RU2200453C2 - Method for treating the cases of abdominal hemorrhages by applying retropneumoperitoneum procedure - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves removing blood from the abdominal cavity by applying retropneumoperitoneum procedure. Carbon dioxide is pumped in to 16-18 mm of mercury column under laparoscopic control. EFFECT: enhanced effectiveness of treatment; low-invasive procedure.

Description

 The invention relates to medicine and can be used in pediatric and general surgery.

 Laparoscopic surgery using a tachocomb [l], CO2 Laser at the site of damage to parenchymal organs is an analogue of the treatment of intra-abdominal bleeding [2].

 The disadvantages of these operations are their complexity and complexity of execution, as well as significant material costs associated with consumables and equipment.

 The prototype of the invention are endoscopic adhesive omentosplenopexy and peritoneosplenopexy [3, 4], which allow you to save the organ and stop bleeding in a minimally invasive way.

 Their disadvantages are the need to use three or more trocars, the technical difficulties of performing operations, especially with damage to the spleen with the passage of the gap to the posterior surface of the organ.

 The objective of the invention is to develop a minimally invasive method that allows you to create conditions for independent hemostasis with intraperitoneal bleeding of various origins with minimal cost.

 According to the invention, the task is achieved by the fact that under the control of a laparoscope, blood is evacuated from the abdominal cavity, the source of bleeding, its intensity and nature of the damage are determined, after which the pressure of carbon dioxide in the abdominal cavity increases, if necessary, to 18 mmHg, which helps to slow down bleeding, activation of the blood coagulation system, clot formation and hemostasis. This allows you to achieve reliable hemostasis for various sources of bleeding in the abdominal cavity without the use of additional expensive equipment and supplies, as well as unnecessary and sometimes not harmless to the patient’s health, and possible complications associated with it, use evacuated blood, if it is without pathological impurities, for reinfusion.

 The proposed method is as follows.

 After application of pneumoperitoneum up to 12-16 mm Hg two five-millimeter trocars are inserted into the abdominal cavity for the introduction of optics and a manipulator. One on the lower crease of the navel. The other is in the mesogastric region on the side of the injury. When confirming the diagnosis of intra-abdominal bleeding, a visual assessment of the intensity of bleeding and the volume of blood loss is carried out. After making sure that there is no impurity of intestinal contents and bile, the blood is taken for reinfusion, and the source of bleeding is established. One of the important points is the appearance of blood clots during laparoscopy. They indicate the appearance of fresh blood and indicate the source. At the same time, this phenomenon confirms the hemostatic effect of pneumoperitoneum, since the "old" blood does not clot without the access of air to the cavities of the human body. After removal of the bulk of the blood from all parts of the abdominal cavity, the intensity of its accumulation in the iliac pocket of the peritoneum on the side of the injured organ or in the small pelvis is estimated. With a tendency to a decrease in bleeding and stable hemodynamic parameters, one can count on its final stop. On this laparoscopy can be completed by summing up the control irrigator to the site of damage.

 Hemostatic therapy should begin before surgery, continue during it and in the postoperative period under constant monitoring of hemodynamics and red blood counts. If necessary, anti-shock measures and replacement of blood loss are carried out. The reliability of hemostasis should be assessed by indicators of blood and hemodynamics, the nature of the discharge by irrigator, and by determining the amount of free fluid in the abdominal cavity using ultrasound.

 Examples.

 1. Girl K., three years old, was admitted to the hospital 2 hours after falling to the left side from a height of 1.5 m with a clinic of damage to the spleen, intraperitoneal bleeding. Hemodynamic parameters and red blood tests were within normal limits, but leukocytosis of up to 23 thousand was noted. According to ultrasound, there was a rupture of the spleen in the area of the gate, in the abdominal cavity was determined free fluid in a volume of about 500 ml. After a short preoperative preparation, which consisted of determining the blood group, Rh factor, other tests, the introduction of hemostatic drugs, the child was taken to the operating room for laparoscopy. During laparoscopy, spleen rupture and intra-abdominal bleeding were confirmed. About 600 ml of blood was evacuated from the abdominal cavity for reinfusion. When removing blood, it was noted that slight bleeding was noted in the area of injury, but blood clots immediately formed, which indicated hemostasis. CO2 pneumoperitoneum in this case reached 16 mm Hg. In sloping places, the accumulation of blood stopped. A control irrigator was placed in the abdominal cavity, which was removed two days later due to the lack of discharge. According to ultrasound, fluid in the abdominal cavity did not accumulate. Discharged girl in satisfactory condition.

