RU2145807C1 - Method of surgical treatment of peritonitis in children - Google Patents

Abstract

FIELD: medicine, pediatric surgery. SUBSTANCE: method includes primary sanitation videolaparoscopy. To introduce laparoscope, use is made of incision 3-4 cm above umbilical hollow and 4-5 cm to left from white line. Introduction of trochar for manipulator and lavage system of abdominal cavity is effected in points 3-4 cm below umbilicus and in direction from white line to upper external spine of ilium upper flaring portion 4-5 cm to right and to left. On the 2nd, 3rd and 5th days of postoperative period, videolaparoscopy is accomplished through the accesses. EFFECT: reduced injury of intervention. 1 dwg, 1 ex

Description

 The invention relates to medicine, namely to pediatric surgery. In pediatric surgery, the problem of treatment of appendicular peritonitis remains relevant. To date, median laparotomy is the only sufficient way to sanitize the abdominal cavity with diffuse forms of purulent peritonitis (Dadvali S.A., // Common purulent peritonitis in patients with destructive forms of acute appendicitis-Surgery - N 10. 1991. P. - 54-58 , Yudin Ya.B., // Laparostomy in the treatment of postoperative peritonitis in children - Pediatrics - N 4. 1995. S. - 146-148. Tsuman VG, // Treatment of common, appendicular peritonitis in children - Surgery No. 8 . 1993. S. - 35-38, Roshal L.M., // Evaluation of local treatment methods is common purulent peritonitis of appendicular origin in children-Surgery-N 8. 1993. St.- 30-35).

 Intralaparoscopic appendectomy is known, most authors use it for uncomplicated forms of acute appendicitis in children. In patients with 4–5 days old diffuse peritonitis under conditions of the formation of an adhesive process in the area of inflammation (periappendicular, inter-intestinal abscess), the use of the intralaparoscopic technique is impossible and it is necessary to switch to laparotomy (V. Kapustin, // Intralaparoscopic appendectomy in children with appendicular peritonitis-Symposium ; laparoscopic operations in children-theses-Yaroslavl. 1996. S. - 11-12, Kotlobovsky V.I., // Laparoscopic operations for complicated forms of acute appendicitis in children-Ibid., S. - 13-14). The disadvantages of a wide laparotomy are trauma to the soft tissues, intestinal tube, which in the postoperative period leads to aggravation of intestinal paresis, the development of purulent complications and the risk of wound suture failure.

 There is a method of rehabilitation and drainage of the abdominal cavity in complicated forms of appendicitis in children (Roshal L.M., // Treatment of peritonitis in children-Pediatrics-N 4. 1995. S. - 143-146, Konovalov AK, // Surgical treatment of appendicular peritonitis in children-Surgery-N 8. 1991. P. -39-31, Prokopenko Yu.D., // Programmed lavage in the treatment of common forms of peritonitis in children-Dushanbe-Materials of the II Congress of Surgeons of Tajikistan. 1989. S. - 303-305, Tiktinsky B.S.// Drainage of the abdominal cavity with appendicular peritonitis in children-Clinical surgery-N 6. 1989. S. - 4-6, Naumov A. A., / / Drainage of the abdominal cavity in children with the use of polymeric materials - Abstract of thesis, candidate of medical sciences - M. 1991), selected as a prototype. All accesses are limited to a wide laparotomy with subsequent variant preservation of the laparostomy, various drainage tube systems for subsequent lavage of the abdominal cavity.

 The disadvantages of the method: extensive trauma of the peritoneum, constant drainage of the abdominal cavity, which increases the risk of adhesions and the need for subsequent operations for this reason. The volume of treatment and the patient's stay in the clinic significantly increase.

