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Hola mi nombre es Dr. Justin Chura y soy Director Asociado de
Ginecología Oncológica en el Centro Médico Crozer-Chester
en Uppland, Pennsylvania. Y hoy tengo el agrado de hablarles
sobre el Sistema de Cierre Seguro de puertos laparoscópicos "Carter - Thomason".
He usado este producto por este producto por varios años
puesto que satisface las necesidades de mis pacientes. El objetivo principal
del sistema de cierre laparoscópico es replicar un cierre efectivo,
asegurando que se captura efectivamente la fascia, el músculo y el peritoneo.
El cierre de los puertos laparoscópicos con pacientes delgados es relativamente fácil
pero con los pacientes más pesados u obesos es dificil estar seguro que estás
trabajando con la fascia
y que estas teniendo una buena porción de la fascia, no solo eso, sino también de todas las capas
fascia, músculo y peritoneo. Los problemas que puedes tener
son cerrar la fascia pero seguir teniendo un defecto en el peritoneo
que causa una Hernia de Richter. Por eso es un reto para los pacientes
obesos mas que para los pacientes delgados
nosotros cerramos cualquier puerto laparoscópico que sea más grande de un centímetro
porque es aquí donde el riesgo que se forme una hernia se convierte en significativo
Sin embargo cerrar un 5 mm - 8mm
que ha estado dentro y fuera del paciente múltiple veces, el puerto se ha aflojado
y parace suelto por exceso de mani[ulación pero generalmente no cierro estos puertos.
El Sistema "Carter-Thomason"consiste en
una guía piloto en forma de cono y un pasador de sutura
Los ángulos de la guía piloto aseguran la colocación precisa de la sutura
para resultados consistentes y repetitivos. Este sistema tiene dos formas de uso
incluyendo una versión de longitud extendida para pacientes extremadamente obesos
y pacientes bariátricos. Para el Sistema Carter Thomason lo que vamos ha hacer
es sacar el trócar y luego insertar la guía piloto
te das cuenta que en la guía piloto tiene
dos agujeros en la parte superior que sirven como guía cuando yo inserto el pasador
Salgo por la parte lateral de la punta del cono, esa dirección lateral ayuda a asegurar
que tenemos una ancha porción de la fascia, y sabemos esto porque estamos a un centimetro
de distancia de la punta de la guía
out trying to make sure that we're getting at least a good centimeter out
the factual tissue
and that also that includes muscle in Paraty medium so we're doing a true mass
closure
would deliver through one side we let go
and then we come back to our other pilot hole and take
and grab our suture with the other that can result in a good true mass closure
with a nice port closure
the benefits are doing it laparoscopically to we're gonna see the
poor closer site close
will also then palpate the port so site closure
to make sure it's close so look for any visible defects as well as any palpable
the fact
to ensure we've got a good closure here every move my poor
and I insert my pilot guidance my whole I keep my thumb over the holes as I do
that just a minute prepared to name doesn't drop down
TL take the introducer please once I'm in position
running introduce the states to one of our pilot died holes
you'll see that wanna come in here I come out nice and lateral there
and my assistant keep the needle in viewers you come in keep that you don't
view
we just keep a needle in view so we know where say I also know unsafe because I
have
plenty of exposure here sorry move that number to going through the opposite
side
is simply a nice wide by coming completely around
and now I'm just going to grab the other side %uh that's that's
and pull it through we remove the pilot died
holding on to both sutures and now what you can see isn't gonna close that
close this off by time I stepped down and you can see right away
that port side is closing up nicely
now that I've set my second not we have a nice
snug closer here
and so now we can see there's no palpable the fact is I probed the word
there's also no visible defects as we look at it in addition
we can hear there's no gas escaping so that also reassures me that we've got a
nice closure
why the key points the poor closure is
ideal for placement we try to make the ports perpendicular to the patient's
body
this when you can see tracks a little bit it's had some excessive talking
during the case
just related to the robotic arms pushing on it so because I
accessed working I'm gonna close this eight-millimeter port today
if there weren't that excess talking and might not close this one
so we're going to use the five car loan
which is the smaller size I remove my poor
an answer
the pilot guy rate in right into my
port opening I have the suture passer ready again with about 68 centimeters
and then introduce my first States through the pilot guy
you can see we're going and nice wide by there
on the pair 10 a.m. I system keeping in view although I know unsafe because I'm
a good name appears in EM
I have several centimeters between me and the ball I withdraw the passer
going through the opposite side he said there boo
and come back n wanna grab now that other suture
and pour it up and threw just as with that 12 millimeters system for we close
then
what I this down
and we'll be able to see our closure up above the 50 very nicely how that defect
is closing
really strange is that shot very nicely there
and again no defect that I can't help a no defect that we can see
no defect that we can hear so nice closure reports but as patients today
and that will allow me to sleep a little bit better at night knowing that I don't
have to worry about a port side hernia
from a teaching perspective if a resident has basic laproscopic skills
here she can learn it relatively quickly is also very simple and fast procedure
if I do it myself it takes less than 60 seconds at the end of the case
if I'm working with the resident and teaching maybe ninety seconds
finally and most importantly is very beneficial for patient outcomes
in using this system you are significantly reducing the risk reports
a
hernias and maybe even eliminating the risk especially the acute hernia
which is the most dangerous do
I'm