RU2242170C2 - Method and device for healing generalized abdominal cavity peritonitis - Google Patents

Abstract

FIELD: medicine; medical engineering.

SUBSTANCE: method involves supplying oxygen via irrigating tubes set into the right and left mesenterial sinuses into the right and left subdiaphragmal space. The oxygen exits via laparostoma. Physiological salt solution is supplied in opposite direction via the laparostoma. The exudate is discharged via draining tubes set in the small pelvis cavity area and along the right and left lateral canal. Planned inspection of the abdominal cavity is carried out 24-48 h later. The device has protection frame manufactured as plate having hole. The protection frame is to be sutured along the laparotomy wound using the holes for receiving suture thread available in the frame. The device has net, border having protrusion, arranged along hole boundary, and cover congruent to the border. The border is set for laying the net. The net is pressed with the cover in the lower part. Recess is available in the lower part of the cover. The recess is engageable with the protrusion on the border and fixable. Holes for receiving suture thread are spaced along the border.

EFFECT: enhanced effectiveness of treatment; preventing drying of peritoneal integument; reduced risk of secondary infection.

2 cl, 5 dwg

Description

The invention relates to medicine, namely to general surgery, and can be used in the treatment of generalized forms of peritonitis.

A known method of sanitation of the abdominal cavity in the postoperative period, developed by Neidhardt et al. (1979, France), which consists in the fact that by creating a laparostomy (open midline wound of the abdomen), the abdominal cavity remains open. Through laparostomy, constant or fractional (intermittent, at least four times a day) lavage (lavage) of the abdominal cavity is carried out. Fluid (dialysate) flows through tubular or strip drains previously introduced through separate incisions in the dorsal (posterior abdominal wall) sections of the abdomen. The direction of fluid flow is from top to bottom. The total flow rate of lavage fluid is 18-68 liters per day. [Tolstykh P.I., Ivanyan A.N. Drainage in surgery, obstetrics and gynecology. Moscow-Smolensk, 2000. - P.67].

The disadvantages of this method.

- This method of treating peritonitis has the disadvantages of peritoneal dialysis. The peritoneum, lining the entire surface of the abdominal cavity, is a biological membrane through which the exchange of electrolytes, proteins, and other trace elements occurs. Due to the large flow rate of lavage fluid (lavage) from the abdominal cavity, in addition to microbes and pathological exudate (purulent effusion), the body's natural protective factors, such as fibrin, immune defense cells, protein fractions, electrolytes, are washed out. In this regard, not only local immunity is violated, but also a protein and electrolyte deficiency arises in the body, requiring replenishment to maintain homeostasis.

- The program (planned) revision of the abdominal cavity is not carried out. Considering that in the abdominal cavity during the period of inflammation, an adhesive-adhesive process is expressed due to the loss of fibrin, the intestinal loops stick together, forming isolated non-draining cavities and pockets between themselves, where pathological exudate (effusion) with a large number of microbes accumulates. Subsequently, these cavities suppurate, forming intra-abdominal abscesses. Program revision of the abdominal cavity (examination of the abdominal cavity during operations under general anesthesia) allows you to destroy loose adhesions and empty the resulting accumulation of exudate, thoroughly rinse and drain the abdominal cavity, remove fibrin threads, necrotic tissue, check the patency of the drainage tubes, and, if necessary, change them , determine the consistency and tightness of the stitches, visually assess the dynamics of the course of the inflammatory process.

- As a result of the adhesive-adhesive process, the installed drainages in the abdominal cavity are delimited (isolated) from the free abdominal cavity in the next day. For this reason, the drainage does not adequately exclude the fluid introduced through the laparostomy (middle wound of the abdomen). Part of the fluid remains in the abdominal cavity and subsequently becomes infected and suppurates, forming abscesses between the loops of the intestine.

