RU2628060C1 - Conductor catheter for laser adenotomy with transoral access, set of conductor catheters and method for laser adenotomy with transoral access - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: conductor catheter for laser adenotomy by transoral access is made in the form of a rubber tube with Shore A-120 hardness, which is curved along the anatomical structure of the nasopharynx and has a straight working end of 10-40 mm, oriented at an angle of 85-145° to its longitudinal axis. The end part of the working end is designed to guide and position the surgical laser light guide at the pole of the nasopharyngeal tonsil. A set of conductor catheters for laser adenotomy by transoral access, containing three catheter-conductors intended for the lower, middle or upper poles of the nasopharyngeal tonsil, is developed. The method for laser adenotomy by transoral access involves laser vaporization of adenoid vegetations, with lymphoid tissue being removed from the bottom up using a set of developed conductor catheters.

EFFECT: possibility of laser radiation delivery to the nasopharyngeal tonsil by a transoral route, laser vaporization of the adenoid tissue from hard-to-reach areas.

8 cl, 1 dwg

Description

The group of inventions relates to medicine, in particular to otorhinolaryngology, and can be used in the treatment of patients with chronic adenoiditis and hypertrophy of the nasopharyngeal tonsil.

Adenoid vegetation is one of the most common pathologies of the upper respiratory tract in children. According to the literature, adenoids are not uncommon in adults. Adenotomy is the most common operation in pediatric otorhinolaryngology. In recent years, there has been an increase in the number of adenotomy in the adult patient population.

There are many methods for performing adenotomy:

• Classical adenotomy (Beckman adenotomy and its modifications)

• Shaver adenotomy

• Vacuum adenotomy

• Ultrasonic dispersion of the pharyngeal tonsil

• Diathermocoagulation

• Electrocautery adenotomy

• Cold plasma adenotomy

• Laser adenotomy (KTP-, neodymium laser)

Of the many lasers in otorhinolaryngology, CO ₂ (carbon dioxide), Nd: YAG (neodymium) and Ho: YAG (holmium) lasers are predominantly used. Adenotomy using a holmium (Ho: YAG) laser is one of the most rational and justified methods of surgical treatment of chronic adenoiditis and hypertrophy of the nasopharyngeal tonsil. We can say that a holmium laser combines the advantages of a neodymium and CO ₂ laser, and at the same time it is free from their disadvantages.

The literature describes various methods of laser treatment of adenoid vegetation (Method for the treatment of pharyngeal tonsil hypertrophy with laser destruction, S. Korenchenko, application for invention: 94003925/14, 02.02.1994; Method for the treatment of adenoid vegetation, Ageeva S. A., Armichev A. V., Eliseenko V.I., Kutovoy BC, Minaev V.P., RU 2242947). In the presented methods, the laser fiber was fed to the adenoid tissue through the nasal cavity.

With massive proliferation of lymphoid tissue in the nasopharyngeal arch, the area of the mouth of the auditory tube, in addition to the endonasal approach, we suggest using a laser conductor through the oropharynx. However, the quartz conductor of a holmium laser tends to straighten when bent.

In practical otorhinolaryngology, there are ear catheters for the Eustachian tube according to Hartmann (TP Mchelidze, Otorhinolaryngological Dictionary. 2007, St. Petersburg, p. 123), which are a cylindrical tube 15-18 cm long, one end of which is expanded in the form of a socket, and the other bent at an angle of 140-150 ° and has the shape of a rounded beak. Catheters of various lumen widths from 1 to 3 mm and wall thicknesses from 0.5 to 1 mm are available. This catheter could serve as a conductor for a holmium laser fiber, but the bending angle of the latter and the length of the distal end do not correspond to the anatomical structure of the nasopharynx.

In connection with the foregoing, we were tasked with the development of a catheter guidewire for a holmium laser fiber, which allows for an adenotomy using the transoral approach.

Achieved during the implementation of the group of inventions developed by us, the technical result is the possibility of delivering laser radiation to the nasopharyngeal tonsil by the transoral route, performing laser vaporization of adenoid tissue from hard-to-reach areas of the nasopharynx (nasopharynx arch, region of the mouth of the auditory tube, opener).