 The objective of the invention is to create a combined method that would allow atraumatic surgery of children of any age, perform final abdominal sanitation, stage medical laparoscopy and use endoscopy for television monitoring and video recording of the operation, in addition, would eliminate the additional drainage of the abdominal cavity with tubes that increase the possibility of development adhesive disease and adhesive intestinal obstruction, significantly reduce the duration of surgical benefits and anesthetically risk, facilitate well-being, the condition of children and the course of the postoperative period (exclusion of pain for 2-3 days, lack of respiratory function and early departure from mechanical ventilation, relief of bowel paresis for 3-4 days), and significantly reduce treatment time due to the early active regimen of the patient.

 The task is achieved by the fact that during the initial debridement video laparoscopy, the introduction of the laparoscope is carried out through an incision made 3-4 cm above the umbilical fossa and 4-5 cm to the left of the white line of the abdomen, the introduction of the trocar for the manipulator and the abdominal lavage system is carried out at the points located below the umbilical fossa by 3-4 cm and in the direction from the white line of the abdomen to the upper external spine of the iliac wing to the right and left by 4-5 cm, while after performing appendectomy in the postoperative period through targeted access On days 2, 3 and 5, medical video laparoscopy is performed respectively through the mentioned laparoscopic approaches (see drawing).

 The method of video laparoscopic sanitation of the abdominal cavity in combination with targeted appendectomy allows solving the problem due to small accesses, sparing attitude to the soft tissues (muscles, nerves and vessels of the anterior abdominal wall are not dissected, but are moved apart by the trocar stylet), sufficient visual control for complete sanitation of the abdominal cavity, more objective choice of surgical access and the absence of additional intraoperative trauma of internal organs (mechanical impact, the influence of external environmental factors s). It allows to solve the issue of prevention of early (limited peritonitis and amentitis) and late (adhesive intestinal obstruction) complications.

 The operation is carried out in the following sequence.

 1. Conduct a diagnostic laparoscopy with the establishment of the form and prevalence of the inflammatory process.

 2. Conduct primary video laparoscopic sanitation of the abdominal cavity (removal of pus from the sloping places of the abdominal cavity, abscess cavity with electric suction pump). The points of introduction of the laparoscope and lavage system described above allow for maximum visual examination of the abdominal cavity, the introduction of trocars directly through the rectus muscle of the anterior abdominal wall is the prevention of possible postoperative complications (epiploic gasket, postoperative hernias), manipulation of several instruments does not create difficulties for the operator and assistants due to the absence of intersection their guides, however, all entered and moved in the abdominal lost tools. The latter allows you to freely change the manipulator to the lavage system without removing the trocar tube from the anterior abdominal wall, reduce the invasiveness of the operation, and shorten its duration.

 3. After the optimal choice of access perform targeted appendectomy with immersion of the stump in purse string and Z-stitches.

 4. Carry out the final rehabilitation of the abdominal cavity.

 5. Conduct a planned therapeutic video laparoscopy with lavage and sanitation of the abdominal cavity on the second and third days of the postoperative period (24 - 48 hours). Inspect the bed of the removed appendix, evaluate the consistency of the sutures on the dome of the cecum. The existing accumulations of exudate between the loops of the small intestine, pelvic cavity, and subhepatic space are removed. The forming flat commissures are separated, fibrin accumulations on the parietal and visceral peritoneum are removed with the washing liquid. Objectively assess the degree of intestinal cut and the potential peristaltic readiness of the intestinal tube in mechanical contact with the instrument after performing blockade of the mesentery root of the small intestine with novocaine solution.

 6. Conduct the final therapeutic video laparoscopy on the fifth day of the postoperative period after stopping purulent inflammation in the abdominal cavity and intestinal paresis. The effect of the treatment is objectively evaluated. There are no signs of inflammation of the greater omentum of the intestinal abscesses. They conduct breeding of the forming strangulation adhesions and eliminate the deformation of the intestinal tube sections with planar adhesions throughout, which is the prevention of adhesive intestinal obstruction in the long-term postoperative period.