This method of treating peritonitis is carried out using a device known from the same invention for applying a laparostomy, which we have chosen as a prototype. The device is represented by an elastic ring with a transparent plastic cone, at the top of which there is a catheter. The device operates as follows. Along the perimeter of the laparotomy wound, an elastic ring with a plastic, transparent cone, which is suspended above the patient’s bed, is inserted into the abdominal cavity. Through a catheter located at the apex of the cone, dialysate (flushing fluid) is introduced. [Tolstykh P.I., Ivanyan A.N. Drainage in surgery, obstetrics and gynecology. Moscow-Smolensk, 2000. P.67].

The disadvantages of this device.

- This laparostomy device performs a narrow function and allows you to enter only liquid into the abdominal cavity and does not provide the function of excretion, for example, gas.

- The device is quite traumatic for the tissues of the abdominal wall. A long stay of the device in a laparotomic (median) wound subsequently causes rigidity (loss of elasticity, mobility) of the muscles of the anterior abdominal wall, and this makes it difficult to suture the median wound of the abdomen. Subsequently, a postoperative hernia may form.

A known method of treating generalized peritonitis developed by Guthy et al. (1980, Germany), which consists in continuous dorsoventral lavage (washing the abdominal cavity in the direction from the back wall to the front) with the outflow of dialysate (flushing fluid) through the laparostomy (not sutured median wound of the abdomen) into the bandage. The fluid is supplied through tubes pre-installed on the posterior wall of the abdominal cavity. For washing, an electrolyte with a total flow rate of 40 liters per day is used [Tolstykh P.I., Ivanyan A.N. Drainage in surgery, obstetrics and gynecology. Moscow-Smolensk, 2000. P.68].

The disadvantages of this method.

- Large volumes of electrolyte injected into the abdominal cavity lead to disorders characteristic of peritoneal dialysis.

- The soft tissues of the abdominal wall are infected in the region of the laparotomy (median) wound. This leads to its suppuration in the future.

- Difficulty in caring for the patient, since the outflow of 40 liters of dialysate occurs through the non-sutured laparotomy wound into the dressing: there is a need for frequent changes to the dressing, bedding.

- Maintains constant contact with the air.

- It is not possible to record injected and withdrawn fluids.

- There is no software revision of the abdominal cavity.

The method of ascending gas-liquid flow was chosen as a prototype as a way to prolonged rehabilitation of the abdominal cavity with generalized peritonitis [Remizov I.V., Savchenko Yu.P., Azaryants S.V., Matosyan T.R. Using the method of ascending gas-liquid flow as an option for prolonged rehabilitation of the abdominal cavity with widespread purulent peritonitis // Materials of the third Russian scientific forum “SURGERY 2001”, Achievements of modern surgery ”M.,“ Aviaizdat ”, 2001. - P.269-270].

The essence of the method is directed gas-liquid flow from the posterior wall of the abdominal cavity to the anterior in a closed abdominal cavity. After eliminating the source of peritonitis, washing and draining the abdominal cavity, the omentum is wrapped up and fixed with a suture to the omentum, if there are signs of amentitis (inflammation of the omentum), it is resected (removed). Four perforated irrigators are inserted through separate contra-perforations (incisions-punctures) on the side walls of the abdomen into the abdominal cavity, which are installed dorsally (along the posterior wall of the abdominal cavity) along the right lateral canal into the pelvic cavity, above and below along the root of the mesentery of the small intestine along towards the mesentery root of the transverse colon, along the left lateral canal into the subphrenic space through an opening made in the crescent ligament of the liver. Thus, irrigator tubes are located in the main anatomical pockets of the abdominal cavity.

A perforated drainage tube was placed over intestinal loops along the median laparotomy wound. The abdominal cavity is sutured in layers hermetically. After the operation, a pulsating jet of a mixture of an antiseptic solution with air is supplied through irrigator tubes, the frequency of washing sessions is 4-5 times a day, and ascending turbulent flows with high mechanical cleaning properties appear in the abdominal cavity, and an air bubble is created under the anterior abdominal wall . The evacuation of liquid and air is carried out through a ventrally located perforated drainage tube, which is located at the boundary between the upper level of the liquid and the gas bubble, and therefore no demarcation of the drainage tube occurs. Between rinsing sessions, hydropneumoperitoneum (gas and liquid in the abdominal cavity) is preserved, for which the tubes overlap. After stopping peritonitis, the fluid passively (due to gravity) is drained through irrigator tubes, which are then removed from the abdominal cavity.