When performing laser vaporization of the nasopharyngeal tonsil by the transoral route, a set of catheters-guides allows you to deliver the laser beam to the adenoids, which runs along a tangent parallel to the posterior wall of the nasopharynx. This circumstance prevents excessive trauma to the posterior wall of the nasopharynx and underlying structures (prevertebral fascia, cervical vertebrae). This circumstance necessitates the vaporization of adenoid tissue from the lower pole towards the upper pole of the nasopharyngeal tonsil.

The catheter itself performs two functions: 1 - the function of the conductor; 2 - the function of the smoke aspirator, which is formed in the field of surgical intervention during laser vaporization of adenoid tissue. This possibility is due to the connection of the proximal end of the catheter guide to the vacuum tube.

Visual control of surgical intervention is carried out by introducing an endoscope through the nasal cavity. Thus, transoral delivery of laser radiation has an advantage over transnasal, as the endoscope inserted into the nose does not interfere with the manipulation of the laser.

The catheter guide developed by us for transoral access laser adenotomy has an optimal shape that allows performing surgical treatment in hard-to-reach areas of the nasopharynx. As a result of a vector study of computed tomograms of 90 patients with II-III degree adenoid vegetation, the optimal angles of bending of the catheter guidewire were determined to guide the fiber to the lower, middle and upper poles of the nasopharyngeal tonsil, as well as the optimal length of the distal end of the catheter guidewire.

The catheter guide for laser adenotomy by transoral access (Fig. 1) is made in the form of a tube of rubber with Shore hardness A-120, which is curved along the anatomical structure of the nasopharynx. Such parameters of rubber hardness (A-120) make it possible to straighten a catheter guidewire for introducing a laser fiber, after which the catheter guidewire returns to its original shape. The catheter guide has a straight working end with a length of 10-40 mm, oriented at an angle of 85-145 ° to the longitudinal axis of the tube. The end face of the working end is made to summarize and position the Ho: YAG laser fiber at the pole of the nasopharyngeal tonsil.

The catheter guide can have a straight length of 150 mm from the end of the non-working end to the bend. It is advisable to carry out its pipe from silicone rubber.

The catheter guide developed by us can be made in the following versions, depending on the anatomical region, for which it is planned to be used to bring it:

- the direct working end of the tube with a length of 20 mm is oriented to its longitudinal axis at an angle of 130 °, while the end of the working end is made to summarize and position the fiber at the lower pole of the nasopharyngeal tonsil (Fig. 1a).

- the direct working end of the tube 25 mm long is oriented to its longitudinal axis at an angle of 115 °, while the end of the working end is made for summing and positioning the fiber at the middle pole of the nasopharyngeal tonsil (Fig. 1b).

- the straight working end of the tube with a length of 30 mm is oriented toward its longitudinal axis at an angle of 90 °, while the end of the working end is made to summarize and position the fiber at the upper pole of the nasopharyngeal tonsil (Fig. 1c).

The figure 1 shows a catheter guide for laser adenotomy by transoral access:

1 - the proximal end of the catheter guide, an outer diameter of 8 mm, an inner diameter of 4 mm;

2 - amplifier node from the catheter to the vacuum tube;

3 - catheter guide for laser adenotomy by transoral access;

4 - bend 90 °, 115 ° and 130 ° in the distal end of the catheter at a distance of 150 mm, facing up;

5 - the distal end of the catheter guide;

6 - catheter diameter 3 mm.

When performing laser adenotomy with transoral access, it is optimal to use a kit containing three catheter guides designed for the lower, middle or upper poles of the nasopharyngeal tonsil.

Laser adenotomy with transoral access using the device we developed is as follows.

Operation progress:

1. Anesthesia

• Local anesthesia (Sol. Lidocaini 10% - 1.0 ml - application on turunds before surgery, Sol. Lidocaini 1% - 5.0 - infiltration) - the patient is sitting in a chair or lying on an operating table with a raised head end;

• Combined endotracheal anesthesia (KETN) + local anesthesia (Sol. Lidocaini 1% - 5.0 - infiltration) - the patient's position lying on the operating table with a raised head end.

