RU2271756C1 - Method for preventing the development of peritoneal viscero-parietal adhesions - Google Patents

Abstract

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with operations upon organs of abdominal cavity. One should introduce a device in the form of a film of either oval or rhombus shape into abdominal cavity, the shortest diagonal of rhombus is about 10-15 cm, the longest one corresponds to wound's length. A polymeric tube is located along the longest diagonal with two cords coming along film's perimeter at tube's one end. Ligature is fixed to the middle of each cord. Tube's end with fixed ends of cords should be fixed with a through ligature to internal surface of abdominal wall being above the upper angle of the wound. Another end of the tube with free ends of cords should be withdrawn through separate incision of abdominal wall being below the lower angle of the wound. Cord-fixed ligatures should be withdrawn being cross-sectionally against wound's axis. Before removing the device one should cross fixing ligatures. Due to traction by tube's external end one should remove the device. The innovation prevents the development of postoperational adhesions.

EFFECT: higher efficiency of prophylaxis.

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Description

The invention relates to medicine, namely to surgery, and can be used in abdominal operations.

One of the unsolved problems of general surgery is the problem of combating the postoperative adhesive process in the abdominal cavity and the complications associated with it. Most of the complications are due to viscero-parietal adhesions of the abdominal organs in the area of the abdominal wall scar. Reliable means of preventing viscero-parietal adhesions of the peritoneum are absent.

According to the authors of US patent No. 6391939, effective prevention of the formation of adhesions between the internal organs is their isolation using "physical barriers", which can be used biocompatible polymer films (for example, Teflon, silicone and others). In the patent of the Russian Federation No. 2177332 it is indicated that the materials currently approved for clinical use are barriers based on mechanically stretched polytetrafluoroethylene, polyethylene or polypropylene. However, the problems of the occurring displacement of this film due to movements of the internal organs and body of the patient have not yet been resolved. The main disadvantage of using these barriers is the need for repeated intra-abdominal surgery to remove the film, which represents a major surgical trauma, requires the use of general anesthesia and can lead to the formation of new viscero-parietal adhesions.

A known method of preventing the formation of adhesions using a device that separates the internal organs and the parietal peritoneum (US patent No. 5192296). In this method, before suturing the laparotomy wound, a device in the form of a balloon made of an elastic biocompatible polymer material is placed in the abdominal cavity. After the operation, liquid is periodically injected into the balloon, which ensures the mechanical separation of the resulting adhesions. The disadvantage of this method is its high morbidity.

The closest analogue is a method for preventing the formation of viscero-parietal adhesions of the peritoneum after surgical interventions, including introducing into the abdominal cavity and fixing to the abdominal wall a device for separation of internal organs and parietal peritoneum and its removal after restoration of intestinal motility before suturing the laparotomy wound (RF patent No. 2150897 , IPC 7 A 61 B 17/00, A 61 L 24/00, 2000 - prototype). In the postoperative period, for 4-5 days, periodic (1-2 times a day) mechanical separation of the formed adhesions between the internal organs and the abdominal wall is carried out using a device made in the form of a movable elastic cord, to the middle of which a long thread is fixed from a non-absorbable suture material with outward-facing free ends.

The specified method does not prevent the occurrence of adhesions, and carries out a mechanical separation of adhesions at the initial stage of their formation. The disadvantages of the method are high trauma, the need for daily separation of adhesions, accompanied by pain in the patient, the lack of drainage of the space under the laparotomy wound, which can lead to hemorrhagic and inflammatory complications in the abdominal cavity.

The objective of the invention is the prevention of the formation of postoperative viscero-parietal adhesions.

EFFECT: reliable isolation of the visceral peritoneum of the internal organs from the parietal in the area of the postoperative wound, reducing trauma and simplifying the method, providing drainage of the space under the sutured laparotomy wound.