The disadvantages of this method.

- The absence of a programmatic revision of the abdominal cavity does not allow us to visually assess the dynamics of the inflammatory process, sanitize and revise (inspect) all the anatomical pockets of the abdominal cavity, and empty out any accumulations that may fester in the postoperative period. There is no way to verify the consistency of the joints at the site of the remote source of peritonitis, to destroy the formed adhesions that isolate the tubes installed in the abdominal cavity.

- Intra-abdominal pressure is always increased, as hydropneumoperitoneum (gas and fluid in the abdominal cavity) is maintained. With peritonitis, when there is intestinal paresis (lack of motility and intestinal motility) and edema of its wall, conditions of increased intra-abdominal pressure are unfavorable. Complications of microcirculation in the intestine are aggravated, the load on the diaphragm increases, which leads to a decrease in ventilation in the lungs in the lower sections. The risk of developing pulmonary complications increases.

- In conditions of peritonitis, an adhesive-adhesive process is expressed. Therefore, irrigation tubes within the next 16-24 hours are delimited (isolated) from the free abdominal cavity, and ascending gas-liquid turbulent flows will look for the smallest resistance path to exit through the ventrally (drainage installed under the anterior abdominal wall, over the intestinal loops) located drainage.

- With this method of sanitation, gas and, to a lesser extent, pathological exudate and wash fluid will be removed from the abdominal cavity. This is due to the fact that the flow direction of the gas-liquid mixture goes from bottom to top, against gravity.

The closest is the "Device for laparotomy" according to patent SU 1713562, MKI 5 A 61 B 17/00, BI No. 7, 1992, p.17. The wound protection unit is made in the form of a cuff with a glove manipulator, in which wound size retainers are installed, each of which is made in the form of two vertical rods with a heel and a horizontal tube with telescopic extension.

The disadvantages of this device.

- This device can only perform a draining function and does not provide for active rehabilitation.

- The device does not provide the introduction of fluid into the abdominal cavity.

- The device does not allow for scheduled audits, as it serves as the final and only method for draining the abdominal cavity.

- The design does not allow creating a water lock, delimiting the abdominal cavity from the external environment.

The objective of the invention.

To create a method that allows to increase the effectiveness of treatment by combining active rehabilitation of the abdominal cavity under conditions of lalarostomy by creating an ascending gas stream and an oncoming liquid stream at a pressure close to atmospheric inside the abdominal cavity with ongoing program revisions of the abdominal cavity. Moreover, the additional installation of drains allows more efficient removal of pathological exudate. To provide more effective protection of the tissues of the anterior abdominal wall, to prevent its infection due to the design of the device and to delimit the abdominal cavity from the external environment, preventing the drying of the peritoneal cover by creating a water seal through which gas escapes and fluid is supplied.

The problem is achieved by the method of sanitation of the abdominal cavity with generalized peritonitis, including the flow of gas through the tube-irrigators and fluid through the laparostomy in the abdominal cavity in the opposite direction. At the same time, the exudate is removed through drainage tubes and gas from the abdominal cavity. The gas is oxygen. Irrigator tubes are installed in the right and left mesenteric sinus, in the right and left subphrenic space. Gas escapes through the laparostomy (midline abdominal wound), into which fluid is supplied in the opposite direction. Exudation and wash water are discharged through drainage tubes installed in the pelvic cavity and along the right and left lateral canals. After 24-48 hours, a routine revision of the abdominal cavity (program relaparotomy) is carried out, on which the formed loose adhesions are divided, the patency of the drains is restored, the entire abdominal cavity is examined, washed, drained, the non-drained cavities and pockets are emptied, and the dynamics of the inflammatory process are evaluated.

