RU2147444C1 - Method for treating the cases of peritonitis - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves removing the greater omentum. Round and falciform ligaments of the liver are dissected. Irrigating members are spaced in sloping parts of the abdomen along the right lateral canal and the small pelvis on the right side, along the small intestine omentum root, along the left lateral canal into the subdiaphragmatic space. Pulsating antiseptic jet mixed with air is supplied through the irrigating members. The contents is sucked through the middle drain. The middle drain is positioned along the anterior abdominal wall above the intestinal loops. Gas bubble is created after performing the intervention between the visceral organs and the anterior abdominal wall. Sodium hypochlorite solution is used for draining. Washing is carried out every 5-6 hours. EFFECT: enhanced effectiveness of treatment. 3 cl, 2 dwg

Description

 The present invention relates to medicine and can be used in surgery in the treatment of acute surgical diseases of the abdominal cavity.

 Acute widespread purulent peritonitis is one of the most formidable complications of emergency surgical pathology. In recent decades, this disease has attracted attention due to the insufficient effectiveness of the use of antibacterial therapy, high mortality, and the significant cost of treating peritonitis. Various treatment options for peritonitis have been proposed, however, they are not without various drawbacks, often quite traumatic and not sufficiently radical. One of the most important and problematic components of the complex treatment of peritonitis is the question of adequate surgical correction, or rather, the issues of full intra- and postoperative rehabilitation of the abdominal cavity. All other components of therapy, as in general in purulent surgery, are important, but more effective moments in the treatment of this pathology, and therefore the relevance of solving the issue of postoperative correction is of the greatest interest for improving the therapeutic effect.

 A known method of repeated laparotomy (programmed relaparotomy).

 The essence of this method is to carry out repeated laparotomies after 24-48 hours, in which exudate is removed, loose adhesions are separated, the forming intra-abdominal abscesses are eliminated, and the abdominal cavity is washed with antiseptics. Tsybyrne K.A., Angelich G.A., Luka N.A. The First Moscow International Congress of Surgeons. Moscow 1995. - p. 45-46).

The disadvantages of this method are:
1. A significant interval between abdominal rinses leads to the progression of the process.

 2. The invasiveness of the method.

 3. High complexity and high cost.

 There is also known the method of "open abdomen" (laparostomy, peritoneostomy).

 The method consists in leaving the laparotomic wound after the operation unsecured. Gauze napkins, perforated plastic film, polymer mesh, etc. are placed on top of the abdominal organs. Thus, the abdominal cavity is drained through the laparotomy wound, which is sutured after the relief of the inflammatory process (Anisimov A.Yu., Chuprin V.G., Yaradaykin V.V. First Moscow International Congress of Surgeons. Moscow, 1995. - pp. 48-49 )

The disadvantages of this method:
1. The abdominal cavity is drained only on a limited area of the open wound area, the anterior abdominal wall sticks together with the abdominal organs, which leads to the formation of adhesions.

 2. The method does not exclude the attachment of an exogenous hospital infection.

 3. The method does not exclude the possibility of forming intra-abdominal abscesses.

 4. Some authors believe that the method contributes to the formation of intestinal fistulas.

For the prototype, we took the author. St. USSR N 1601810, class A 61 M 7/00 "Method for the prevention of peritonitis after radical surgery in the abdominal cavity in cancer patients." The method involves washing the abdominal cavity in risk areas. For this purpose, before suturing the abdominal cavity at the end of the operation, 3 drains are introduced into the abdominal cavity through separate punctures of the abdominal wall. The first of them is located in the subphrenic zone on the right, the second - in the subphrenic zone on the left, the third - in the douglas space. To implement the method using two-channel drainage from medical polyvinyl chloride, while the inner tube is connected to a source of constant negative pressure in the mode of 0.2-0.4 kgf / cm ² . Aspiration begins immediately after the installation of drainage in the abdominal cavity. Washing continues for 6-9 days until the end of infection of the abdominal cavity with Escherichia coli.

The method has the following disadvantages:
1. When delimiting (as a result of adhesion processes) drainage tubes, exfusion through them is not adequate to the amount of fluid introduced, which may lead to its delay and intense hydroperitoneum.

 2. In connection with the adhesive processes in the abdominal cavity, no antiseptic washing of all intra-abdominal formations takes place, the fluid goes along the "line of least resistance".

 3. The method can contribute to the failure of intestinal anastomoses, as well as cause protein metabolism disorders.

 The aim of the invention is to increase the therapeutic effect of the treatment of peritonitis.

Tasks:
- elimination of the inadequacy of exfusion to the amount of injected fluid and, as a result, the occurrence of intense hydroperitonium;
- elimination of the possibility of the formation of intra-abdominal abscesses and adhesions;
- elimination of the risk of failure of anastomoses and disorders of protein metabolism;
- reduction of bed days by 25-30%.