This result is achieved by the fact that in the method of preventing the formation of viscero-parietal adhesions of the peritoneum, including surgery, before suturing the laparotomy wound, the authors introduce into the abdominal cavity and fixation to the abdominal wall a device for separating internal organs and the parietal peritoneum after restoration of intestinal motility, it is proposed to place the device in the form of a film of a biocompatible polymer material in the form of an oval or rhombus in the abdominal cavity, the smaller diagonal of which is 10-15 cm, and a large one corresponds to the length of the wound; a polymer drainage tube is placed along the larger diagonal, the length of which exceeds this diagonal by at least 5 cm, the ends of two polymer strands are fixed at one end of the tube, passing along the perimeter of the film towards each other to the other end of the tube, where they are movably fixed to the tube with free ends at the place of its contact with the edge of the film, with a ligature attached to the middle of each of the strands; after installing the device in the abdominal cavity, it is proposed to fix the end of the tube with the fixed ends of the strands through the ligature to the inner surface of the abdominal wall above the upper corner of the wound, and bring the other end of the tube together with the free ends of the strands out through a separate section of the abdominal wall below the lower corner of the wound, attached to the polymer strands of ligature, bring out across the axis of the wound out through punctures of the abdominal wall, remote from the axis of the wound at a distance of at least half the smaller diagonal of the film, after which the laparotomy Well take in tension and ligatures stretch film; Before removing the device, cross the ligatures that fix it, fold the film by pulling the free ends of the cords and traction the outer end of the tube to remove the device.

The use of a film of biocompatible polymeric material (for example, polyethylene, fluoroplastic, polypropylene, etc.), which is placed in the abdominal cavity between the internal organs and the parietal peritoneum, reliably isolates them from each other, preventing the formation of adhesions. The design of the device (the presence of strands with ligatures, skipped around the perimeter of the film and fixed rigidly at one end of the tube and movably at the other) allows you to straighten the film after suturing the wound over the entire necessary contact area of the visceral and parietal peritoneum, and then fold it for less traumatic removal from the abdominal cavity . Fixing the device at 4 points ensures a constant position of the expanded film and separation of organs, regardless of their movements. The shape (oval or diamond-shaped) and the size of the film (the length of one diagonal is 10-15 cm, and the second is 15-50 cm) due to the shape and size of the laparotomy wound. Reducing the size of the film compared to those indicated will lead to incomplete isolation of the organs from the postoperative wound, and an increase in size will lead to technical difficulties when removing the device, the possibility of wrinkles on the film and its loose fit to the parietal peritoneum. The length of the drainage tube must exceed the largest diagonal of the film by at least 5 cm in order to bring its end free from the film through the abdominal wall to the outside to drain the abdominal cavity under the sutured laparotomy wound and subsequent removal of the device. The presence of a drainage tube in the device prevents the accumulation of blood and exudate between the film and the parietal peritoneum and reduces the likelihood of intra-abdominal hemorrhagic and inflammatory complications.

Figure 1 presents a device for preventing the formation of viscero-parietal adhesions of the peritoneum, figure 2 is a horizontal section of the abdominal cavity before suturing the laparotomy wound with the device installed in the abdominal cavity. The numbers indicate:

1 - polymer film;

2 - a drainage tube;

3 - elastic cord;

4 - the end of the drainage tube 2 with the ends of the cords 3 fixed on it;

5 - the end of the drainage tube 2 with the loose ends of the cords 3 movably fixed on it;

6 - ligatures attached to the middle of the cords 3;

7 - anterior abdominal wall;

8 - intestinal loops.