Distinctive features of the proposed method are that:

- as the gas supplied through the tubes, irrigators, use oxygen;

- irrigator tubes are installed in the right and left mesenteric sinuses, in the right and left subphrenic space,

- the gas exits through the laparostomy, into which liquid is supplied in the opposite direction. Due to the oncoming movement of gas and liquid, a turbulent movement arises with a mechanical cleaning effect,

- the removal of pathological exudate and wash water is carried out through drainage tubes installed in the pelvic cavity and along the right and left side channels,

- A planned revision of the abdominal cavity (programmed relaparotomy) is carried out after 24-48 hours.

The proposed method is illustrated by the drawings presented in figure 1, figure 2, figure 3.

Figure 1 shows the location of the irrigator tubes and drainage in the abdominal cavity.

Figure 2 shows the location of the tubes-irrigators, drains and devices in the laparostomy.

Figure 3 shows the movement of fluid and gas in the abdominal cavity.

To achieve the named technical result, a device for creating a laparostomy, including a protective frame sewn along the contour of the laparotomy wound, is proposed. The protective frame is made in the form of a plate with a hole along the contour of which the side with the protrusion passes, holes for suture thread are made along the side of the protective frame, a mesh is laid on the side of the side of the side, which is pressed by the cover of the congruent side of the protective frame with the hole in the upper part, along the lower contour part of the lid there is a recess that can interact with the protrusion on the side and fixation, while the holes for the suture thread are located along the side.

Distinctive features of the proposed device are that:

- additionally contains a grid,

- placed along the contour of the hole side with a protrusion and congruent side cover,

- the side is made for laying the mesh, and the mesh is made for pressing the lid, in the lower part of which there is a recess that has the ability to interact with the protrusion on the side and fixation,

- holes for suture thread are located along the side.

The laparostomy device isolates the tissues of the anterior abdominal wall from the free abdominal cavity. The infection of the tissues of the abdominal wall with pathological peritoneal exudate is reduced, which is the prevention of suppuration of the median wound in the postoperative period. The design allows liquid solutions (physiological saline) to be introduced into the abdominal cavity through the laparostomy (middle wound of the abdomen) and at the same time, given that the abdominal cavity remains open, gas (oxygen) can be freely discharged. In such conditions, when the abdominal cavity is open, the intra-abdominal pressure during active rehabilitation will be slightly increased. Due to the design, a layer of fluid (hydraulic shutter) is created in it, which delimits the abdominal cavity from the external environment. Such protection of the abdominal cavity from the external environment prevents drying of the peritoneal cover, reduces the risk of secondary infection of the abdominal cavity. The device eliminates the eviscination (prolapse) of the internal organs through the laparostomy.

The device is illustrated by the drawings presented in Fig.4 and Fig.5.

Figure 4 is an exploded view of the device.

Figure 5 - the device is assembled.

