RU2341207C1 - Method of surgical treatment of deep wounds of liver - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: find the first flap of epiploon on a vascular pedicle. Stitch the flap with a ligature in a cross-section direction on 1.0-1.5 cm more proximally from its basis. Using the extremities of the same ligature, stitch the flap on lateral surfaces till 2/3 of its length having receded on 1.0 cm from its edge. In the subsequent pass to opposite lateral faces of the flap, not reaching its extremity on 1.0-1.5 cm. Find the second flap from the epiploon in the size 4×3 cm which have been not bound to the epiploon by the vascular pedicle. Using the extremities of the ligature of the first flap stitch the bottom of the wound with puncture of needles on an opposite surface of a liver and underrunning of the second flap of the epiploon. Reduce the first flap in a cavity of the wound till its bottom by pulling up of the extremities of the ligature. Fasten the ligature extremities over the second flap of the epiploon. In addition impose separate sutures on wound edges through the basis of the first flap for reapproachment of edges of the wound and hemostasis.

EFFECT: allows carrying out a tamponade of deep departments of a wound of liver without leaving residual cavities in it.

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Description

The invention relates to medicine, mainly to abdominal surgery, and can be used for surgical treatment of patients with deep liver wounds.

Liver injuries are observed with closed and open abdominal injuries and belong to one of the severe injuries of the abdominal organs. They are accompanied by bleeding and bile leakage of varying severity in the peritoneal cavity, as well as the shock state of the body. Therefore, the main treatment method is an emergency surgery, which is aimed at suturing the wounds of the liver, stopping bleeding and bile flow. When suturing shallow wounds of the liver, various methods are used to stop bleeding: local hemostasis (collagen, fibrin glue and other preparations based on them - tissucol, tachocomb), electrocoagulation, laser coagulation, plasma and argon coagulation. The closure of liver wounds does not always provide reliable hemostasis. Therefore, for deep wounds of the liver, a combination of their biological tamponade with the application of hemostatic sutures is used (L.N. Bisenkov et al. Emergency surgery of the chest and abdomen. - St. Petersburg: Hippocrates. - 2002. - P.504). For a biological tamponade, a freely cut piece of muscle, adipose tissue, a large omentum flap, as well as a large omentum flap on a feeding leg, a diaphragm flap on a feeding leg, a stomach wall flap on a feeding leg, liver ligaments, an autodermal flap (A.S. Ermolov, M. M. Abbakumov, E. S. Vladimir. Liver injuries. - M .: Medicine. - 2003. - P.97-103; K. A. Tsyberne et al. Differentiated methods of diagnosis and surgical treatment of focal and traumatic liver injuries. . - In: Actual Clinical and Theoretical Issues . Cal medicine - Chisinau: Shniintsa - 1991 - S.116-119).. The most commonly used flap is a large omentum on the supply leg. As a rule, a cut flap of a large omentum or other tissue is carried out under the seams superficially applied to the edges of the wound. However, often at the bottom of the deep wounds of the liver there are not tamped cavities in which bleeding and bile flow continue. In the future, this leads to the formation of hematomas, suppuration of the wounds of the liver and the formation of bile fistulas. Therefore, it was proposed to drain the residual cavities in the deep wounds of the liver with an additional drainage tube. By stopping bleeding and bile flow, this drainage tube was removed. In some cases, to compress vessels and bile ducts in the residual cavity of a deep wound of the liver, a probe was installed with a swollen balloon such as the Blackmore probe, which was also removed from the wound of the liver after stopping bleeding and bile leakage (A.S. Ermolov, M.M. Abbakumov, E. S.Vladimirova, ibid., P. 103). Suturing deep in the wound of the liver is technically very difficult and dangerous, as the conditions are created for the development of necrosis of liver tissue and damage to blood vessels and bile ducts. Therefore, shallow superimposed simple knotted seams, eight-shaped seams, block-shaped or double looped seams. In this case, only flashing of bleeding vessels and large bile ducts deep in the wound of the liver is possible (A.A. Levin, K.G. Kubachev. Liver injuries. - In the book: Manual on surgery of the liver and biliary tract. - T.1. - St. Petersburg - 2003 .-- S.352-354).

