive tube, passing the probe through it is accompanied by significant friction between them, which greatly complicates or completely makes intubation impossible;

- there is no possibility of manual control and advancement of the tip of the probe, especially when it stops against the wall of a hollow organ;

- the way of roads, time-consuming, complicated, inconvenient and is accompanied by a significant waste of time due to its multi-stage;

- the method is not feasible during laparoscopic intervention.

The most reliable method selected as a prototype is the method of conducting a probe for nasogastric intubation of the small intestine (patent RU 2265457, publ. 10.12.2005), which is carried out during laparoscopy as follows. First, a silicone probe 3 m long is carried out, with an outer diameter of 8 mm into the stomach. The end of the probe is visually detected by the stomach, an elastic metal conductor with an outer diameter of 3 mm, a length of 4 m is drawn along its entire length along its inner channel, and a silicone tube with an outer diameter of 15 mm, an inner diameter of 10 mm, and a length of 70 cm is drawn along its outer surface. until its end stops in the pyloric pulp and placing the tube at the bottom of the stomach along its great curvature. A probe with a conductor is passed through the tube through the pyloric pulp to the duodenojejunal bend. Instrumentally and by turning the patient to the right side, they reduce the angle of duodenojejunal bending. Conduct a probe with a conductor for duodenalunal bending. Advancing along the lumen of the gastrointestinal tract occurs due to axial pressure on the outer end of the probe with a conductor.

The disadvantages of this method:

- it is possible to fold the probe in the esophagus when moving into the stomach due to the excessive softness of the intubation probe and the refusal to introduce the conductor into its lumen at the initial stage;

- not always the visualization of the probe entering the stomach, which can be limited due to the massive adhesive process in the upper floor of the abdominal cavity;

- with a "blind" introduction of a metal conductor into the probe, the risk of complications increases - perforation of the esophagus, stomach, due to the uncontrolled exit of the tip of the metal conductor through the holes of the probe;

- leads to extensive trauma to the mucosa of the oropharynx, esophagus, stomach when holding a thick tube through the probe and further pressure on this tube;

- there is no possibility of manual control and advancement of the tip of the probe, especially when it stops against the wall of a hollow organ;

- the movement of the probe occurs only due to axial pressure on the outer end with the conductor;

- time-consuming, complex, inconvenient and requires considerable time for its implementation due to multi-stage.

The authors were tasked with developing a method for laparoscopic intubation of the small intestine and a device for its implementation, which are cheap, simple in technical design and convenient to use, avoiding complications, intubating in almost all clinical situations, controlling the position and promoting the probe laparoscopically, simplifying the process itself , reduce the time spent on the intubation process.

The problem is achieved in that in the method of laparoscopic intubation of the small intestine, including the introduction of a probe with a conductor through the esophagus into the stomach, holding the probe under the control of the laparoscope for twelve duodenal bending, a new thing is that during laparoscopy, a laparoscopic magnetic instrument is inserted into the abdominal cavity, which lead to the distal end of the probe inserted into the stomach, equipped with round proximal and distal permanent magnets connected by means of a nail new monofilament yarns drawn through them, the laparoscopic instrument probe distal magnet for magnet through the stomach wall, then simultaneously fed with the probe and the outside conductor via magnetic laparoscopic tool is advanced along the wall of the tip of the hollow body for dvenadtsatiperstnoeyunalny bending.

A device for implementing the method includes a probe with a conductor and a magnetic tool, and at the distal end of the probe, a circular proximal permanent magnet is mounted with a through channel in the center, connected to the distal round permanent magnet with a through channel in the center, by means of a monofilament nylon thread passed through the magnets, a distal magnet is fixed at one end of the thread, a stop is installed at the other end, with the possibility of moving the thread along the through channel of the proximal nit under the influence of the magnetic laparoscopic instrument, designed as a plastic tube, plugged at both ends of the stainless steel inserts, with mounted in the distal end of a permanent magnet in the form of a cylinder with rounded edges.

The technical result of the proposed method and device is convenience, reducing the risk of complications, reducing costs, intubation in almost all clinical situations, monitoring the position and advancement of the probe laparoscopically, simplifying the process itself, and reducing the time spent on intubation.