The positive effect of using this method is achieved:
1) ease of execution;
2) objectivity and the possibility of full visual control, subject to minimal invasiveness;
3) The method allows you to perform operations in children of any age with any form of purulent peritonitis and a reappendicular abscess (according to S.Ya. Doletsky).

 4) Excluded additional drainage of the free abdominal cavity by tubes (drains, flushing systems).

 5) Monitoring and timely intervention during the inflammatory process in the abdominal cavity in the early postoperative period without any additional surgical trauma is carried out.

 6) Significantly reduced the time of operational benefits and anesthetic risk.

 7) The well-being, condition of children and postoperative management are facilitated (the exclusion of pain syndrome on the 2nd-3rd day of the postoperative period, the absence of a decrease in respiratory function and the early departure from mechanical ventilation, the relief of bowel paresis on the 4th day and the locality of its manifestation from the first day).

 8) The treatment time is significantly reduced due to the early active regimen of patients.

 9. Contributes to a sharp reduction in the risk of developing adhesive disease and adhesive intestinal obstruction, which breaks the vicious circle of repeated laparotomies.

 To perform the method, a diagnostic laparoscope and a set of surgical instruments for performing appendectomy are used.

 The method is as follows.

 1. After processing the surgical field with an antiseptic solution, a transverse skin incision is made up to 1.0 cm above the umbilical fossa 3-4 cm and to the left of the white line of the abdomen 4-5 cm. A Verishi needle is inserted through the incision. Nitrous oxide is insufflated in the abdominal cavity, depending on age, up to 1-1.5 liters. After removing the needle, a laparoscope tube is inserted through the incision. Through the tube into the abdominal cavity, the optical system of the laparoscope is inserted. Examination starts from the crescent ligament of the liver counterclockwise to the splenic angle. The prevalence of a purulent process, the localization of a reappendicular abscess, and the degree of intestinal paresis are evaluated.

 2. Through additional accesses on the anterior abdominal wall (extending to 0.6-0.7 cm) below the umbilical fossa 3-4 cm at points located to the right and left of the white line of the abdomen at a distance of 4-5 cm towards the upper the external spine of the ilium wing, a trocar is introduced for the manipulator and the abdominal lavage system. On the route described above, pus is aspirated from the sloping places of the abdominal cavity, if necessary, from the visible cavity of the reappendicular abscess. For a more convenient operation, the manipulator and the system for aspiration of pus can be changed without shifting the tubes of trocars previously installed due to one diameter of the latter.

 3. After aspiration of pus according to the route scheme, the abdominal cavity is washed with a 0.9% NaCl solution with alternating introduction and removal of the electric pump of the washing liquid. The stage is carried out under the constant supervision of video monitoring, which allows you to remove not only pus, but also most of the fibrin from the parietal and visceral peritoneum. Abdominal lavage is performed until the initial transparency solution removed from the abdominal cavity (total volume of the solution is 2000-4000 ml).

 4. After video endoscopic sanitation of the abdominal cavity and choice of access, targeted appendectomy is performed with the stump immersed in purse string and Z-stitches.

 5. In the early postoperative period, therapeutic video laparoscopy is performed on days 2, 3, and 5 with the aim of diluting the emerging adhesions, removing accumulations of exudate between the loops of the intestine and the pelvic cavity, novocaine blockade of the mesentery of the small intestine according to indications. The degree of intestinal paresis and the course of the inflammatory process in the abdominal cavity are objectively evaluated.

 With a variety of options for the location of the appendix and the severity of the inflammatory process, the proposed method is simple, economical, and most effective. It can be combined with various options for conservative treatment (hemosorption, plasmapheresis, blood ultraviolet, HBO, etc.).

