RU2248757C2 - Method for plasty of limb's skin after early necrectomy - Google Patents

Abstract

FIELD: medicine, plastic surgery.

SUBSTANCE: at carrying out necrectomy of deep burns upon patient's limbs by applying a hemostatic tourniquet it is necessary to perform skin plasty with a one-piece skin transplant under the tourniquet, and the latter should be removed after applying a pressing bandage onto the wound that enables to decrease intraoperational blood loss and shorten the terms of operation for hemostasis before plasty.

EFFECT: higher efficiency.

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Description

The present invention relates to medicine, namely to plastic surgery, and can be used for more rapid treatment of deep burns on the extremities with improved functional and cosmetic results.

Basically, surgical treatment of deep burns boils down to two main types of operations. The first of these involves the removal of dead tissue (necrectomy). The second is the restoration of lost skin. Dead tissue (scab) is the cause of intoxication and microbial inflammation, often leading to a breakdown of adaptation processes. To completely get rid of these undesirable consequences only early removal of the scab allows. When performing necrectomy in the early stages after an injury, two main objectives are pursued: removing a burn scab, which is one of the sources of infectious-toxic complications and accelerating the preparation of wounds for plastic closure (Paramonov B.A. et al. Burns: A Guide for Doctors. - St. Petersburg. , 2000 .-- 489 p.).

Significant blood loss usually accompanying the excision of dead tissue is one of the reasons that limit the possibility of early surgical treatment of burns (Vikhreev BS, Burmistrov VM Burns: Manual. - M .: Medicine, 1986. - 231 p.). To reduce blood loss, surgeons focus on the technique of performing the operation, preferring to operate under hemostatic tourniquets whenever possible (Gusak V.K. et al. Thermal subfascial lesions. - Donetsk, 2000. - 192 p.).

There is no doubt the desirability of replacing a wound defect with skin grafts immediately after excision of the dead tissue in order to minimize the pathological effect of the resulting wound (Vikhreev BS, Burmistrov VM Burns: Guide. - M .: Medicine, 1986. - 231 p.) . After hemostasis, the majority of surgeons close the resulting wound surface with perforated autografts with small perforation indices, which in their properties approach non-perforated ones, but have better drainage ability, which partially prevents the development of hematomas under flaps (Aminev V.A. et al. A modern approach to the treatment of deep burns in children // Actual problems of thermal injury: Abstracts of international conference - SPb, 2002. - p. 318-319). Although non-perforated flaps provide the best functional and cosmetic result (Vikhreev B.S., Burmistrov V.M. Burns: Manual. - M .: Medicine, 1986. - 231 p.).

A known method of performing early tangential necrectomy, described by B.S. Vikhreev and V.M. Burmistrov (Burns: A Guide. - M .: Medicine, 1986. - 231 p.). For tangential necrectomy, it is most convenient to use an electrodermatitis, which allows you to cut off dead tissue up to 2 mm thick. Excision can be carried out 2-3 times. The bottom of the resulting wound is even. Blood and tissue fluid appearing at the time of excision do not interfere with the instrument. To reduce blood loss, necrectomy on the limbs, it is advisable to carry out after applying a hemostatic tourniquet. After the necrectomy is completed, the tourniquet is removed. Produce hemostasis: the application of hemostatic clamps, the use of electrocoagulation, local use of hemostatic drugs. Blood loss during necrectomy with simultaneous plastic surgery on average 1 ml per 1 cm ^{2 of the} wound to be closed. For the prevention of acute hemodynamic disturbances during surgery and postoperative anemia, timely compensation for intraoperative blood loss is necessary. After hemostasis, plastic is most often performed with a perforated flap.

The disadvantages of the method of operation include:

1) large blood loss during surgery and, as a consequence, the need for blood transfusion;

2) the duration of the operation;

3) preference for plastic mesh (perforated) autoloscoot.

For the prototype, we adopted the method of plastic surgery after the tangential excision of the scab described by H.F. Karvayal and D.H. Parks (Burns in children. Transl. From English. - M .: Medicine, 1990. - 512 p.). The method involves the use of a pneumatic tourniquet on the limbs with periodic bloodletting. Necrectomy is performed with a dermatome. To achieve hemostasis after depressurization of the air braid, apply pressure dressings with elastic bandages for at least 20 minutes. Then transplants are transplanted onto a hemostatic wound. Perforated skin grafts are preferred, as the process of "implantation" of the flap is accelerated and peeling hematomas and tumor-like accumulations of blood serum are not formed. Apply dressings.

The disadvantages of this method of treatment include:

1) lengthening of the operation time due to the application of elastic pressure dressings for at least 20 minutes;

2) preference for perforated autolosks due to the threat of hematomas and, as a consequence, the presence of a net pattern on autolosks in the postoperative period.

Tasks:

1) Improve early necrectomy with primary skin autoplasty.

2) Reduce intraoperative blood loss due to plastic surgery under the tourniquet.