The method is as follows. After completing the main stage of the operation, before suturing the laparotomy wound, a device is placed in the abdominal cavity (Fig. 1), made in the form of a film 1 of a biocompatible polymer material, for example, polyethylene, in the form of an oval or rhombus, one diagonal of which is 10-15 cm and the other - 15-50 cm. A polymer drainage tube 2 is placed along the largest axis of the film 1. The ends of two polymer strands 3, made of, for example, polyvinyl chloride tubes or ligatures of nylon, polyamide, etc., are fixedly fixed on the end 4 of the tube 2. Link 3 skipped from conc 4 the tube 2 on the perimeter of the film 1 toward each other until the end 5 of the tube 2, which is movably fixed. A ligature 6 is attached to the middle of each of the cords 3. The device is folded and placed in the abdominal cavity (Fig. 2) along the axis of the laparotomy wound. The end 4 of the drainage tube 2 is fixed through the ligature to the inner surface of the abdominal wall 7 above the upper corner of the wound. The end 5 of the drainage tube 2, together with the free ends of the cords 3, is brought out through a separate incision 1.5-2 cm long, located 3-4 cm below the lower corner of the wound, and sutured to the skin by pulling the film 1 along the largest diagonal. The ligatures 6 are brought out across the wound through punctures of the abdominal wall 7, which are at least 5-10 cm distant from the wound axis. After suturing the laparotomy wound, the ligatures 6 are pulled and fixed on the skin, allowing the film to straighten 1. Film 1, straightened on the tube 2 and strands 3, delimits the loops of intestines 8 covered with visceral peritoneum from the parietal peritoneum and prevents the formation of viscero-parietal adhesions. A container for collecting exudate is attached to the outer end 5 of the drainage tube 2. On the 4-5th day after the operation, after restoration of intestinal motility, ligatures 6 are crossed and the free ends of cords 3 are pulled, as a result of which film 1 is folded. The ligatures that fix the upper 4 and lower 5 ends of the tube 2 cross. When pulling on the drainage tube 2, the device is freely removed from the abdominal cavity. The abdominal incision site is sutured.

EXAMPLE: Patient Z., 47 years old, was operated on as planned for a 1-barrel enterostomy, adhesive disease of the peritoneum. Performed median laparotomy with excision of the old postoperative scar, enterotransverse anastomosis, drainage of the abdominal cavity. At the end of the operation, a device for implementing the claimed method is installed in the abdominal cavity. The abdominal cavity is sutured in layers tightly. By pulling the ends of the ligatures attached to the middle of the cords, a film has been straightened that delimits the parietal peritoneum from the internal organs. 4 days after surgery, intestinal motility was restored. On the 5th day after the operation, the ligatures fixing the device were crossed in the dressing room. The free ends of the cords were tightened, and during traction for the lower end of the drainage tube, the device was removed through an abdominal wall incision at the lower corner of the wound. The incision is sutured with two interrupted sutures. In the postoperative period, there were no symptoms of intestinal obstruction, the wound healed by primary intention. Complications associated with the use of the method were not identified. The sutures were removed on the 10th day after the operation, and after another 2 days the patient was discharged from the hospital. After 3 months, during control clinical and radiological studies, viscero-parietal adhesions were not found.

Thus, the claimed method effectively prevents the formation of viscero-parietal adhesions due to the reliable isolation of internal organs from the parietal peritoneum and the drainage of the space under the sutured laparotomic wound. The method is technically simple, less traumatic, a device for its implementation can be manufactured in any surgical hospital.

Claims (1)

A method for preventing the formation of viscero-parietal adhesions of the peritoneum, including surgery, and before suturing the laparotomy wound, introducing into the abdominal cavity and fixing to the abdominal wall a device for separating internal organs and the parietal peritoneum and removing it after restoration of intestinal motility, characterized in that in the abdominal cavity place the device in the form of a film of a biocompatible polymer material having the shape of an oval or rhombus, the smaller diagonal of which is 10-15 cm, and the larger It exists length wound; a polymer drainage tube is placed along the larger diagonal, the length of which exceeds this diagonal by at least 5 cm, the ends of two polymer strands are fixed at one end of the tube, passing along the perimeter of the film towards each other to the other end of the tube, where they are movably fixed to the tube with free ends at the place of its contact with the edge of the film, with a ligature attached to the middle of each of the strands; after installing the device in the abdominal cavity, the end of the tube with the fixed ends of the cords is fixed through the ligature to the inner surface of the abdominal wall above the upper corner of the wound, and the other end of the tube together with the free ends of the cords are brought out through a separate section of the abdominal wall below the lower corner of the wound; ligatures attached to polymer strands are brought out across the wound axis through punctures of the abdominal wall, removed from the wound axis by a distance of at least half the smaller diagonal of the film, after which the laparotomy wound is sutured and the ligatures are tensioned to straighten the film; before removing the device, the ligatures fixing it cross, the film is folded by pulling on the free ends of the cords and traction on the outer end of the tube, the device is removed.

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