RU2204953C1 - Method for treating the failure of suppurated sutures of uterine wall complicated with metroendometritis - Google Patents

Abstract

FIELD: medicine, obstetrics. SUBSTANCE: the present method could be applied after Caesarean operation complicated with metroendometritis. It is suggested to drain uterine cavity so that one of the drainages should be installed into uterine cavity through cervical canal, the second one should be installed along the line of sutures of anterior uterine wall, and the third one should be installed into retrouterine space. By intrauterine drainage one should perform constant aspiration-washing treatment of uterine cavity at evacuation of purulent contents and local antibacterial therapy at exposure being below 1.5-2 h, by the second and third drainages one should carry out evacuation of purulent contents incoming out of uterine cavity through sutures and, additionally, carry out the supply of antibiotics into uterine circulation system through vascular catheter installed either into iliac or uterine arteries. EFFECT: higher efficiency of therapy. 1 cl

Description

 The invention relates to medicine, namely to surgery, and can be used to treat insolvency of the sutures of the uterine wall both after cesarean section and as a result of any damage to the uterine wall, which led to surgical intervention on the uterus and complicated by metroendometritis.

 Cesarean section currently occupies a prominent place and is a common surgical intervention in obstetric practice. However, there are cases of peritonitis after the operation due to a number of reasons.

 According to special studies conducted by prof. Pobedinsky N.M. (Collection of scientific works. M., 1991) in 30% of women undergoing cesarean section, obstetric peritonitis arose as a result of infection of the peritoneum after cesarean section, complicated by metroendometritis, and therefore, the contents of the uterus were the source of peritonitis.

 In 15% of cases, peritonitis occurred as a result of violation of the intestinal function barrier as a result of its prolonged paresis in patients. In 55%, peritonitis arose due to the inferiority of postoperative uterine sutures with their subsequent discrepancy.

 With severe obstetric peritonitis and a far-reaching disease, the uterus suture is almost always found to be inconsistent (inferior), with complicated metroendometritis, which refers to severe lesions of the female reproductive system. To date, the vast majority of such patients undergo radical surgical treatment in the amount of removal of the affected uterus (see MS German and other Treatment of postoperative obstetric peritonitis. Chisinau, 1981, Sat scientific works).

 According to D.F. Kostyuchenok (Kazan medical journal, 1990, Combined therapy of peritonitis in gynecological patients) for all patients with obstetric peritonitis women (120 people) performed supravaginal amputation or uterine extirpation. Moreover, mortality was about 4% of progressive peritonitis.

 There is a method of treating peritonitis as a result of insolvency of the sutures of the uterine wall and metroendometritis that occurred after cesarean section, this is the amputation of the uterus with the treatment in the postoperative period using drainage of the abdominal wall and traditional drug therapy.

 The disadvantage of this method of treatment is not only that it is a traumatic and risky operation for patients who are often in serious condition, but it is also a crippling operation for the vast majority of patients within the age range of 17-25 years, leading to an irreversible loss of reproductive function and, often fatal.

 Closest to the claimed method is the "Method of surgical treatment of insolvency of sutures on the uterus," described in patent 2170061 from 07/10/2001.

 The disadvantage of this method of treatment is that, against the background of a serious condition of the patient, the entire volume of surgical interventions proposed in this method leads to a very high trauma, and given the presence of gaping vessels from the uterine cavity, when it is cured (curettage), this circumstance sharply increases the risk of sepsis in the long term, even in case of recovery, the patient leads to obliteration and closure of the fallopian tubes.

 The objective of the present invention is to significantly reduce the morbidity and risk of surgical intervention due to a fundamentally new minimally invasive surgical tactics, achieve an organ-preserving effect with the possibility of reproductive function of the uterus and further reproductive function of a woman, reduce the number of complications and shorten the hospital and outpatient duration of treatment.

 The problem is solved in that in the method of treating the failure of the sutures of the uterine wall, complicated by metroendometritis, including drainage of the uterus and antibiotic therapy, drain the uterine cavity with one of the drains, which is installed through the cervical canal, the second drainage is installed along the suture line of the front wall of the uterus, and the third drainage is installed in the adjacent space, moreover, through the intrauterine drainage, a permanent aspiration-washing treatment of the uterine cavity with evacuation of pus is carried out content and local antibacterial therapy with an exposure of at least 1.5-2 hours, through the second and third drains, purulent contents coming through the sutures from the uterus are evacuated, while, according to indications, additionally, antibiotics are fed into the uterine blood supply through the vascular a catheter inserted in the uterine or iliac artery.

 Our goal is to significantly reduce the morbidity and risk of surgical intervention due to a fundamentally new minimally invasive surgical tactics, achieving an organ-preserving effect with the possibility of reproductive function of the uterus and further reproductive function of a woman, reducing the number of complications and shortening inpatient and outpatient treatment periods.