The invention is illustrated by drawings, where:

in FIG. 1 shows a probe for laparoscopic intubation of the small intestine;

in FIG. 2 - the distal part of the probe for laparoscopic intubation of the small intestine;

in FIG. 3 shows a laparoscopic magnetic instrument for intubation of the small intestine;

in FIG. 4 is a photo of a laparoscopic magnetic instrument for intubation of the small intestine;

in FIG. 5 - a device for implementing the method of laparoscopic intubation of the small intestine, the probe magnet is attracted to the instrument magnet through the wall of the hollow organ;

in FIG. 6 - photo of the device, the probe magnet is attracted to the tool magnet.

A device for implementing the method of laparoscopic intubation of the small intestine contains a probe 1, which is a PVC tube (Fig. 1, 2) with a lumen diameter of 0.5-0.7 cm, 3 m long, with side openings with a diameter of 2-2.5 mm, at a distance of 3 cm from each other, except for 70 cm of the proximal segment. A metallic conductor 2, coated with a sliding coating, with a rigid main part and a flexible curved tip to a mounted magnet 3, is introduced into the probe lumen. A round proximal permanent magnet 3 with a diameter of 5 mm with a through channel in the center is mounted in the distal end of the probe 1. The second distal circular permanent magnet 4 with a diameter of 5 mm with a through channel in the center is fixed to 2 cm of nylon monofilament yarn 5 with a thickness of 2 mm, drawn through magnets 3 and 4 and connecting them. At the same time, a distal magnet 4 is fixed at one end of the thread, for example, using glue 7 for bonding metal and plastic, a stopper 6 is installed at the other end of the thread 5, with the possibility of moving the thread 5 along the through channel of the proximal magnet 3. Laparoscopic magnetic instrument (Fig. 3, 4) is made of a plastic tube 8 with a length of 40 cm, an outer diameter of 9 mm, an inner diameter of 8 mm, sealed at both ends with stainless steel inserts 11 in the form of a cylinder with a diameter of 8.5 mm, a height of 1 cm, with a distal end mounted in the working tube 8 with a permanent magnet 9 with a diameter of 9 mm, in the form of a cylinder 1 cm high with rounded edges.

The magnets in the device may be, for example, neodymium.

The limiter 6 can be performed, for example, by heating and melting the end of the thread 5 over the fire, and the distal magnet 4 can be fixed on the thread 5, for example, using glue 7, designed for bonding metal and plastic.

The tube 8 of the laparoscopic magnetic instrument can be made of aluminum, and the permanent magnet 9 can have a height of 1 mm to 4 cm, having different strengths. The most convenient, optimal, with sufficient strength, relatively “standard” based on clinical and experimental data is a cylinder-shaped magnet with dimensions of 9 × 10 mm. However, in some clinical situations, depending on the wall thickness of the hollow organ 12, the severity of its pathological changes, height, i.e. Magnet strength 9, must be individually selected. The inserts can be made of stainless or medical steel. The magnet 9 can be fixed at the distal end of the tube 8, for example, by “double” fixing the magnet to stainless steel 11 due to the forces of magnetism and gluing the space between them, for example, by means of glue 10 for gluing metals. Magnets 9 can be fixed at the two plugged ends of the tube. Thus, it is possible to carry out a set of tools with various magnets. It is advisable, as it seems to us, 5-6 pieces of laparoscopic magnetic instruments in a set. For example, the height of the magnets is 9 - 1 mm-3 mm - 5 mm - 10 mm - 40 mm.

In the normal state, due to attractive forces, magnets 3 and 4 are in contact, forming a probe olive (Fig. 1, 2). When approaching a laparoscopic magnetic instrument (Fig. 3, 4), due to its exceeding attractive force of the permanent magnet 9, the distal magnet 4 is attracted, while the olive turns into a “dumbbell” shape (Fig. 5, 6). Progress of the probe into the small intestine is accompanied by minimal trauma. Thanks to the material, shape and size of the nodes, the laparoscopic magnetic instrument allows you to safely, without loss of tightness through the trocar, easily, quickly get to the operation area and hold the probe into the small intestine during laparoscopy, it is ergonomic, not bulky, convenient, simple in design, cheap in production, does not cause interference in electronic devices. Passing along the surface of the hollow organ during laparoscopy, the magnetic instrument allows you to quickly detect the distal end of the probe 4 by the characteristic attraction between them through the wall of the hollow organ 12. This device allows you to: less traumatic intubation of the intestine, manually adjust and advance the tip of the probe in the lumen of the gastrointestinal tract laparoscopically, overcoming bends of a hollow organ, to avoid complications, it is convenient and simple in technical design.