The method is as follows. After eliminating the source of peritonitis, washing and draining the abdominal cavity, the omentum is sutured to the omentum so that it does not impede the outflow of peritonial exudate into the laparostomy. Irrigators tubes are installed in the left (D) and right (C) mesenteric sinuses, in the left (B) and right (A) subphrenic spaces. Drainage tubes are installed in the pelvic cavity (E) and in the right (F) and left (K) side channels. The small intestine is drained nasogastroitestinally (an intestinal tube is inserted through the nose, is carried out through the esophagus, through the stomach, and through the small intestine). A protective frame (1) is sewn into the laparotomy wound with nodal P-sutures (10), passed through all the tissues of the abdominal wall. Between the device and the laparotomy wound, a gauze napkin (11) is laid, abundantly saturated with ointment. Thus, the tissues of the abdominal wall are isolated from the abdominal cavity. In the postoperative ward, humidified oxygen begins to flow through the irrigator tubes (A, B, C, D) at a pressure of 0.2 atm, and physiological saline solution (NaCl 0.9%) is poured through the opening (9) of the device cover. Saline solution has the least damaging effect on the cells of the peritoneal cover and to a lesser extent has the effect of peritoneal dialysis. The fluid supply rate and gas supply volume are selected so as to create a fluid layer in the device, which serves as a delimiter of two media (the abdominal cavity and atmosphere), and thereby creates a water seal. The fluid gradually leaves the device in the abdominal cavity, where it meets an upward gas flow of oxygen. Oxygen exits through the opening (9) of the device. Turbulent-liquid bubble flows occur. A drilling effect appears, which has a mechanical cleaning effect. Oxygen acts bactericidal on the microflora, in addition, locally increases the oxygenation of tissues, reduces the adhesion process. The outflow of peritoneal exudate is carried out through drains (E, F, K), and to restore the liquid layer, physiological saline continues to drip through the opening (9) of the device. The effect of “mini-lavage” of the abdominal cavity is achieved. The volume of injected saline solution is 3-5 liters per day. A small amount of saline injected into the abdominal cavity to a lesser extent than during dialysis causes a negative effect of leaching of electrolytes and proteins through the peritoneum. After 24-48 hours, a planned revision of the abdominal cavity is carried out: the structure is removed, sterilized according to the standard procedure in a solution of formic acid. The abdominal cavity is inspected, loose adhesions are separated, the patency of the drains (E, F, K) and irrigation tubes (A, B, C, B) is checked, and the abdominal cavity is washed and thoroughly drained. If the phenomena of peritonitis have not stopped, the device in the laparostomy wound is restored, active rehabilitation of the abdominal cavity continues. Gauze napkins (11) abundantly saturated with ointment change daily. They additionally ensure the tightness of the device, protect the tissues of the abdominal wall from drying out and infection. Planned revisions of the abdominal cavity are carried out before the relief of the phenomena of widespread peritonitis, after which the irrigator tubes (A, B, C, D) are removed. Drain pipes (E, F, K) are left. Laparotomic wound is sutured in layers, thereby closing the abdominal cavity. If the left drainage (E, F, K) in the postoperative period ceases to function (the exudate of the abdominal cavity ceases to flow over them), they are removed.

Using the proposed method can significantly increase the effectiveness of rehabilitation (cleansing) of the abdominal cavity, thereby improving the results of treatment of peritonitis. This is achieved by creating an upward gas flow and an oncoming liquid flow through the laparostomy. In this case, a turbulent movement occurs in the abdominal cavity, which has a high mechanical cleaning effect. Such rehabilitation is carried out in conditions of laparostomy. Gas leaves through the open abdominal cavity (laparostomy), while the pressure in the abdominal cavity remains slightly increased. Such conditions for the blood supply to the internal organs are more favorable than the conditions of the closed abdominal cavity, when the intra-abdominal pressure with peritonitis, due to intestinal paresis, is always increased. The turbulent movement that occurs in the abdominal cavity causes not only a cleansing effect, but also prevents the adhesive process in the abdominal cavity. Turbulent flows cause the effect of drilling in the abdominal cavity, which prevents the adhesion of internal organs to each other. Due to this, less blind pockets and closed cavities are formed in the abdominal cavity, where peritoneal exudate accumulates. Oxygen introduced into the abdominal cavity acts bactericidal on the microflora and oxygenates (saturates the tissues with oxygen) tissues of the abdominal organs, which improves their nutrition and blood supply. Preservation of laparostomy (open abdominal cavity) can significantly reduce intra-abdominal pressure. A constant supply of a fluid solution (Saline solution) through the laparostomy allows you to keep a moist environment in the abdominal cavity, preventing the drying of the peritoneal cover. Drying the peritoneal cover of the internal organs leads to damage to the cells of the peritoneum, which enhances the adhesion process in the abdominal cavity. Due to the continuous introduction of fluid through the laparostomy and its removal through the drainage tubes, the abdominal cavity is constantly washed (lavage), which ensures dilution and removal of pathological exudate. Given that the volume of fluid injected into the abdominal cavity per day does not exceed 3-5 liters, there is no negative effect of peritoneal dialysis. Additionally installed drains allow more efficient removal of pathological exudate and wash water. Gauze wipes, richly soaked with ointment, additionally protect the soft tissues of the abdominal wall from drying out and infection, and improve the hermetic function of the device.

