RU2373869C1 - Method of laparostomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to abdominal surgery, can be applied in treatment of diffused peritonitis with clinic of sepsis with effect of intraperitoneal hypertension. Reticular endoprosthesis is applied for temporary closing of abdominal wall. Perforated material with size of holes not less than 5 mm is placed on abdominal organs. Coarse-cellular reticular endoprothesis with total size of cells 70% is used. Endoprothesis is fixed to medial borders of wide abdominal muscles and to aponeurosis of straight abdominal muscles near borders of laparatomy wound from each side. Diastase between wound borders is left. Skin wound is connected by means of "zipper". In relaparotomy reticular endoprosthesis is cut. After relaparotomy edges of reticular endoprothesis are sutured end to end. During next relaparotomy said seams are removed. During final closing of laparotomy wound edges of reticular endoprothesis are sewed in form of duplication.

EFFECT: method allows to improve outflow of inflammatory exudate from abdominal cavity, create conditions for final closing of laparatomy wound without sharp increase of intra-abdominal pressure and strengthen abdominal wall after closing of laparatomy wound for prevention of post operational eventrations and hernias.

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Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of common peritonitis with a clinic of severe abdominal sepsis with phenomena of intra-abdominal hypertension.

Closest to the proposed method is a method of temporarily closing the abdominal wall (laparostomy), which consists in using a mesh endoprosthesis sewn into the wound edges to close the abdominal cavity (A. Schachtrupp, V. Fackeldey, U. Klinge, J. Hoer, A. Tittel, C. Toens, and V. Schum-pelick Temporary closure of the abdominal wall (laparostomy). Hernia, Dec 2002; 6 (4): 155-62.). The method described by the authors allows to ensure the outflow of infected exudate from the abdominal cavity, to carry out visual monitoring of the state of internal organs, to spare the edges of muscle-aponeurotic tissues during repeated surgical interventions, thereby improving the healing of the postoperative wound. The disadvantages of this method are: inadequate drainage of the abdominal cavity through the mesh endoprosthesis due to the small size of the cells in the structure of the endoprostheses used by the authors, the inability to completely close the laparotomy wound without tension and without reducing the volume of the abdominal cavity due to the development of contracture of the wide muscles of the abdomen, as well as insufficient strength in the suture area, increasing the likelihood of postoperative events and hernias.

The objective of the invention: to develop a method of laparostomy, which allows to improve the outflow of inflammatory exudate from the abdominal cavity, create conditions for the final closure of the laparostomy wound without a sharp increase in intra-abdominal pressure and strengthen the abdominal wall after closing the laparostomy wound for the prevention of postoperative events and hernias.

The task is achieved by the fact that to perform a laparostomy, a large-mesh mesh endoprosthesis with a total mesh size of 70% is used, which is fixed to the medial edges of the broad muscles of the abdomen, dissected longitudinally to perform debridement relaparotomy and sutured when the laparotomy wound is finally closed in the form of a duplicate.

The invention is illustrated by the figures:

Figure 1 - the organs of the abdominal cavity are covered with a perforated spanbond flap.

Figure 2 - coarse mesh polypropylene mesh endoprosthesis with a total cell size of 70% (photo, UV. 3 times).

Figure 3 - coarse mesh endoprosthesis, fixed to the medial edges of the wide muscles of the abdomen.

Figure 4 is a dissection line of a coarse mesh endoprosthesis during rehabilitation reaparotomy.

Figure 5 - flaps of coarse mesh endoprosthesis stitched in duplicate at the final closure of the laparotomy wound.