The following methods of treating liver wounds are known in the patent literature. “A method of suturing a liver wound” (RF patent No. 1630794, IPC АВВ 17/00, publ. Bull. No. 8, 1991), which provides for the cathegut suture subhepatic with its output to the liver surface from the opposite side. Then both ends of the thread are carried out on the surface of the liver perpendicular to the axis of the wound. After injecting into the liver parenchyma, the ligatures are carried out in depth parallel to each other and brought to the surface in the middle of the wound from the opposite side. After that they are tied together. The method is complex and does not exclude the possibility of leaving residual cavities at the bottom of the liver wound.

“A method for the surgical treatment of closed liver injuries” (RF patent No. 2195182, IPC АВВ 17/00, publ. Bull. No. 36, 2002), according to the claims of which a cross-shaped incision is made in the right hypochondrium on the anterior abdominal wall. A retroperitoneoscope blade is inserted through it into the abdominal cavity, it is placed above the rupture of the liver, the segments of the liver and organs of the right and left hypochondria are examined. This method is aimed at accurate diagnosis of liver damage.

“A method for suturing wounds of the liver and spleen” (RF patent No. 2218099, IPC АВВ 17/00, publ. Bulletin No. 34, 2003), involving the overlapping diagonal of the liver wound of two intersecting sutures. This method is applicable only for suturing shallow wounds of the liver.

As a prototype of the claimed technical solution, “The method of final hemostasis in liver resection” (RF patent No. 22525674, IPC AB 17/00, publ. Bull. No. 19, 2005), which provides for the fixation of a large omentum flap to the wound surface of the liver stump by overlay of U-shaped seams. In this case, the injection with a needle is carried out on the diaphragmatic surface with a puncture on the wound surface through the gland above the midline. Then, a needle is injected through the gland below the midline with a puncture on the visceral surface of the liver. Then they inject with a needle on the visceral surface of the liver with a puncture on the wound surface through the omentum below the midline. Next, a needle is injected through the gland above the midline with a puncture on the diaphragmatic surface of the liver. At the same time, each subsequent seam overlaps the previous one by 1/3. The disadvantage of this method is the impossibility of using such a fixation of the flange of the greater omentum with deep lacerated wounds of the liver, as well as stab-cut and gunshot wounds, since it is not possible to fill the entire cavity of the wound to its bottom with a flap of a large omentum. These disadvantages are eliminated in the proposed technical solution.

The aim of the present invention is to develop a method that allows tamponade of the deep sections of the wound of the liver without leaving residual cavities in it.

This goal is achieved by the fact that, to the entire depth of the wound, a large omentum flap is carried out on the feeding leg, stitched on the sides with two ends of the catgut thread, the ends of which are brought to the opposite surface of the liver and tied on a different oversized flap of a large omentum, previously cut out and placed on this place .

Detailed description of the invention and examples of its practical implementation

During the operation, laparotomy determines the location of the liver wound, its depth and length. Its cavity is filled with a gauze swab for temporary hemostasis. Two flaps of a large omentum are harvested at this time. The first (Fig. 1), on the feeding leg, should be 1.5 times longer in length along the wound depth, and should correspond in length to the length of the wound, provided that there is a well-developed large omentum. In cases of a weakly expressed large omentum, the width of the flap to be cut out should be 1.5 times the length of the wound. Having cut the flap (1) of the required size, flashing it with a catgut ligature (2) is carried out along two opposite side surfaces corresponding to the flap width. To do this, departing proximal from the base (3) of the flap (1) by 1.0-1.5 cm, stitch the large omentum (4) in the transverse direction, and then flap the flap (1) along its lateral surface to 2/3 of it length, departing 1.0 cm from its edge. Then the needle is turned on the opposite side surface and first the cross-section (5) of the flap is flashed in an oblique direction, and then its opposite side side is not reaching 1.0-1.5 cm to the end of the flap. The second end of the ligature carry out a similar flashing on the other side of the flap. Then, a second flap (6) 4 × 3 cm in size, not connected to the large stuffing box with the feeding leg, is prepared. After that (FIG. 2), the liver tissue (7) is stitched with the ends of the ligature (2) of the first flap (1) through the bottom of the wound in both its corners with a needle poked out onto the opposite surface (8) of the liver. Here, with the same ends of the ligature (2), the second flap (6) of the large omentum at both its ends is stitched along with continuation. Next, the first flap (1) of the greater omentum is immersed in the wound cavity (9). To do this, the distal end of the flap (1) is placed in the upper part of the wound cavity (9) of the liver and pulling the ends of the ligature (2) lower it to the bottom of the wound. During the flap reduction, the assistant doctor additionally with a gauze tupfer helps immerse him in the cavity of the liver wound. After making sure that the flap is completely immersed in the wound cavity, tying the ends of the ligature (2) over the stitched second flap (6) of the large omentum is carried out. On the edges of the wound of the liver near the flap (1), additional single sutures (10) are imposed through its base to bring the edges of the wound and hemostasis closer.