The proposed method allows to increase the effectiveness of the treatment of generalized peritonitis due to the combination of active rehabilitation of the abdominal cavity under laparostomy due to the creation of an ascending gas (oxygen) flow and a counter-descending fluid flow (physiological solution) inside the abdominal cavity with ongoing program revisions of the abdominal cavity. Counter-directed gas and liquid flow causes the appearance of turbulent motion with a cleaning effect. Additionally installed drains allow more efficient removal of pathological exudate and wash water.

Clinical example.

Patient G., 65 years old, was admitted in serious condition with a clinic of diffuse peritonitis.

Anamnesis: 10 years suffering from gastric ulcer with frequent exacerbations. Last exacerbation two weeks ago. A day ago, a sudden sharp pain appeared in the upper abdomen, which then decreased slightly, but did not pass. The pain did not disappear, radiating along the right lateral canal, and then spread throughout the abdomen.

Objectively: a serious condition, acrocyanosis (cyanosis of the skin), lies motionless on the back, any movement causes increased pain in the abdomen. HELL 90/40 mm RT. Art., heart rate (HR) 130 per min. The abdomen is swollen, does not participate in the act of breathing, intestinal peristalsis noises are not heard, with palpation, moderate tension in all departments with a positive peritoneal reaction. In blood tests - pronounced leukocytosis with a shift of neutrophils to young forms. After 3 hours of preoperative preparation, the patient was taken to the operating room.

Operation: the patient is laid on the operating table in the supine position. A catheter is placed in the bladder to control diuresis. A probe has been inserted into the stomach. The patient was given endotracheal anesthesia (ETN). After processing the surgical field, the upper-mid-median laparotomy was performed - the abdominal cavity was opened. In all parts of the abdominal cavity, a murky purulent-fibrinous effusion in an amount of about 2 liters was taken, the effusion was taken to determine the microflora spectrum and its sensitivity to antibiotics. Drainage of the abdominal cavity by electric suction pumps. During the audit, a perforated ulcer of the anterior wall of the pyloric stomach was found, which was sutured according to the Oppel-Polikarpov method. There is diffuse purulent-fibrinous peritonitis in the toxic phase: on the loops of the intestines, non-removable plaque of fibrin. The peritoneum is swollen, crimson, loops of small intestines are paretic. The disassembled device was processed in a formic acid solution according to a standard method. The abdominal cavity was washed with furatsilin solution (10 liters), drained. The small intestine is intubated transnasogastric. 1 liter of stagnant contents was evacuated. In the sloping places of the abdomen, in the right lateral canal, left lateral canal and small pelvis, polyvinyl chloride drainage tubes (E, F, K) are installed, which are led through separate incisions to the anterior abdominal wall. Drainage tubes are hermetically fixed to the skin. Irrigator tubes (A, B, C, D) are installed in the left and right mesenteric sinuses and in the subphrenic spaces on the left and right. The large omentum is hemmed with interrupted seams to the small omentum. The protective frame through all layers is sewn along the contour of the laparotomy wound. The construction cover is worn on the side of the protective frame. Thus, the device is hermetically sewn into the laparotomy wound. Between the device and tissues of the laparotomy wound, gauze napkins were laid, abundantly soaked with Vishnevsky ointment (balsamic liniment according to Vishnevsky).