The method is as follows

After performing the main stage of the operation with the removal of the source of peritonitis, debridement and drainage of the abdominal cavity, if there are indications, they begin to impose a laparostomy. To delimit the abdominal organs from above, sterile perforated material (for example, a spanbond flap or polyethylene flap) is placed on top of them with dimensions exceeding the laparotomy wound in all directions by 5 cm, impregnated with an antiseptic solution (figure 1). The size of the holes should be at least 5 mm for an adequate outflow of exudate from the abdominal cavity. After that, with the help of an electric knife, a skin-fatty flap is separated from the aponeurosis of the rectus abdominis muscles to the side to a level 2 cm outwards from the lateral edges of the rectus muscles. For temporary closure of a defect in the muscle-aponeurotic tissues of the abdominal wall, a coarse mesh polypropylene endoprosthesis with a total mesh size of 70% sufficient for an adequate outflow of exudate is used (Fig. 2). An endoprosthesis on both sides is freely fixed without tension with a continuous polypropylene suture to the broad muscles of the abdomen along the edge of the wound at the level of the separated subcutaneous tissue to prevent contracture during the functioning of the laparostomy, as well as to the aponeurosis of the rectus muscles at the edges of the laparotomy wound on each side, departing from the latter by 1.5-2 cm and leaving diastasis between the edges of the wound to maintain the volume of the abdominal cavity and prevent an increase in intra-abdominal pressure (figure 3). Sutures on the skin and subcutaneous tissue are not imposed. The wound is covered with gauze napkins soaked in an antiseptic solution. A skin wound is temporarily connected with a zipper.

At the subsequent sanitation relaparotomy, the “zipper” is unzipped, gauze napkins are removed from the wound. Access to the abdominal cavity is carried out by longitudinal dissection of the mesh endoprosthesis over its entire length (figure 4) and removal of the barrier material (spunbond). After the completion of the rehabilitation stage of relaparotomy, while maintaining the phenomena of peritonitis and the presence of indications for the subsequent (rehabilitation) relaparotomy (s), the abdominal organs are covered in a similar manner to the method described above. Dissected edges of the mesh endoprosthesis are sutured edge to edge with a continuous twisting stitch, which can be easily removed with subsequent relaparotomy. Sutures on the skin and subcutaneous tissue also do not overlap, the wound is covered with gauze napkins soaked in an antiseptic solution. The edges of the skin wound are connected using a zipper.

When stopping the phenomena of peritonitis after the rehabilitation stage of relaparotomy, they begin the final closure of the laparotomy wound. To do this, eliminate diastasis, suturing the peritoneum and tightening the edges of the muscle-aponeurotic tissue with a continuous suture. Free flaps of the mesh endoprosthesis are sutured over the suture line of muscle-aponeurotic tissues in the form of a duplicate (Fig. 5). A perforated tubular drainage is installed above the endoprosthesis in the subcutaneous tissue, sutures are placed on the subcutaneous tissue and skin. Drainage is connected to an active aspiration system.

Case Study

Patient S., 38 years old, medical history No. 17173, was admitted to the purulent surgery department of the MUZ GB SMP Kursk on 12/27/06 in an extremely serious condition 3 days after the onset of the disease with a diagnosis of closed abdominal injury with rupture of a hollow organ, widespread peritonitis, intra-abdominal compartment syndrome. The intra-abdominal pressure before surgery was 31 mm Hg. After preoperative preparation, the operation was performed: laparotomy, resection of the small intestine with the application of entero-enteroanastomosis, nasointestinal intestinal intubation, sanitation and drainage of the abdominal cavity. Intraoperatively in all parts of the abdominal cavity there was up to 1.5 l of purulent effusion with a fetid odor; on the parietal and visceral peritoneum - massive overlays of fibrin, the loops of the small intestine were sharply swollen, swollen and did not peristal. At a distance of 60 cm from the ligament of Treitz there was a rupture of the small intestine by 2/3 of its circumference. Given the above, as well as high rates of intra-abdominal pressure before the operation, it was decided to perform a laparostomy in order to reduce intra-abdominal pressure and subsequently programmable rehabilitation sanitation relaparotomies. The abdominal organs were covered with a sterile perforated spunbond flap with a diameter of perforations of 5 mm soaked in an antiseptic solution. After that, with the help of an electric knife, a skin-fat flap was separated from the aponeurosis of the rectus muscles to the sides to the broad muscles of the abdomen. A large-mesh mesh polypropylene endoprosthesis with dimensions of 30 × 25 cm with a total size of 70% freely without tension was fixed on each side by a continuous suture with 2/0 polypropylene monofilament to the medial edges of the broad muscles of the abdomen at the level of the separated subcutaneous tissue to prevent their contracture during the functioning of the laparostomy, and also to the aponeurosis of the rectus muscles at the edges of the laparotomic wound on each side, departing from the latter by 1.5 cm. Diastasis between the edges of the muscle-aponeurotic tissues located under the endo the prosthesis was 6 cm. The wound was covered with gauze napkins soaked in an antiseptic solution. The edges of the skin wound were connected using a zipper.