 For this, in the method of treating the failure of the sutures of the uterine wall after cesarean section, complicated by metroendometritis, including the evacuation of purulent contents, we installed and fixed two-channel drainage of TMMK along the sutures of the front wall of the uterus, into the posterior space and, through the cervical canal, directly into the uterine cavity. A sutured surgical wound was drained with the same tube to prevent its suppuration. After completion of the operation, aspiration-washing treatment was immediately started. The TMMK tube, installed along the line of insolvent sutures of the uterine wall, serves to evacuate possible inflow of purulent contents between the sutures into the free abdominal cavity. The TMMK tube installed in the uterine cavity constantly evacuates purulent exudate from there. In addition, it allows you to repeatedly wash the uterine cavity with antibacterial drugs and several times a day (usually 2-3 times) to carry out local exposure of antibiotics for 1.5-2 hours. Moreover, the concentration of antibiotics in endo- and myometrium significantly exceeds that at their parenteral administration. And the combined - local and parenteral administration of antibiotics - in general, can reliably stop the inflammatory process in endo- and myometrium.

 The tube installed in the adjacent space is safety and allows you to evacuate the possible ingress of exudate and washing antibacterial solution past the first / first / tube installed along the seam line.

 In a very serious condition of the patient or the slow development of positive dynamics, parenteral administration of antibiotics can be additionally carried out through a catheter installed according to Seldinger into the uterine artery or ileum, closer to the uterine discharge site.

 If the patient suspects inconsistency of the sutures of the uterine wall, we perform a lower middle laparotomy or transverse access according to Pfannenstiel. The main thing in access is a sufficient area for viewing and surgical intervention in the lower half of the abdominal cavity. If necessary, we carry out the rehabilitation of this section of the abdominal cavity. The front wall of the uterus is isolated, not reaching 1.5-2 cm to its section, which was sutured after a cesarean section, since it is not additionally sutured.

 A drainage is installed through the cervical canal into the uterine cavity, through which the uterine cavity is rinsed with purulent exudate evacuated and local antibiotic therapy with an exposure of at least 1.5-2 hours. The second and third drainages are installed along the line of sutures of the uterine wall and into the posterior space, respectively . Through them, the purulent contents coming through the sutures from the uterus are evacuated. If necessary, the second and third drains can also be used for local supply of antibiotics.

 In addition, to achieve greater therapeutic efficacy, additionally, according to indications, antibiotics are fed into the uterine blood supply system through an intravascular catheter, which is installed in the uterine artery or at its mouth.

Clinical example
Patient S. v. E.V., 26 years old, and.b. 1367-93g., Delivered to the Research Institute of Ambulance them. Sklifosovsky from the genus. at home in 22/1 - 93, in very serious condition with a diagnosis of "infiltration of the left half of the abdominal cavity." 13 / 1-93, due to discoordination and weak labor, acute asphyxia of the fetus, she underwent caesarean section in the lower uterine segment. Retrieved viable full-term boy. In the postoperative period, almost from the first day, there is hyperthermia up to 38 ^o C or more. A blood test the very next day: leukocytes - 13900, stab - 12, lymphocytes - 5, ESR - 53. Antibiotic therapy was carried out in the hospital, however, the temperature and inflammatory changes in the blood increased, the general condition worsened, and a few days before the transfer to the research institute pain on palpation in the left mesogastric region began to be noted and, in the same place, a formation (painful) was not clearly palpated.

 During examination at the institute: painful infiltration in the left mesogastric region is determined by palpation 15 × 10 cm, a volumetric formation above the bosom, the upper pole of which is 3 cm below the navel, and the lower goes into the pelvic cavity (abscess? Enlarged uterus?). In the blood - leukocytosis with a sharp shift of the formula to the left. Ultrasound - signs of inflammatory infiltrate in the left mesogastric region, with an isotope study with labeled leukocytes - areas of increased accumulation of radiopharmaceuticals in the same area and in the pelvic area.

 On 29 / 1-93, in connection with the signs of abscess formation of the infiltrate, an extraabdominal opening and drainage of the abscess was made in the left mesogastric region with the evacuation of 120 ml of pus. The uterus is walled around the perimeter, intestinal loops and omentum are a single conglomerate, do not differentiate. Revision of the supporting space is not possible.

 Despite the operation, the patient retained high fever and intoxication, chills, pains in the left chest (radiological - pneumonia), moderate pains in the right hypochondrium, where painful infiltration began to be determined. The condition remained extremely serious. As before, formation remains just below the umbilical line to the bottom of the pelvis. To clarify its nature (abscess or uterus?), Ultrasound, X-ray and computer studies were performed again on the 4th and 5th / 11–93, which identified this formation as a giant abscess. Consultation prof. CM. Selitskaya: divergence of sutures on the uterus after cesarean section. Perimetritis, endometritis (panmetritis). Multiple abscesses of the abdominal cavity, apparently, were formed in connection with the divergence of sutures on the uterus. Sepsis. Pleuropneumonia. Due to the presence of a source of pus in the uterus, discrepancies in sutures on the uterus, as well as computer topography data (purulent inclusions in the myometrium wall - purulent metroendometritis), an operation is shown - mid-access laparotomy, hysterectomy with tubes, drainage of the abdominal cavity and vagina.