In the postoperative period, a catheter is installed in the epidural space of the spine for anesthesia and treatment of intestinal paresis (the so-called epidural block). Subsequently, against the background of the peridural block, oxygen was supplied through the irrigator tubes into the abdominal cavity, and physiological saline was dripped through the round opening of the device cover so that a layer of fluid remained between the abdominal cavity and the external environment (water seal). Oxygen is passed through physiological saline solution to moisturize before being fed to irrigator tubes. Oxygen is supplied at a pressure of 0.2 atm. The outflow of peritonial exudate was carried out through drainage tubes. The flow rate of saline is 3-5 liters per day. The supply of saline is selected so that a layer of liquid is created in the device, creating a water seal. Bandaging was carried out daily. Wipes with Vishnevsky ointment changed. During dressing, the lid and mesh were removed, intestinal loops that were to be wound were examined. Then the lid and mesh were put back into working condition. Intestinal peristalsis appeared on the second day, the clinical manifestations of endotoxemia decreased. After two days (after 48 hours), a planned revision of the abdominal cavity was performed. The device is removed from the laparotomy wound. The abdominal cavity was examined (revised). The effusion is scarce, of a serous nature, the loops of the intestines are collapsed, peristaltic, their serous cover is bright pink, no fibrin deposits. Thus, peritonitis regressed. Irrigator tubes have been removed. Drain pipes left. The laparotomic wound is sutured in layers. In the postoperative period after revision of the abdominal cavity, active intestinal motility restored by the second day. In blood tests, a decrease in the inflammatory response.

There is no discharge through the drainage tubes, they are removed. On the third day, the patient was completely transferred to enteral (natural) nutrition, the gases began to go off on their own, there was a stool. On the fifth day, the patient began to walk. The wound healed by first intention, the sutures were removed on the tenth day after the last operation. The patient was in the hospital since the receipt of 18 bed days. Discharged in satisfactory condition without complications.

To obtain such a technical result in the proposed method for the treatment of peritonitis, a device (Fig. 4 and Fig. 5) is used to create a laparostomy (open middle wound of the abdomen) containing a protective frame (1) in the form of a plate with a hole made for suturing along the contour of the laparotomy wound (median wound of the abdomen) and having openings for suture thread (5). A flange (3) with a protrusion (4) passes along the contour of the hole (2), along the flange (3). The device further comprises a grid (6). A grid (6) is laid on the ledge (4) of the side (3), which is pressed by the cover (7), congruent to the side (3) of the protective frame (1), with an opening (9) in the cover (7) in its upper part. Along the contour of the lower part of the cover (7) there is a recess (8) interacting with the protrusion (4) on the side (3) of the protective frame (1) with the possibility of fixation.

The device consists of a protective frame (1) in the form of a plate made in the shape of a laparotomy wound, i.e. oval, and made, for example, of polyethylene 5 mm thick. In the center of the protective frame (1) there is an opening (2), also oval. A contour (3) of a height of 20 mm is made along the contour of the hole (2). In the upper part of the side (3), along its entire contour, there is a protrusion (4) with a size of 5 × 5 mm. On the protective frame (1) along its entire contour, along the side (3) there are perforations (5) with a diameter of 3 mm for a suture thread. A polyethylene mesh (6) is laid on the protective frame (1), which closes the oval hole (2) of the protective frame (1). Its thickness is 3 mm. The oval-shaped lid (7) has a side wall 50 mm high and its perimeter corresponds to the perimeter of the oval hole (2) of the protective frame (1). In the upper part of the cover there is a round hole (9) with a diameter of 30 mm. 20 mm from the lower edge of the side wall of the lid (7) around the entire perimeter there is a recess (8) congruent to the protrusion (4) of the protective frame (1). Due to their elastic interaction, fixation is carried out.