In the postoperative period, complex therapy was carried out in the conditions of the anesthesiology and intensive care unit, and intra-abdominal pressure was monitored. 12/29/06 a programmed debridement relaparotomy was performed. A gauze napkin was removed from the wound, the endoprosthesis was cut in the midline. A spunbond flap and old drainage tubes were removed from the abdominal cavity. Purulent discharge and plaque of difficult to separate fibrin remained in the abdominal cavity, the diameter of the small intestine was 4.5-5 cm. Based on this, peritonitis was recognized as non-stopping. Indications for subsequent debridement relaparotomy were determined. The abdominal cavity was sanitized with an antiseptic solution and drained at 4 standard points. On top of the loops of the small intestine was placed a sterile perforated spunbond flap measuring 30 × 30 cm soaked in an antiseptic solution. An endoprosthesis dissected along the midline is sewn end to end with a continuous suture. A gauze napkin soaked with an antiseptic was placed on top. The edges of the skin wound are connected by a zipper. A similar programmed debridement relaparotomy was performed on 12/31/06. In the postoperative period, complex therapy and monitoring of intra-abdominal pressure were performed.

There was an insignificant amount of light effusion in the abdominal cavity on rehabilitation sanitation relaparotomy on 02.01.07, the loops of the small intestine were not inflated, hyperemia of the parietal and visceral peritoneum decreased: peritonitis was recognized as stopping. It was decided to completely close the abdominal cavity. The abdominal cavity was sanitized with furatsillin solution and drained at 4 standard points. The intestinal loops are laid, covered from above with a large omentum. The edges of the aponeurosis and the peritoneum are sutured with a continuous suture of polypropylene monofilament 2/0. Dissected edges of the endoprosthesis are sutured in the form of duplicature with fixation of the edges by separate interrupted sutures with a 2/0 polypropylene thread. Perforated tubular drainage from the lower edge of the wound is installed in the subcutaneous tissue. Stitches are applied to the skin. In the postoperative period, conservative therapy was continued. Drainage from the subcutaneous tissue was removed on the 8th day. The median wound healed by primary intention. The patient was discharged in satisfactory condition 02.16.07.

When viewed after 1 year, the patient's condition is satisfactory. Postoperative hernia is not observed.

Thus, the task was achieved due to the fact that to perform laparostomy with subsequent rehabilitation relaparotomy, a large-mesh mesh endoprosthesis with a total mesh size of 70% was used, which was fixed to the medial edges of the broad muscles of the abdomen, dissected longitudinally to perform rehabilitation sanitation and stitched at the final closure laparotomy wounds in the form of a duplicate.

Claims (1)

A laparostomy method, including the use of a mesh endoprosthesis for temporary closure of the abdominal wall, characterized in that perforated material with openings of at least 5 mm is placed on the abdominal organs, using a coarse mesh endoprosthesis with a total mesh size of 70% and fixing it to the medial edges of the wide muscles the abdomen and to the aponeurosis of the rectus abdominis muscles at the edges of the laparotomy wound on each side, leaving diastasis between the edges of the wound, connect the skin wound using a “zipper”, with relaparotomy p the mesh endoprosthesis is secreted, and after it the edges of the mesh endoprosthesis are sutured edge to edge, with a subsequent relaparotomy, this suture is removed, and when the laparotomy wound is finally closed, the edges of the mesh endoprosthesis are sutured in the form of a duplicate.

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