usisxlo RviZlis modelis Fformireba in vivo eqsperimentSi

b. mosiZe, k. kupreiSvili, d. miqelaZe

 qirurgiis erovnuli centri, Tbilisi

 

 

RviZlis keTilTvisebiani da avTvisebiani simsivneebi miekuTvneba farTod gavrcelebul daavadebaTa ricxvs da maT uwodeben progresisa da civilizaciis daavadebas. masStaburi qirurgiuli HCarevebi RviZlze misi onkopaTologiis dros dResac did riskTan  aris dakavSirebuli.  maRali rCeba  sikvdilianoba intra- da postoperaciul periodSi, rac ganpirobebulia rogorc masiuri operaciuli travmiT da didi moculobiT sisxlis kargviT, aseve operaciis Semdgom periodSi aRmocenebuli specifiuri GgarTulebebiT. aqedan Ggamomdinare, literaturaSi moyvanilia sxvadasxva araerTgvarovani, xSirad urTierT sawinaaRmdego  rekomendaciebi, rac aucilebels xdis aRniSnul problemisadmi mecnieruli midgomis GganviTarebasa da daxvewas (1, 2, 3).

        teqnikis Ggaumjobesebam hepatobiliarul qirurgiasa da RviZlis transplantaciaSi SesaZlebeli Ggaxada operaciebis warmoeba RviZlis sruli GgamoTiSviT sisxlis mimoqcevidan intraoperaciuli porto-kavaluri veno--venozuri  Suntirebis da calmxrivi mimarTulebis pompis GgamoyenebiT. biologiis dargSi miRwevebma ki saSualeba mogvca SevinarCunod RviZlis sicocxlisunarianoba xangrZlivi periodis (8-12sT) ganmavlobaSi misi hipoTermuli perfuziis saSualebiT. aRniSnulma miRwevebma qirurgiasa da biologiaSi Gganapiroba RviZlis rezeqciuli meTodikebis axali tipebis SemuSaveba da e.w. "mSral organoze" radikaluri Carevebis warmoeba iseTi zomis da lokalizaciis simsivneebze, romlebic aqamde inoperabelurad iTvlebodnen (4, 5).

         arsebul literaturul monacemebze dayrdnobiT HCvens mier Gganxorcielebul iqna in vivo sisxlis mimoqcevidan GgamorTuli RviZlis modelis formirebaze mimarTuli eqsperimentuli kvleva, romelSic dasaxul iqna Semdegi miznebi:

1.      optimaluri porto-kavaluri Suntis formireba calmxrivad Ggamtari pompis Ggamoyenebis GgareSe;

2.     RviZlis karis elementebisa da kavaluri segmentis minimaluri travmireba;

3.     operaciis xangrZlivobis, sisxldenis moculobis da GgarTulebebis minimumamde dayvana.

eqsperimentebi Catarda orive sqesis 7 ujiSo ZaRlze. zogadi gautkivarebis qveS rio_brankos ganakveTid muclis Rrus gaxsnis Semdeg Tanmimdevrulad tardeboda Semdegi manipulaciebi:

1.   RviZlis gamorTva sisxlis mimoqcevidan SemovliTi Suntirebis gziT;

2. RviZlis konservacia;

3.  uSualo Careva parenqimaze da RviZlSida sisxlZarRvebze;

4.  organos revaskularizacia.

RviZlis gamoTiSva sisxlis mimoqcevidan xorcieldeboda SemovliTi Suntirebis gziT. amisaTvis Cvens mier Seqmnil iqna ramodenime saxesxvaobis Sunti (anatomiuri variaciebis gaTvaliswinebiT), romlis meSveobiT sisxli karis venidan da RviZlis arteriidan RviZlis SemovliT Caedineboda qvemo Rru venis im segmentSi, sadac mas ukavSirdebian marjvena da marcxena wilis venebi. aRniSnuli operaciis dros RviZlis arteriis, karis da qvemo Rru venis gadakveTa ar xdeba, aramed maT kedelze keTdeba 1_1,5 sm gaswvrivi ganakveTi Suntis boloebis Sesayvanad da dasafiqsireblad. paralelurad karis venidan iwyeba RviZlis hipoTermuli perfuzia henqsis xsnariT 40C temperaturaze. amisaTvis karis venaze arsebul ganakveTSi Suntis "portaluri" totis sawinaaRmdego mimarTulebiT vafiqsirebdiT meore mils, romelsac sterilur pirobebSi uerTdeboda sistema saperfuzio xsnariT.