The method using the device is as follows.

The patient is in a supine position on the operating table under endotracheal anesthesia. After the introduction of the 1st trocar according to the Hasson method, for example, above the navel, at the level of carboxypneumoperitoneum 10-12 mm Hg. Art. start laparoscopy. In the absence of contraindications to the continuation of the operation, endovideosurgery (for example, visualized necrotized gut), indications for nasointestinal intubation, as well as with the aim of improving the review of the abdominal organs and performing an adequate revision, for example, in the right side of the abdomen, a second 10 mm plastic trocar is introduced for a laparoscopic magnetic instrument, the 3rd trocar, for example, in the left hypochondrium or left side of the abdomen (for endoscopic Babcock clamp). The places of introduction of trocars, the location of instruments can be individual, and depend on clinical and instrumental data. First, a metal conductor 2, lubricated with, for example, Vaseline, coated with a sliding coating, with a rigid main part and a flexible curved tip to the mounted magnet 3, is introduced into the probe. Then the anesthesiologist, on the command of the surgeon, conducts a probe 1 lubricated with Vaseline with a conductor 2 into the stomach through the nose. A laparoscopic magnetic instrument is inserted into the abdominal cavity through a 10 mm plastic trocar (Fig. 3, 4). After introducing 1 m of the probe into the stomach, the tip of the latter is quickly found using a laparoscopic magnetic instrument by the characteristic attraction through the wall of the stomach to the distal magnet of the probe 4. As the instrument approaches, due to its exceeding attractive force of the permanent magnet 9, the distal magnet 4 is attracted, this olive turns to form a “dumbbell” (Fig. 5, 6), allowing less traumatic intubation of the intestine, manually adjusting and promoting the tip of the probe in the lumen of the gastrointestinal tract laparoscopically, overcoming bending the hollow organ without complications. After this, while synchronizing the probe advancement with the conductor by the anesthesiologist and manually correcting the position, the tip of the probe 4 is advanced with a magnetic tool along the front wall of the stomach, the upper horizontal, descending part of the duodenum 12, then the transverse colon is pulled upwards with endocissus, and the laparoscopic magnetic instrument is pulled upward. - of the horizontal part 12 of the duodenum, the distal magnet of the probe is also attracted through its front wall, while feeding the probe with a conductor from the outside, continue the probe tip is moved along the walls of the hollow organ by the duodenum unique bend by 10-15 cm. Further, the probe tip is moved through the wall of the small intestine with a synchronous feeding of the probe with a conductor by an anesthesiologist, if necessary, intercepting the wall of the small intestine with endoconstriction of Babcock is technically simple laparoscopic intubation of the small intestine to the required level, spending less time. After fixing the tip of the probe, such as an endoscopic Babcock clamp, the conductor is removed. Evacuating the intestinal contents, through an established nasointestinal probe under the control of a laparoscope, improve the overview of the abdominal organs, conduct an audit, and in the absence of indications for conversion, the subsequent stages of the operation are performed.

If necessary, with a thinned wall of a hollow organ, a laparoscopic magnetic instrument can be replaced with a similar one, with a magnet having a lower height, i.e. with less attractive force, for example from 10 mm to 2 mm.