Clinical example
Patient Shestakov Alexander, 11 years old. The medical history N 2005. He was admitted to the hospital 05/17/96. at 3.40. Complaints on admission to abdominal pain, vomiting, fever up to 39.0 ^o C. An.morbi: Ill acutely 05/14/96. When there was abdominal pain, I did not seek medical help. Parents treated with analginum, but no spear. 05/15/96. abdominal pain persisted. The night was restless. 05/16/96. the pain syndrome increased sharply, vomiting was noted up to 3 times, an increase in body temperature to 38.8 ^o C. Parents lowered the temperature with aspirin. 05/17/96. against the backdrop of deteriorating well-being, he was delivered to the children's surgical department. Upon receipt, the condition is serious. Body temperature 38.7 ^o C. The skin is pale with a gray tint. Shortness of breath up to 20 in 1 min. Pulse up to 154 in 1 min. The abdomen is swollen, the anterior abdominal wall is not involved in the act of breathing. On palpation, pronounced tension of the anterior abdominal wall and sharp pain in all departments. Peritoneal symptoms are sharply positive. With a rectal examination, the overhang and pain of the anterior rectal wall are determined. Complete blood count: leukocytosis up to 19.0 THOU, a pronounced shift of the formula to the left, erythrocytes-4.82 MIL, hemoglobin-13.6 g / dl, ESR-21 mm / h. General urine analysis, biochemical blood parameters within the age norm.

 Diagnosis at admission: 0. appendicitis. Spilled peritonitis.

 For the purpose of preoperative preparation, the child was hospitalized in the intensive care unit. After four hours of preoperative preparation under endotracheal anesthesia, an operation was performed: debridement video laparoscopy, abdominal lavage, targeted appendectomy.

 After treatment of the skin with a chlorhexidine solution, the incision is up to 1.0 cm at a point above the umbilical fossa by 3 cm and to the left of the white line of the abdomen by 4 cm. A Verishi needle is inserted into the abdominal cavity through the incision. The abdominal cavity is filled with nitrous oxide, after which a trocar and a laparoscope are introduced through the described access. Examination of the abdominal cavity revealed fluid pus spreading from the subphrenic space to the right, along the right flank, in the small pelvis and left flank to the spleen. The parietal peritoneum is sharply hyperemic. Paresis of the small intestine to the III degree is noted. Loops of the small intestine are swollen, hyperemic. In the right ileal fossa, a reappendicular abscess is formed by the dome of the cecum, parietal peritoneum, loops of the ileum, a section of the sigmoid colon and a lock of the omentum. The right ileal fossa, loops of the ileum and the pelvic cavity are covered with fibrin. Additionally, on the anterior abdominal wall, at points located to the right and left below the umbilical fossa by 3 cm and departing from the white line of the abdomen by 4 cm towards the upper anterior spine of the ilium, the skin is cut to 0.7 cm. Through accesses under the control of a laparoscope introduced trocars for the manipulator and the lavage system. After aspiration of pus with a total amount of up to 400 ml, abdominal lavage was performed with 0.9% NaCl solution with a total volume of 4000 ml. An abdominal cavity was opened in a layer-by-layer, open access approach up to 6.0 cm above the abscess in the right iliac region. The separation of the loops included in the reappendicular abscess is made. Resection of the omentum, appendectomy with immersion of the stump in the purse string and Z-stitches. After the final drainage of the pelvis, the wound is sutured tightly.

 Diagnosis after surgery: Gangrenous-perforated appendicitis. Reappendicular abscess III. Spilled purulent-fibrinous peritonitis.

 From the operating room, the child was transferred to the intensive care unit, where the standard infusion, antibacterial therapy was continued (gentamicin 0.4, claforan 1.0), fractional lasmapheresis was performed.

05/17/96. The condition of the child is serious. From 16.00 on the background of the restoration of independent breathing, extubation was performed. Body temperature during the day from 36.4 to 37.5 ^o C. Pulse-120 in 1 min. AD-130/65. Available to contact. There are no complaints. The abdomen is not swollen, with palpation moderate pain in the wound area. Intestinal paresis of the II-III degree is preserved. Auscultatory peristalsis is absent. On a probe from the stomach 200 ml of stagnant contents. Diuresis 2000 ml. Stool on the background of intestinal stimulation with 0.05% solution of proserin after an enema 2 times.