The device in the laparotomy wound is installed as follows. The entire structure is sterilized according to standard procedures in formic acid solution. The protective frame (1) is sutured along the laparotomy wound with interrupted P-sutures through all layers of the abdominal wall by passing the thread through the perforation holes (5) located on the protective frame (1), which ensures isolation of the dissected abdominal wall tissues from the abdominal cavity. In addition, the horizontal part of the protective frame (1) also enters the abdominal cavity and further isolates the abdominal wall tissue from it. A mesh (6) is laid on the protective frame (1), then a cover (7) is put on, which is tightly fixed to the protective frame (1) due to the congruent connection between the protrusion (4) of the protective frame side (3) (1) and the recess (8) covers (7). Between the dissected tissues of the abdominal wall and the structure itself, napkins with ointment are placed, which mechanically protects the soft tissues and additionally ensures the tightness of the abdominal cavity. Napkins are periodically changed 1 time per day during dressings. At the next revision, the device is completely removed. If peritonitis has not stopped, then the device is restored again, creating an airtight laparostomy. When stopping peritonitis, after removing the device at the next revision, the median wound is sutured in layers. The abdominal cavity closes.

The device operates as follows. In the postoperative period, drip saline is supplied through a round opening (9) of the lid (7). When physiological saline is introduced into the structure, a layer of fluid is created that separates the abdominal cavity from the external environment and serves as a water seal. It is impossible to create such a layer of liquid without construction. The thickness of this layer is not more than 1-2 cm. The gas (oxygen) that is supplied through the irrigator tubes exits through the round hole (9) of the cover (7). Saline, due to gravity, gradually goes into the abdominal cavity. Washes its organs and is removed through drainage tubes. Therefore, the liquid layer in the structure is constantly restored by dropping it through the round hole (9) of the cover (7). Thus, continuous washing of the abdominal cavity is created.

The device provides the creation of an airtight laparostomy, which allows sterile fluid (physiological saline) to be introduced into the open abdominal cavity towards the upward gas flow. In this case, the gas freely passes through the liquid layer in the device (hydraulic shutter) and exits through the round hole (9) of the cover (7), without creating high intra-abdominal pressure. The device allows you to isolate the tissues of the anterior abdominal wall from the free abdominal cavity, which reduces their infection and prevents suppuration of the median wound after it is sutured. Thanks to the device that creates a seal between the dissected tissues of the abdominal wall and the abdominal cavity, a physiological solution is created through a physiological solution through which a layer of liquid is created (hydraulic shutter). The resulting water seal will separate the abdominal cavity from the external environment. A fluid layer (water trap) is the least traumatic separator of two media, unlike synthetic materials (gauze, various types of nets, films) used in other laparostomy devices to protect the intestinal loops of the small intestine, which are exposed to the laparotomy wound, from drying out and secondary infection of the entire abdominal cavity . The device eliminates eventration (prolapse of internal organs). The device allows you to visually control the dynamics of the inflammatory process, since the lid (7) and mesh (6) can be removed from the protective frame (1) and the intestinal loops adjacent to the laparotomy wound can be examined and their morphological changes evaluated. Then re-lay the net (6) on the protective frame (1) and put on the cover (7), assembling the device in working condition.

The proposed device and method is used in practice in the treatment of generalized forms of peritonitis in the emergency surgical department of the City Clinical Hospital No. 1 of Novokuznetsk.

Claims (2)

1. The method of sanitation of the abdominal cavity with generalized peritonitis, including the supply of gas through the tube-irrigators and fluids into the abdominal cavity, the removal of exudate and gas, characterized in that oxygen is supplied through the tube-irrigators installed in the right and left mesenteric sinuses, into the right and left subphrenic spaces that exits through the laparostomy into which physiological saline is supplied in the opposite direction, the exudate is discharged through drainage tubes installed in the cavity of the small behind and along the right and left side channels, after 24-48 hours, a planned revision of the abdominal cavity is performed. 2. A device for creating a laparostomy, comprising a protective frame in the form of a plate with a hole, made for suturing along the contour of the laparotomy wound and having openings for suture thread, characterized in that it further comprises a mesh placed along the contour of the hole side with a protrusion and congruent edge cover, moreover, the rim is made for laying the net, and the net is made for pressing the lid, in the lower part of which there is a recess that can interact with the protrusion on the rim and fix, while the holes d suture disposed along the rail.

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