Clinical example

Patient K., 56 years old, was urgently admitted to the surgical department 10 hours after the onset of the disease. Upon admission, he complained of moderate constant pain in the epigastrium, nausea, twice vomiting with bile, without pathological impurities. From the anamnesis: considers himself sick for 10 hours, when, after errors in the diet, abdominal pain suddenly appeared. Previously, there were similar pains in history. I did not seek medical help. He took no-shpu with little relief. In connection with the preservation of pain, he sought medical help. From the anamnesis of life: Acute cerebrovascular accident 10 years ago, observed by a neurologist at the place of residence, takes aspirin 75 mg orally at night. Other chronic diseases categorically denied. Postponed operations: at the age of 19, while serving in the Soviet army, herniation for a left-sided inguinal hernia (which method he cannot say). General condition of moderate severity. Consciousness is clear. The skin is of normal color. HELL 120/60 mm RT. Art., pulse 80 beats / min, temperature 36.6 ° C. Vesicular breathing, no wheezing. Heart tones are rhythmic. The tongue is wet, coated with a white coating. In the left inguinal region there is a postoperative scar measuring 10 × 0.3 cm, soft, painless, mobile, of normal color. Hernial protrusions were not detected. The abdomen is symmetrical, slightly swollen, participates in the act of breathing, and is mild and painful in the epigastrium. There are no symptoms of peritoneal irritation. Appendicular, symptoms of Kera, Ortner, Voskresensky negative. Liver, spleen, kidneys are not enlarged. Peristalsis is heard, there is no “splash” noise. Pasternatsky’s symptom is negative on both sides. The chair was on the eve of normal coloring, without impurities. Gases depart. Constipation does not bother. Diuresis sufficient, painless, urine of normal color. Per rectum: the perianal region is not changed, stools of normal color, overhang, soreness of the walls, pathological neoplasms were not detected. The sphincter tone is normal. At the admission department, he was examined by a therapist: no therapeutic pathology was detected, examined by a neurologist, conclusion: at the time of examination, there was no evidence of acute cerebrovascular accident. OAK, OAM, ECG are within normal limits. Blood amylase 120 IU / l, other biochemical parameters are normal. Fibrogastroduodenoscopy was performed, conclusion: gastroduodenitis, ultrasound of the abdominal organs: hepatobiliary system, kidneys without pathological changes, free fluid, cavity-volume formations were not detected. On radiography of the abdominal organs: there is no free gas, there are single, insignificant small intestinal levels in the projection of the mesogastrium. Against the background of intramuscular administration of antispasmodics in the receiving department, abdominal pain did not stop. The patient was hospitalized in the surgical department with a diagnosis of acute pancreatitis. In the department, the patient received conservative treatment: infusion, analgesic, antispasmodic therapy, protease inhibitors, quamatel, observation. 1.5 hours after hospitalization during therapy, the patient's condition worsened. They began to disturb constant intense pain throughout the abdomen, more in the lower sections. Nausea, no vomiting. General condition of moderate severity. Consciousness is clear. The skin is of normal color. HELL 110/60 mm RT. Art., pulse 82 beats / min, temperature 36.6 C. The vesicular breathing, no wheezing. Heart tones are rhythmic. The tongue is wet, coated with a white coating. The abdomen is symmetrical, swollen, the lower half of the abdomen is limitedly involved in the act of breathing, with palpation it is slightly strained in the meso-hypogastrium, painful in all parts of the abdomen, more in hypogastrium. Doubtful symptoms of peritoneal irritation are also determined there. Appendicular symptoms are also dubious. Symptoms of Kera, Ortner, Voskresensky are negative. There are no hernial protrusions. Liver, spleen, kidneys are not enlarged. Intestinal motility is active, there is no “splash” noise. Pasternatsky’s symptom is negative on both sides. In the department there was a “mushy” stool of usual color, without impurities. Gases depart. Diuresis is sufficient. On repeated radiography of the abdominal organs, the number and size of the small intestine levels increased. The patient had a clinic of abdominal distress. Therefore, in order to clarify the diagnosis and determine further tactics, indications were made for laparoscopy, with a further decision of the course of the operation intraoperatively. Examined by related specialists, there are no contraindications. Patient consent is obtained.