05/18/96. The condition is the same. There are no complaints. Body temperature from 36.7 to 38.1 ^o C. The abdomen is soft. Clinically preserved intestinal paresis to the II degree. Auscultatory single peristaltic murmurs. There is no discharge from the stomach from the probe; the latter has been removed. Diuresis-1200 ml. Once on the background of intestinal stimulation, an independent stool and twice after an enema. In a planned manner, therapeutic laparoscopy was performed.

 After treatment of the skin with chlorhexidine solution, a laparoscope was inserted into the abdominal cavity through the available laparoscopic accesses on the anterior abdominal wall. When viewed in the pelvis, a cloudy effusion of up to 100 ml. On the parietal peritoneum, sigmoid colon - lysed fibrin, which is removed by the manipulator. Loops of the ileum and omentum were loosely soldered to the bed of the appendix. The loops of the ileum, included in the abscess, are swollen, covered with fibrin. Peristaltic contractions are not observed in them, but peristalsis is satisfactory in the overlying departments. Adhesions of loops of the small intestine, omentum divided. Abdominal lavage 2000 ml of 0.9% NaCl solution. The seams on the dome of the cecum are wealthy. Laparoscope trocars removed. The operation is completed by suturing wounds. Control biochemical blood tests without pathology. Complete blood count: leukocytes-9.0 THOU, the shift of the formula to the left is retained, red blood cells - 3.99 MIL, hemoglobin - 10.9 g / dl, ESR-30 mm / h.

05/19/96. The condition is serious. Well-being: does not suffer. There are no complaints. Nausea, vomiting absent. Body temperature 36.6 - 37.9 ^o C. Skin and visible mucous membranes of normal color and humidity. Hemodynamics is stable. Pulse 90-100 in 1 min. AD-120/70. The abdomen is not swollen, soft on palpation. Moderate wound pain persists. With a rectal examination, there is no overhanging of the anterior wall of the rectum; palpation of the latter is painful. Correction of homeostasis continued. Antibacterial therapy has remained the same, given the growth of E. coli, sensitive to gentamicin and claforan.

 In a planned manner (after 48 hours) in the operating room, therapeutic laparoscopy was performed through the mentioned laparoscopic approaches. When examining the abdominal cavity, the sigmoid colon is fixed to the parietal peritoneum over the small pelvis by commissures. When separating the latter in the pelvic cavity, a cloudy effusion with lysed fibrin up to 50 ml. Sowing. On the flanks, there is no effusion in the subhepatic space. There is no fibrin in the bed of the removed process. The seams on the dome of the cecum are wealthy. Loops of the small intestine of normal color, peristaltize well throughout. Infiltration and vascular injection are preserved at the site of resection of the lock of the greater omentum. Abdominal lavage with 0.9% NaCl in a volume of 2000 ml. At the control examination, there is no fibrin on the parietal peritoneum. There are no clogged effusions of effusion between the loops of the small intestine. A marked adhesion process remains between the ileum loops that were part of the reappendicular abscess. From the complete separation of adhesions, at this stage, given the persistent inflammation in the abdominal cavity, it was decided to abstain. The operation is completed by removal of the laproscope from the abdominal cavity, the application of individual sutures to the edges of the wound.

05/20/96. The child's condition is stable, closer to moderate severity. No complaints. Body temperature 36.6-37.2 ^o C. Started taking fluid per os up to 350 ml during the day. No vomiting noted. Hemodynamics is stable, pulse 70-80 beats. in 1 min. HELL 120/70. The abdomen is not swollen, soft on palpation. Peritoneal symptoms are absent. Auscultatory peristalsis is satisfactory. Stool on the background of intestinal stimulation during the day three times. Diuresis 1050 ml. Control an. blood count: white blood cells-6.7 THOU, white blood cell count unchanged, red blood cells-4.36 MIL, hemoglobin-12.2 g / dl, ESR-41 mm / h. Biochemical blood tests within the age norm.