Example. Bnoy P-v, 26 years old (I.B. No. 23844, was admitted to the combined trauma unit of the City Hospital of Emergency Medicine No. 2, Rostov-on-Don, Moscow City, regarding a closed abdominal injury, rupture of the diaphragmatic surface of the right lobe liver, shock grade 2. Injured abdomen during a traffic accident. Upon receipt of a moderate condition. Pulse 118 in 1 minute, blood pressure 110/60. During laparoscopy revealed a large blood clot over the right lobe of the liver and up to 0.5 l blood in the abdominal cavity. An emergency operation was performed laparatomy. laceration of the diaphragmatic surface of the liver measuring 6 × 3 cm, depth 4 cm. Bleeding from the wound stopped with a gauze swab. 0.6 L of blood was collected for reinfusion. 2 flaps were cut from a large omentum, one of which was 6 cm long with a catgut ligature using the proposed method and after stitching the bottom of the liver wound onto the visceral surface, it was relegated to the wound and fixed in it by tying the ends of the ligature over the second flap stitched with a large omentum on the visceral surface of the liver. Additionally, 2 sutures were applied to the edges of the liver wound through the base of the first flap. The abdominal cavity is washed away from the remnants of blood and is drained by tubes located in the subhepatic space and in the small pelvis. The postoperative course is severe. The patient was in the intensive care unit for 4 days. Gradually, his condition improved, there were no complications after the operation. In satisfactory condition, the patient was discharged for outpatient treatment 16 days after surgery.

In total, 3 patients underwent surgical operations using this method. There were no complications. Compared with the prototype, the proposed method has the following advantages: 1 - allows you to fill the entire wound channel with a flap of a large omentum on the nutrient leg; 2 - fixation of the flap with a ligature on the opposite surface of the liver makes it possible to exclude the formation of a residual cavity in the wound of the liver; 3 - flashing and tying the ligature through the flaps of the greater omentum prevents the eruption of sutures and the possibility of bleeding from the sites of puncture of the liver tissue and its capsule.

Claims (1)

A method of surgical treatment of deep liver wounds, including tamponade with a large omentum flap on a vascular pedicle, characterized in that the first flap is cut out of a large omentum on a vascular pedicle, stitched with a ligature in the transverse direction 1.0-1.5 cm proximal to its base, and then with the ends of the same ligature along the lateral surfaces of the flap to 2/3 of its length, departing 1.0 cm from the edge of the flap, with the subsequent transition of flashing to the opposite sides of the flap, not reaching its end by 1.0-1.5 cm; they cut out the second flap from the greater omentum, which is not connected with it by a feeding leg, 4 × 3 cm in size, with the ends of the ligature on the first flap suture the wound bottom with a needle on the opposite surface of the liver and suture the second flap of the omentum, lower the first flap into the wound cavity to it the bottom by pulling the ends of the ligature and tying them over the second flap of the greater omentum, additionally impose separate sutures on the edges of the wound through the base of the first flap to bring the edges of the wound and hemostasis closer.

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