After putting into anesthesia and intubation of the trachea with the installation of a conservator using a long needle under the control of an operating endoscope of 0 °, local anesthesia of Sol is performed endonasally. Lidocaini 1% - 5.0 - infiltration into the area of adenoid vegetation. During surgical intervention under local anesthesia, Turunds with Sol are pre-installed in both halves of the nose. Lidocaini 10% - 1.0 ml + Sol. Adrenalini 1.0 ml. With turundas in the nose, the patient is served in the operating room. Further, local anesthesia is performed in the operating room after removal of the turundum from the nasal cavity according to the standard scheme described above.

2. Laser vaporization of adenoid vegetation

Under the control of an operating endoscope 0 ° endonasally, using a Ho: YAG laser beam transorally delivered via a catheter guide with an aspiration system, hypertrophied lymphoid tissue is vaporized from a nasopharyngeal arch by means of a point remote action on adenoid vegetation. First, a catheter guide is used, bent at 130, then at 115 and 90, thereby phasing out the lymphoid tissue from the bottom up. After vaporization of the hypertrophic lymphoid tissue from the nasopharyngeal arch using an operating endoscope of 0 °, the nasopharyngeal arch is examined for bleeding. When visualizing foci of bleeding from the nasopharyngeal arch, a coagulation of the foci of bleeding is also performed using a holmium laser beam, thereby “sealing” the blood vessels, which is intraoperative prophylaxis of bleeding in the early and delayed postoperative period.

We tested the use of a catheter in 33 patients with hypertrophy of grade II-III adenoids from 18 to 42 years old.

Claims (11)

1. A catheter guide for laser adenotomy by transoral access, made in the form of a tube of rubber with a shore hardness of A-120, which is curved along the anatomical structure of the nasopharynx and has a straight working end 10-40 mm long, oriented at an angle of 85-145 ° to its longitudinal axis, while the end of the working end is made to summarize and position the fiber of the surgical laser at the pole of the nasopharyngeal tonsil. 2. A catheter guide according to claim 1, characterized in that the straight working end of the tube with a length of 20 mm is oriented to its longitudinal axis at an angle of 130 °, while the end of the working end is made to bring and position the fiber at the lower pole of the nasopharyngeal tonsil. 3. A catheter guide according to claim 1, characterized in that the straight working end of the tube 25 mm long is oriented to its longitudinal axis at an angle of 115 °, while the end of the working end is made to bring and position the fiber at the middle pole of the nasopharyngeal tonsil. 4. The catheter guide according to claim 1, characterized in that the straight working end of the tube 30 mm long is oriented to its longitudinal axis at an angle of 90 °, while the end of the working end is made to bring and position the fiber at the upper pole of the nasopharyngeal tonsil. 5. The catheter guide according to claim 1, characterized in that the length of its straight section from the end of the non-working end to the bend is 150 mm. 6. The catheter guide according to claim 1, characterized in that it is made in the form of a tube of silicone rubber. 7. A set of catheters-guides for laser adenotomy by transoral access, containing three catheters-guides designed for the lower, middle or upper poles of the nasopharyngeal tonsil, and the catheter guide is made in the form of a tube of rubber with a shore hardness of A-120, which is curved along the anatomical structure of the nasopharynx and has a direct working end oriented at an angle to its longitudinal axis, the end of the working end is made to summarize and position the laser fiber at the corresponding pole of the nasopharyngeal almond us, moreover, for the lower pole of the nasopharyngeal tonsil, the tube has a direct working end with a length of 20 mm, oriented at an angle of 130 ° to its longitudinal axis, the end of the working end is made for summing and positioning the laser fiber at the lower pole of the nasopharyngeal tonsil; for the middle pole of the nasopharyngeal tonsil, the tube has a direct working end with a length of 25 mm, oriented at an angle of 115 ° to its longitudinal axis, the end of the working end is made to summarize and position the laser fiber at the middle pole of the nasopharyngeal tonsil; for the upper pole of the nasopharyngeal tonsil, the tube has a straight working end with a length of 30 mm, oriented at an angle of 90 ° to its longitudinal axis, the end of the working end is made to summarize and position the laser fiber at the upper pole of the nasopharyngeal tonsil. 8. A method for performing laser adenotomy by transoral access, including laser vaporization of adenoid vegetation, wherein the lymphoid tissue is removed from the bottom up using a set of catheters-guides according to claim 7.

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