 2. Boy D., five years old, was taken to the children's clinic by an ambulance after falling from a bicycle with a diagnosis of blunt abdominal injury. Due to severe pain in the upper right abdomen and dullness of percussion sound in the sloping places, the child was suspected of liver damage and intra-abdominal bleeding. Hemodynamic parameters were stable, there was no anemia. Ultrasound due to the absence of a specialist was not done. After a short preoperative preparation, the child was taken to the operating room for laparoscopy, during which it was revealed that there is a rupture of the right lobe of the liver with a length of about 5 cm and a width of 0.8 cm, in the abdominal cavity about 300 ml of free blood. During the evacuation of blood, the formation of clots was noted and at first a slowdown, and then a cessation of blood accumulation in sloping places. CO2 pneumoperitoneum was 18 mmHg. The operation was completed by placing the control irrigator in the abdominal cavity, which was removed on the second day. Postoperative hemodynamic monitoring and ultrasound monitoring confirmed the reliability of hemostasis. The child was discharged in satisfactory condition.

3. A 13-year-old child was taken to the children's surgical clinic by an ambulance 10 hours after the onset of the disease, when a painful sensation of a splash appeared in the abdomen when changing position, and then frequent painless urination in small portions with a thin stream. Diagnosis with direction: hemophilia A, hematoma of the mesentery of the sigmoid colon?
Upon receipt, the condition is regarded as serious. Pallor of the skin, lethargy, and dynamism were noted. In the sloping places of the abdominal cavity, a distinct blunting of percussion sound, positive symptoms of peritoneal irritation with a soft abdomen. In blood tests, moderate anemia, tachycardia up to 140 beats per minute, blood pressure - 110/60 mm Hg Lee White coagulation 47 min 53 s. According to ultrasound, in the abdominal cavity of the free fluid is about two liters. 6 doses of cryoprecipitate and 300.0 erythrocyte mass were urgently ordered and transfused. Hemostatic therapy is prescribed. Lee-White coagulation decreased to 19 minutes and the child was taken to the operating room. On laparoscopy revealed an extensive omentum hematoma, which occupies the entire small pelvis, and about one and a half liters of free blood in the abdominal cavity. After the evacuation of blood, it was noted that the hematoma does not pulsate, does not increase, and blood does not accumulate in sloping places. CO2 pneumoperitoneum was 18 mm Hg. Art. Laparoscopy culminated in the placement of a control irrigator in the abdominal cavity, which was removed 2 days after surgery. According to ultrasound, the hematoma decreased in dynamics and soon disappeared. The child was discharged in satisfactory condition.

SOURCES OF INFORMATION
1. Gorsky V.A., Sukhodulov A.M. The use of "TAKHOKOMBA" in abdominal surgery // Materials of the All-Russian Conference. "New technologies in surgery." - Moscow .. 1999. - S. 53-54.

2. Martino A.A., Pushkarev O.G., Krivikhin V.T., Osokin V.V. СО ₂ Laser in surgery of parenchymal organs // Materials of the All-Russian Conference "New Technologies in Surgery". - Moscow. - 1998 .-- S. 107-109.

 3. Rozinov V.M., Saveliev SB, Ryabinskaya G.V., Belyaeva O.A. and other Organ-preserving treatment of injuries of the spleen in childhood // Ros. West perinatol. and pediatrician. - 1994 - T. 39 - 2 - S. 20-25.

 4. Savelyev S. B., Rozinov V. M., Keshishyan R. A., Chokovadze G. A. Endosurgical treatment of children with closed transcapsular lesions of the spleen // Symposium "Laparoscopic operations in children": abstracts. - Moscow. - 1996.S. 20.

Claims (1)

 A method of treating intraperitoneal bleeding with pneumoperitoneum, which involves evacuating blood from the abdominal cavity when applying pneumoperitoneum by injection of carbon dioxide to 16-18 mm RT. Art. under the control of a laparoscope.