3) Reduce the time of surgery for hemostasis before plastic surgery.

4) Achieve improved cosmetic results in the postoperative period due to the use of non-perforated split autografts.

The essence of this invention is that when conducting an early tangential necrectomy of deep burns on the extremities using a hemostatic tourniquet, skin plasty with a split non-perforated graft taken before necrectomy is performed under the tourniquet, and the tourniquet is removed after applying a pressure dressing to the wounds.

An early necrectomy with primary autoplasty in patients with deep burns is carried out on the 2-7th day from the moment of injury, after stabilization of the general condition of the patient. The operation begins after standard preparation and processing of the surgical field. First, an electrodermatome takes out skin autologous flaps 0.2-0.3 mm thick in places free of burns, an area equal to the estimated necrectomy. Dressings with antiseptics are applied to donor wounds. Autoloscoats are wrapped in bandages with furatsilinom. Then, a hemostatic tourniquet is applied to the affected limb, proximal to the burn. Non-viable tissues to the lower layers of the dermis and mosaic sections of exposed subcutaneous tissue are tangentially removed with an electrodermatome. No bleeding is observed. After a visual assessment of the complete removal of necrosis, autoplatia is performed with a split skin non-perforated graft. The edges of the flap are hemmed. Apply a bandage with an antiseptic. The wound is tightly bandaged in 5-7 rounds with a medical bandage. For tissue immobility on the opposite side of the limb in the projection of the unaffected skin areas, a gypsum splint is applied with mobilization of adjacent joints with maximum stretching of the skin in the affected areas. The tourniquet is removed immediately after applying a pressure bandage and spacers. The time of application of the tourniquet depends on the area of necrectomy and ranges from 10 to 30 minutes. In the postoperative period, an elevated position is created for the limb. The first dressing is performed on the 3-5th day. Full adaptation of skin autologous flaps is noted, as a rule, on the 7th-9th days.

According to this technique, 23 patients with deep burns of the extremities were operated on.

Example 1. Patient S. No. 957 delivered by the ambulance one hour after the injury: stepped in a container with hot water. Diagnosis: Thermal burn (boiling water) of the right foot 3% (2.5%) / IIIA-IIIB Art. On the 3rd day after stabilization of the general condition and the beginning of the formation of the scab of burns IIIB Art. the patient was taken to the operating room (see the appendix, photo 1). Autologous flaps 0.2 mm thick and an estimated necrectomy area of 250 cm ² were taken from the right thigh with an electrodermatome. A tourniquet was applied to the middle third of the lower leg proximal to the burn wound. An electrodermatome tangentially removed layer by layer the forming scab up to 0.7-0.9 mm thick, to the lower layers of the dermis and mosaic sections of the subcutaneous tissue. In this case, bleeding is not observed (see the appendix, photo 2). Further, without removing the tourniquet, we perform autoplasty with a split non-perforated flap with hemming of the edges (see the appendix, photo 3). Then we apply a bandage, tightly bandage 5-7 rounds with a medical bandage. Remove the harness. The duration of the operation from the moment the tourniquet is applied until it is removed is 15 minutes. Blood loss is noted only from the donor site. The first dressing after plastic surgery on the 5th day. Complete adaptation of autolosks is noted. The patient was discharged for outpatient treatment 10 days after surgery. He began to walk 15 days after the operation. 4 months after the injury, the restoration of the function is complete, the formation of contractures and hypertrophic scars is not observed, a good cosmetic result is noted due to plastic surgery with an unperforated autolosug (see the appendix, photo 4).

Example 2. Patient K. No. 11375 transferred from the Central District Hospital on the second day after the injury. Diagnosis: Thermal burn (flame) of the left upper limb 7% (2%) / II-IIIA-IIIB Art. Localization of deep burns - the rear of the hand and forearm. 2 days after admission to the hospital operated by the proposed method. On the 9th day after the operation, a complete adaptation of autolosks is noted. Burns II-IIIA Art. epithelized on the 20th day after the injury. The patient was discharged for outpatient treatment. 2 months after the injury - complete restoration of the function of the left upper limb, post-burn contractures and hypertrophic scars is not noted, full recovery, working as a driver.

Despite the permutation of the stages of the operation, the proposed method for plastic surgery of the skin of the extremities after early necrectomy allows to reduce intraoperative blood loss due to plastic surgery under the tourniquet. On average, the operation time required for hemostasis before plastic surgery is reduced by 15-20 minutes. Full adaptation of autolapses is observed on the 7th-9th day after surgery. Due to the use of non-perforated autolosks in the postoperative period, the full function of the affected areas is restored, post-burn contractures and hypertrophic scars are not formed, and a good cosmetic result is noted.

Claims (1)

The method of plasty of the skin of the limbs after an early necrectomy, including applying a tourniquet, removing dead tissue, applying a pressure bandage, removing the tourniquet, characterized in that the plastic is performed with a whole skin graft immediately after removing the dead tissue, and the tourniquet is removed after applying a pressure bandage.

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