In the position of the patient on his back under conditions of endotracheal anesthesia, the first trocar above the navel, at the level of carboxypnevoperitoneum 10-12 mm Hg, was introduced using the Hasson technique openly. Art. laparoscopy started. Surveillance laparoscopy showed a serous effusion of about 100 ml in the lateral canals, swollen loops of the small intestine up to 4 cm in diameter, slightly hyperemic, satisfactory motility, with a shiny peritoneum, without plaque of fibrin. The appendix is not visualized. The ileum in the ileocecal angle was reduced. In the small pelvis, the loops of the small intestine are fixed. A full-fledged detailed revision of the abdominal organs due to the swollen loops of the small intestine is impossible. Therefore, in order to improve the review of the abdominal organs and perform an adequate audit, it was decided to perform laparoscopic intubation of the small intestine with emptying the contents. For this, a second 10 mm plastic trocar for a laparoscopic magnetic instrument and a third trocar in the left side region for an endoscopic Babcock clamp were introduced in the right lateral abdominal region. An anesthetist introduced a pre-lubricated probe 1 with a conductor 2 into the stomach through the nose. A laparoscopic magnetic instrument was inserted into the abdominal cavity through a 10 mm plastic trocar (Figs. 3, 4). After introducing 1 m of the probe into the stomach, the tip of the latter was quickly detected using a laparoscopic magnetic instrument by the characteristic attraction of the probe 4 through the wall of the stomach to the distal magnet of the probe. After that, while the probe was moving along with the conduit by an anesthesiologist and the position was manually adjusted by the surgeon, the probe tip 4 was moved with the magnetic tool along the front the walls of the stomach, the upper horizontal, descending part of the duodenum 12, then the endoconstriction of Babcock pulled the transverse colon upward, paw The roscopic magnetic instrument was brought to the lower horizontal part 12 of the duodenum, the distal probe magnet was also pulled through its front wall, while feeding the probe with a conductor from the outside, the tip of the probe was continued to move the probe tip along the walls of the hollow organ beyond the duodenum unique bend by 10-15 cm. the tip of the probe was advanced along the wall of the small intestine with simultaneous delivery of the probe with a guide by an anesthesiologist, intercepting the wall of the small intestine with endocrine clamp Babcock, intubating the intestine to that fixing the small bowel loops in the pelvis, spending little time. The tip of the probe was fixed with an endoscopic clamp of Babcock, then the conductor was removed. The intestinal contents were evacuated through an installed nasointestinal probe under the control of a laparoscope, improving the overview of the abdominal organs. A further audit of the abdominal organs revealed that the strand of the greater omentum was soldered to the inner inguinal ring on the left, while a loop of the ileum was wrapped around this strand of the greater omentum, blocking the lumen of the intestine and causing strangulated commissural small bowel obstruction. The underlying ileum was collapsed. The loop of the small intestine was deployed. The fusion between the strand of the greater omentum and the internal inguinal ring was dissected using ultrasound scissors. It was revealed that at a distance of 2 m from the cecum, the ileum loop had a strangulation furrow. After 10 minutes, the small intestine was re-evaluated: the strangulation groove was leveled, the color of the small intestine began to acquire a more physiological color, the intestine peristals, slept, with a shiny peritoneum, without fibrin, the pulsation of the direct vessels is satisfactory. The effusion is aspirated. With a further audit, the appendix is visualized - not changed. The inner inguinal ring on the left is not expanded, solid, on the right unchanged. Stomach, 12 n. K., retroperitoneal space, small and large omentum, colon are not changed. No other visible pathology was detected. The abdominal cavity was sanitized. Control for hemostasis, foreign bodies. Tools removed. Desufflation completed. Layered stitches for wounds. Iodine. Aseptic dressings for wounds.

Postoperative diagnosis: acute commissural strangulation small bowel obstruction.

In the postoperative period, infusion, antispasmodic, analgesic, antibiotic therapy, intestinal stimulation, probe care, and dressings were performed. The postoperative period was normal. On the 3rd day, the nasointestinal probe was removed. The patient was discharged without complications in satisfactory condition under the supervision of a surgeon at the place of residence.

Thus, the proposed method of laparoscopic intubation of the small intestine and a device for its implementation are cheap, simple in technical design, convenient to use, avoid complications, intubate in almost all clinical situations, control the position and advance the probe laparoscopically, simplify the process itself, reduce time spent on the intubation process.

Claims (2)

1. The method of laparoscopic intubation of the small intestine, including the introduction of a probe with a guide through the esophagus into the stomach, characterized in that a laparoscopic magnetic instrument is inserted into the abdominal cavity through the trocar, which is brought to the distal end of the probe with a magnet inserted into the stomach, while the laparoscopic instrument magnet they pull the distal magnet of the probe through the wall of the stomach, then simultaneously feed the probe with a conductor from the outside and advance the tip of the probe along the wall of the hollow organ beyond the duodenum ny bend. 2. A set for laparoscopic intubation of the small intestine, consisting of a probe with a conductor and a magnetic instrument, while a circular proximal permanent magnet is mounted in the distal end of the probe, with a through channel in the center, connected to the distal round permanent magnet by a nylon filament, while the distal the magnet on the thread is fixed, and at the other end of the thread a proximal magnet movement limiter is fixed; The laparoscopic magnetic instrument is made in the form of a tube plugged at both ends with stainless steel inserts, with one or two magnets with rounded edges mounted at the ends of the tube.

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