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[Abstract] Objective: To investigate the clinical effect of incision protector in laparoscopic colorectal cancer resection. Methods: 32 cases of colorectal cancer were assisted with small incision and incision protector during laparoscopic surgery. After the auxiliary small incision is cut layer by layer into the abdominal cavity, first put the fixed ring of the incision protective sleeve generator into the abdominal cavity through the small incision, the fixed ring will automatically open and return to circular, then continuously turn over the traction ring and wind the silicone film sleeve to tighten it until the incision protective sleeve generator is fixed around the auxiliary small incision. Results: under the auxiliary incision, the overall exposure of the surgical field was good, and there was no need for an assistant to pull the surgical incision. The length of auxiliary incision was 4.0 ~ 6.5cm, with an average of 4.5cm. After operation, 32 auxiliary incisions healed in one stage without incision infection. The hospital stay ranged from 7 to 16 days, with an average of 8 days. 32 cases were followed up for 3 ~ 12 months. There was no tumor implantation and metastasis through auxiliary surgical incision and operation hole. Conclusion: the incision protective sleeve generator is simple to use and provides good protection for the incision; The surgical incision can be opened automatically without an assistant pulling with a retractor; The steps of intestinal tube removal and disconnection in laparoscopic colorectal surgery are optimized, which has a good development and application prospect. Laparoscopic colorectal tumor resection has been gradually becoming the preferred operation for colorectal surgery in Japan, Europe, Korea, China and Hongkong and other developed countries and regions because of its small trauma, less pain, quick recovery, and the same radical effect and open surgery. Chinese mainland is also developing vigorously. The issue of incision tumor implantation after laparoscopic surgery is the focus of debate in laparoscopic colorectal cancer surgery. In order to better prevent the planting of tumor cells in the surgical incision and the pollution of bacteria to the incision, and greatly reduce the length of the auxiliary incision, the incision protective sleeve creator was used in 32 cases of laparoscopic assisted small incision colorectal cancer surgery from March 2006 to March 2007, and satisfactory results were obtained. The report is as follows.
1、 Clinical data and methods:
1. General information:
There were 32 cases, 19 males and 13 females. The age ranged from 33 to 72 years, with an average of 55.5 years. 32 cases had no history of abdominal surgery. All patients were diagnosed by fibrocolonoscopy and pathological biopsy before admission, and multiple cancers were excluded. There were 3 cases of blind cancer, 3 cases of ascending colon cancer, 1 case of hepatic flexure of colon, 1 case of adenomatous polyp canceration of transverse colon, 1 case of splenic flexure of colon, 2 cases of descending colon cancer, 9 cases of sigmoid colon cancer, 4 cases of villous adenoma canceration of sigmoid colon and 8 cases of rectal cancer. No organ metastasis was found by abdominal B-ultrasound, CT and chest X-ray.
2. Method:
2.1 incision protective sleeve creator. The instrument is composed of upper and lower rubber rings and silica gel film connected between the two rings. The white one on the upper side is the pull ring and the green one on the lower side is the fixed ring. It is an American applied medical product. The diameter of S-type traction ring and fixation ring is about 9.0CM, and the diameter of automatic exposure wound is about 4.0 ~ 7.0cm; The diameter of M-type traction ring and fixation ring is about 13.0cm, and the diameter of automatic exposure wound is about 5.0 ~ 11.0cm (Fig. 2). These two models can meet the requirements that most of the resected intestinal tubes can be raised from the abdominal cavity to the outside of the abdominal wall.
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2.2 operation method: endotracheal intubation and general anesthesia. For right colon cancer, the head is low and the feet are high in the left oblique supine position. For left colon cancer, the head is low and the feet are high in the right oblique supine position, and the five hole method is used. First, take the subumbilical longitudinal incision of 1.5 ~ 2.0cm, enter the abdominal cavity with a fully open method, insert trocar, establish an pneumoperitoneum of 12mm Hg (1mm Hg = 0.133 kPa), and place the laparoscope. Under the microscope, 5mm and 10mm trocar are selected to puncture into the abdominal cavity in the left lower abdomen and right lower abdomen. 10mm trocar is selected for the right hand operation hole of general operators and assistants to facilitate the smooth insertion of instruments with large diameter such as ultrasonic knife or LigaSure. Laparoscopic tissue dissociation was mainly completed by electric shovel and ultrasonic scalpel, and Hem-o-lok vascular clamp was used for main blood vessels. After the intestinal segment to be resected is fully free and lymph node dissection is completed, an appropriate position is selected for abdominal wall auxiliary incision. The auxiliary incision for radical resection of right colon and transverse colon cancer is the midline incision around the umbilicus. This incision is formed by extending the subumbilical incision with the lens trocar, without additional incision on the right or left abdominal wall. For left hemicolectomy, the left middle and upper abdomen through rectus abdominis incision is selected, and for sigmoid colectomy, Dixon and Milles, the left lower abdomen through rectus abdominis longitudinal incision or transverse incision is selected, The incision is 4.0 ~ 6.5cm long. After the auxiliary incision position is determined and cut into the abdominal cavity, install the incision protective sleeve generator:
① Pinch the circular elastic fixing ring (inner ring) of the surgical incision protective sleeve creator by hand, compress it into an oval shape, and put it into the abdominal cavity through the incision, and the elastic fixing ring will automatically open and return to a circular shape; ② Turn the pull ring (outer ring) and wind the silicone film sleeve to tighten it. The outer surface of the silicone film sleeve is attached to the incision and the skin around the incision respectively. At this time, the fixed ring is closely attached to the parietal peritoneum, while the pull ring is close to the skin surface around the incision, so as to completely isolate the operating field from the incision and skin. After the operation outside the abdominal cavity, return the intestinal tube to the abdominal cavity, put a sterile glove on the traction ring, turn over the traction ring, and wind the glove on the traction ring until it is fixed on the abdominal wall skin. At this time, continue pneumoperitoneum, perform laparoscopic intestinal anastomosis or check, flush the abdominal cavity, indwelling the drainage tube, etc. Suturing auxiliary small incision adopts absorbable suture for subcutaneous knotting or continuous suture without postoperative suture removal.