 05/21/96. The condition for the disease of moderate severity; well-being: does not suffer. Body temperature 36.6-36.9. Pulse-80 in 1 min. HELL 120/70. Against the background of enteral fluid intake, bloating of the lower abdomen was noted. On palpation, there is no pain reaction. There are no peritoneal symptoms. Rectal examination without features.

 In a planned manner, in the operating room, therapeutic laparoscopy was performed through the mentioned laparoscopic approaches. When examining an effusion in the abdominal cavity, there is no small pelvis. Edema, infiltration at the site of the omentum resection. The peritoneum is the usual color, the intestinal loops are not changed. Indications for lavage of the abdominal cavity are not. There is a bloating of the ileum associated with a partial violation of the passage of contents due to its deformation by a cord-like commissure attached to the dome of the cecum. The commissure is removed, planar commissures forming a clonomerate of loops are divorced. Patency restored throughout the ileum. In the control, intestinal contents freely enter the ileum. The operation is completed by removal of the laparoscope, suturing wounds tightly. The child was transferred to the Department of Pediatric Surgery for further treatment.

May 22-23, 1996. The child's condition is stable, almost satisfactory. Relatively active. Body temperature 36.6 ^o C. Started feeding. No vomiting. Pulse up to 90 in 1 min. HELL 120/70. The abdomen is not swollen, palpation is soft, painless in all departments. Postoperative wounds without signs of inflammation. Auscultatory peristalsis is satisfactory. The chair is independent, decorated. There is no dysuria. The cancellation of infusion, antibacterial therapy. A course of postoperative rehabilitation (microwave on a wound, massage, exercise therapy) has begun.

05/24/96. The condition is satisfactory. There are no complaints. Sleep, appetite is not broken. Body temperature 36.6 ^o C. Somatically without features. The abdomen is soft, painless. Canceled bed rest. Sutures were removed from the appendicular access (on the 7th day of the postoperative period).

05/28/96. The condition is satisfactory. There are no complaints. Body temperature 36.6 ^o C. The abdomen is soft, painless. There are no signs of inflammation in the area of postoperative wounds. Healing of the latter by primary intention. Rectal examination without features. The course of treatment is completed. The wound sutures were removed after laparoscopy (on the 7th day from the last operation). The child was discharged home with recommendations. Blood test at discharge: white blood cells-5.3 THOU, red blood cells-4.51 MIL, hemoglobin-124 g / dl, platelets-15.4%, ESR-20 mm / h. Diagnosis at discharge: Gangrenous-perforated appendicitis. Reappendicular abscess III. Spilled purulent-fibrinous peritonitis. Outpatient follow-up for 6 months showed no signs of adhesive disease.

 Using this method, the clinic performed 26 operations in children aged 6 to 14 years. All children undergoing medical video laparoscopy noted relief of purulent inflammatory process in the abdominal cavity for 2-3 days. Two children eliminated early adhesive intestinal obstruction on the 5th and 6th day of the postoperative period. All children were discharged with recovery. Outpatient follow-up for 6-12 months did not reveal complications or signs of adhesive disease.

Claims (1)

 A method of surgical treatment of peritonitis in children, which consists in conducting primary debridement video laparoscopy and targeted appendectomy, characterized in that during the initial debridement video laparoscopy, the laparoscope is inserted through an incision made from the superior fossa 3-4 cm and to the left of the white line of the abdomen by 4-5 cm, the introduction of a trocar for the manipulator and the lavage system of the abdominal cavity is carried out at points located below the umbilical fossa 3-4 cm and in the direction from the white line of the abdomen to the upper outer the spine of the iliac wing to the right and left is 4 - 5 cm, while in the postoperative period, therapeutic video laparoscopy is performed on the 2nd, 3rd and 5th days, respectively, through all the mentioned laparoscopic approaches.