 The essence of the method is that irrigators during rehabilitation of the abdominal cavity are installed in the area of the right and left lateral canals of the pelvis, subphrenic space, along the root of the mesentery of the small intestine and a pulsating stream of antiseptic is mixed with air, mainly sodium hypochlorite solution, through the middle drainage along the front the abdominal wall over the intestinal loops, and after the completion of the surgical procedure, a gas bubble is created between the organs of the abdominal cavity and the anterior abdominal wall. Washing is carried out every 5-6 hours until the inflammatory process is completely stopped.

 The method is as follows.

 After eliminating the source of peritonitis, removing exudate and possibly fibrinous layers of washing the abdominal cavity with an antiseptic solution, a large omentum is resected and the round and sickle ligaments of the liver are dissected. Thus, they create a single subphrenic space and exclude the involvement of the omentum in commissure formation (in the formation of delimited cavities).

 Then, 4 perforated irrigators are introduced into the abdominal cavity through contrapertures and placed along the right lateral canal into the small pelvis (1) of FIG. 1 along the left lateral canal into the subphrenic space (2), along the root of the mesentery of the small intestine, above and below (3, 4).

 A thick perforated drainage tube is inserted through the contraperture and placed along the median laparotomy wound (5).

 A mixture of an antiseptic solution with air, pulsating by a jet, is fed through irrigators, forming an air bubble between the anterior abdominal wall and the organs of the abdominal cavity (6). FIG. 2.

 Through median drainage (5), active aspiration with weak discharge is carried out. The procedure is repeated after 5-6 hours until a visually clean wash solution is obtained (each time), pneumoperitoneum is maintained between the sessions. After each procedure, the residual wash solution is released through irrigators 1, 2, 3, 4. Sodium hypochlorite solution is proposed to be used as a wash solution.

 This method was tested on unfixed corpses and laboratory animals, and then applied in a clinic for 23 patients with disseminated purulent peritonitis, including with spilled spilled. Example: Patient H., 56 years old, was admitted to the clinic on 03/21/96, medical history 1241. Dz "Acute gangrenous-perforated appendicitis, diffuse fibrinous-purulent peritonitis." Operation "Laparotomy, appendectomy, drainage of the abdominal cavity."

 To this end, a large omentum was resected and a round and sickle-shaped ligament of the liver was dissected, that is, a single subphrenic space was created that excluded the omentum from participation in adhesion formation. Irrigators were introduced into the abdominal cavity through contraception: along the right lateral canal into the small pelvis, along the left lateral canal into the subphrenic space, along the root of the mesentery of the small intestine, above and below it. Then, a drainage tube was inserted through the contra-hole and laid along the median laparotomy wound.

 Through irrigators, a solution of sodium hypochlorite with air was supplied as a pulsating jet. In this case, an air bubble is created between the anterior abdominal wall and the organs of the abdominal cavity. The aspiration continued to be carried out through the middle drainage, repeating the procedure for 5-6 hours. The washing was stopped when a clean liquid was obtained at the outlet. Pneumoperitoneum was maintained between the washing procedures, and the residual washing solution was discharged through irrigators.

 Sanitation of the abdominal cavity was carried out for two days. Then the drains are removed. There were no complications. The patient was discharged on the 6th day. Recovery.

 This method of treatment of peritonitis when using allows you to reduce the frequency of deaths by 25-30%. The possibility of complications such as residual abscesses of the abdominal cavity and the progression of peritonitis is reduced. This method often allows you to abandon such a time-consuming and not indifferent for the patient method, such as programming relaparotomy and reduce material costs associated with it, reduce the overall washing time by 3-4 times compared with the prototype. (from 6-9 to 2 days).

Claims (3)

 1. A method of treating peritonitis, including drainage of the abdominal cavity, characterized in that after resection of the greater omentum and dissection of the round and crescent ligaments of the liver, irrigators are installed along the right lateral canal and small pelvis on the right, mesenteric root of the small intestine to drain the abdominal cavity, to drain the abdominal cavity, along the left lateral canal into the subphrenic space and a pulsating stream of antiseptic mixed with air is supplied through them, and aspiration is carried out through the median drainage located along the per days abdominal wall over the intestinal loops, and after completion of surgery between organs of the abdominal cavity and the anterior abdominal wall sutured tight, creating a gas bubble.  2. The method according to claim 1, characterized in that for drainage using a solution of sodium hypochlorite.  3. The method according to claim 1, characterized in that the washing is carried out every 5 to 6 hours, until the inflammatory process is stopped.

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