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2、 Results:
Laparoscopic assisted surgery was successful without conversion to laparotomy. The length of the auxiliary incision was 4.0 ~ 6.5cm, with an average of 4.5cm. The overall visual field under the auxiliary incision was well exposed, and there was no need for an assistant to pull the incision. The operation time was 150 ~ 240 min, with an average of 160 min. The bleeding was 40 ~ 100ml, with an average of 60ml. All the auxiliary incisions healed in one stage, and there were no complications such as incision infection and effusion under the incision. The hospital stay ranged from 7 to 16 days, with an average of 8 days. All resected specimens underwent pathological examination. Postoperative TNM staging included 6 cases in stage I, 19 cases in stage II and 7 cases in stage III. There was no abnormality in eating and defecation after operation, the body temperature was normal, and the surgical incision healed well. They were transferred to the oncology department for chemotherapy according to their personal conditions. 32 cases were followed up for 3 ~ 12 months. There was no tumor implantation and metastasis through auxiliary surgical incision and operation hole.
3、 Discussion:
At present, most domestic doctors use various sterilized plastic bags to protect the incision during laparoscopic gastrointestinal surgery. Although it is simple, it does not have the function of automatically exposing the wound. An assistant needs to pull the surgical incision with a retractor to expose it, so as to carry out operations such as raising the intestinal tube; In addition, the plastic bag can not close the auxiliary incision, so the pneumoperitoneum laparoscopic operation can not be continued. If the laparoscopic operation is required, the auxiliary incision must be sutured first. Hand aids are also used in China to give consideration to incision protection, but the incision is large and expensive.
The incision protective sleeve creator has the following characteristics: ① the upper and lower elastic rings are made of rubber material, and the middle film is made of silica gel, which has the advantages of non-toxic, no residue and harmless to human body. The overall structure design is simple and easy to use and operate. ② Because the silica gel film has no permeability and the elastic rubber ring can be closely attached to the parietal peritoneum, it can effectively prevent the tumor cells in the abdominal cavity from falling off and planting on the surgical incision during the operation, so as to avoid the implanted tumor recurrence of the surgical incision. In addition, it can also avoid the bacterial pollution of the incision, and provide a safe, sterile The tumor free surgical environment fully protects the surgical incision. ③ Because the silicone film is smooth, the tissue damage caused by stimulation, drying and traction of incision skin and adipose tissue during operation is avoided, and the incision is protected. ④ The rubber ring has good elasticity and strong deformability. After being flattened by hand, it is easy to enter the abdominal cavity through a small surgical incision, and then rely on its own elasticity to restore to a circle to support the abdominal wall, which plays the role of abdominal wall retractor. The rubber ring has soft supporting force and does not damage the tissue. It can fully expose the operating field and does not need an assistant to pull the incision, making the operation convenient. In addition, the trocar selected in this group of operations is provided with threads, which is not only conducive to fixing the trocar on the abdominal wall, but also can prevent its detachment and movement. The frequent detachment and movement of trocar is related to the tumor implantation of puncture hole. When we use the incision protective cover creator, the average length of the auxiliary incision is 4.5cm. Although the auxiliary incision is small, the pulling force of the incision protective cover creator to the surrounding is uniform and continuous, coupled with the supporting role of its fixing ring and pulling ring, the overall exposure of the surgical area is good, and the surgical incision can be opened automatically without a hook. In addition, a sterile glove can be sleeved on the traction ring, and the traction ring can be turned over. The glove can be wound on the traction ring until it is fixed on the abdominal wall skin. At this time, the abdominal cavity is closed, and the pneumoperitoneum can continue to be operated under the microscope.
When endo GIA is used to cut the intestinal canal in the abdominal cavity, if the intestinal canal is thick, multiple nail clips are often required, which is complex, time-consuming and expensive. In this group, two patients put a sterile glove on the outer ring (pull ring) of the surgical incision protective cover creator, cut a small opening on one finger of the sterile glove, put the arc cutting suture (kaitu) through the small opening and the surgical incision protective cover creator, and then bind the gap between the glove and kaitu with silk thread. At this time, the abdominal cavity is basically closed and pneumoperitoneum can continue, When the intestinal tube is fixed in kaitu under laparoscopy, the intestinal tube can be completely cut at one time, reducing the application of intraluminal cutting suture device and saving operation cost.
The application of incision protective sleeve creator optimizes the steps of intestinal disconnection and removal in laparoscopic colorectal surgery, which not only protects the wound, but also reduces the wound, and the cost is low, which makes laparoscopic colorectal surgery more complete and has a good application prospect.