 Inspection of the anesthetist - the risk of such a traumatic operation - 4 tbsp. The patient categorically refused the proposed operation, despite a warning about the possible consequences, even fatal.

 In this regard, Yu.M. Maksimov performed a posterior colpotomy on 6/11/93, evacuated about 700 ml of pus from a positive abscess and the abscess cavity was drained with a TMMK-24 double-lumen tube. A TMT-18 double-lumen tube (drainage) was also inserted through the cervical canal through which in the postoperative period, suction-washing treatment (APL) was performed.

 After the drainage of this abscess, the pelvic formation, which protruded far above the womb, ceased to be palpated. A water-soluble radiopaque solution introduced into the uterine cavity, introduced on the next day after the operation during x-ray examination, was installed in the uterine cavity with the rest of the uterus turned off, through insolvent sutures on the front wall of the uterus, immediately filled the marginal space in the area of the drained abscess. Connecting the back-drainage drainage to the suction system freed this space from the contrast solution for 4-5 s. Thus, an adequate evacuation function of this drainage has been identified.

 In the postoperative period, the patient underwent nuclear submarines and fractional manual washing of drained intraabdominal abscesses and the uterine cavity, three-time administration of antibiotics into the cavity of the latter with an exposure of 1.5-2 hours; general antibacterial, infusion and immune therapy, transfusion of erythromass, rheological solutions. Nevertheless, intoxication and hyperthermia remained almost at the same level, in connection with which, this condition was regarded as septic, due to panendometritis.

 To enhance the effectiveness of antibiotic therapy by directly influencing the putative septic lesion, the Institute’s angio-radiologists performed Seldinger aortic catheterization with a catheter placed directly above the aortic bifurcation. A constant intra-aortic drip of antibiotics was established for 3 days in the same way, without a significant effect.

 And only in the future, in connection with the diagnosed subhepatic and left-sided subphrenic abscesses, the patient was again operated on. Autopsy and drainage of these, as it turned out, the latter were carried out with the evacuation of the corresponding 300 ml and 170 ml of purulent contents.

 Only after this a gradual decrease in the temperature reaction and a rapid improvement in the general condition became clearly observed. On average, it took 10-11 days to treat each of the abscesses until their cavity was completely obliterated, and only for the left-sided subphrenic abscess took a significant period (almost a month) due to the presence of the abscess cavity through the pleurobronchial fistula with the bronchial tree of the left lung . Recovery. In 1995 - repeated pregnancy.

Thus, the developed surgical tactics includes drainage with a fixed (one or two) TMMK-24 tube for the entire length of the uterine wall suture failure zone after cesarean section to exclude the purulent contents from the uterine cavity into the free abdominal cavity;
- drainage of the adjacent space or the abscess that has formed here, which has a safety character due to the possible leakage of purulent contents here, bypassing drainage in the joint failure zone;
- drainage of the uterine cavity with a TMMK-18 or 24 tube, which is most suitable for the inner diameter of the cervical canal for constant evacuation of purulent contents, repeated manual fractional washing of the uterine cavity and for 2-3-fold local antibiotic therapy with an exposure of 1.5-2 hours;
- carrying out aspiration-washing treatment through established double-lumen drainage;
- in especially severe or difficult diagnostic cases, it is possible to include in the complex therapy catheterization of the uterine or iliac arteries for continuous drip intra-aortic infusion of antibiotics.

 With the formed rough scar of the uterine wall, plastic surgery is possible (not earlier than 10-12 months).

 The proposed method is less traumatic not only from a medical and psychological point of view, since it allows you to save the uterus, and therefore the reproductive function of a woman, is more effective for antibiotic therapy and can reduce mortality in the most difficult clinical course of the process.

Claims (2)

 1. A method for treating insolvency of suppurative sutures of the uterine wall, complicated by metroendometritis, including drainage of the uterine cavity and antibiotic therapy, characterized in that one of the drains in the uterine cavity is installed through the cervical canal, the second drainage is installed along the suture line of the anterior uterine wall and the third drainage is installed in the adjacent space, through the intrauterine drainage, a constant aspiration-washing treatment of the uterine cavity is carried out with the purulent contents being evacuated and local ant bacterial therapy with an exposure of at least 1.5-2 hours, through the second and third drains, the purulent contents coming through the sutures from the uterus are evacuated.  2. The method according to p. 1, characterized in that they additionally supply antibiotics to the uterine blood supply system through a vascular catheter installed in the iliac or uterine arteries.