RviZlis konservaciisTvis viyenebdiT yinuls da  40C – mde gagrilebul henqsis xsnars. sterilur paketebSi moTavsebuli yinuliT ifareba organos TiTqmis mTliani zedapiri, garda saoperacio arisa. amavdroulad xorcieldeba perfuzia henqsis hipoTermuli xsnariT 40C temperaturaze sufTa siTxis miRebamde. perfuziis sawyis etapze  RviZlis venebidan miRebuli sisxli sterilur pirobebSi ubrundeboda organizms antibiotikebTan da hepatoproteqtorebTan (arginini, hepamerci) erTad. in vivo operaciebis dros lokaluri hipoTermia da konservacia erT-erT mniSvnelovan problemad gvevlineba, radganac iqmneba realuri saSiSroeba sruliad organizmis hipoTermiisa. amis Tavidan asacileblad aucilebelia temperaturisa da gulis cemaTa sixSiris mudmivi  kontroli, RviZlis aris gulmodgine izolacia, raTa civi xsnari ar CaiRvaros muclis Rrus sxva nawilebSi, xolo yinuli ar imyofebodes uSualo kontaqtSi ZiriTad nervul wnulebTan.

parenqimaze uSualo Careva xorcieldeba RviZlis sisxlis mimoqcevidan gamoTiSvis da konservaciis Semdeg "anatomiuri rezeqciebis" saxiT, romlebic emyarebian Cuinaud mier mowodebul RviZlis segmentaluri agebulebis principebs. Cveni eqsperimentebi ar isaxavda miznad RviZlis simsivnis  modelirebas da maszed Carevebis warmoebas , amdenad am etabze pirobiTad xorcieldeboda RviZlis nebismieri wilidan parenqimis mniSvnelovani moculobiT amokveTa da "usisxlo" RviZlze mcire kalibris sisxlZarRvebis ligireba, ris Semdegac xorcieldeboda RviZlis Wrilobis aRdgena ketgutis nakerebiT.

revaskularizacia keTdeboda standartuli meTodikis gamoyenebiT: upirvelesad xorcieldeboda  RviZlis wilobrivi venebis , Semdeg ki karis venisa da RviZlis arteriis mTlianobis aRdgena; hemostazis da biliaruli sekreciis kontroli.

amrigad, Cvens mier SemuSavebul meTodikas gaaCnia rigi upiratesobebi dRemde arsebul analogiuri problemis gadasaWrelad mowodebul operaciebTan SedarebiT (RviZlis orTotopiuli transplantaciisaTvis SemuSavebuli meTodika, pixlmaieris operacia da sxva (3, 6)) : garda imisa, rom am SemTxvevaSi ar arsebobs mocilebis saSiSroeba da avadmyofi erTdroulad warmoadgens rogorc donors, aseve recipients, agreTve:

  1. minimumamde dayvanilia operaciis xangrZlivoba da      sisxlis danakargi.
  2. ar keTdeba qolecisteqtomia;
  3. ar ikveTeba naRvlis saerTo sadinari, riTac Tavidan vicilebT biliarul rekonstruqcias wvrili nawlavis maryuJis gamoyenebiT rus wesiT da amasTan dakavSirebul problemebs;
  4. gacilebiT naklebia RviZlis sakuTari arteriis postoperaciuli Trombozis ganviTarebis riski;
  5. ar xdeba arcerTi magistraluri sisxlZarRvis  gadakveTa, aramed keTdeba mxolod 1_1,5 sm gaswvrivi ganakveTi maT kedelze.
  6. intraoperaciuli SemovliTi Suntireba warmoebs calmxrivad gamtari ZviradRirebuli pompis gareSe;
  7. ar irRveva sisxlis pasaJi qvemo Rru venaSi.

 

 

 

 

literatura

 

  1. À. Í. Ñåâåðöåâ  è ñîàâò. Àóòîòðàíñïëàíòàöèÿ  ïå÷åíè â ëå÷åíèè åå î÷àãîâûõ ïîðàæåíèé. Õèðóðãèÿ, 2002; 1: 52-58
  2. Pichlmayr R., Grosse B., Hauss J. et al . Technique and preliminary results of extracorporeal liver surgery ( bench procedure ) and of surgery on the in situ perfused liver. Br J Surg 1990 ; 77: 21-26 
  3. Pichlmayr R., Rige B., Gubernatis G.  et al. Transplantacion einer Spenderleber auf zwei Empfanger (splitting - transplantacion ) Eine neue Methode in der  Weiferentwicklung  der Lebersegment – transplantacion. Langenbecks Arch  Chir . 1988; 373: 127-130
  4. Morino M., Meriggi F., Adam R., Bismuth H . Use of UW solution in the liver transplantation one year clinical results. Intensive care Med 1989; 15: A410
  5. Kumada K., Yamaoka Y., Morimoto T. et al.  Partial autotransplantation of the liver in hepatocellular carcinoma complicating cirrhosis. Br J Surg  1982; 79: 566-570  
  6. Hesselink E. J. et al. Hepatic artery thrombosis (HAT) after orthotopic  liver transplantation (OLT) the influence of technical factors and rejection episodes. Transplant Proc 1989; 21: 1pt2: 2468

 

 

 

 

 

 

The model of the “bloodless” liver in experiment in vivo

 

B. Mosidze, K. Kupreishvili, D. Mikeladze

National Centre of Surgery, Tbilisi

 

            The model of the “bloodless” liver in vivo has been established in our experiments. The surgery consists of the following stages :  1) cutting the liver of the general blob circulation by means of a roundabout shunting without using the one - way  pump;   2) conservation of the liver;   3) spontaneous intervention on the liver parenchyma;   4) revascularization.       

 

 

 

 

             

 

 

 

 

 

 

 

¹¹