RU2417768C2 - Method of combined abdominal cavity and abdominal wall wound drainage - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can find application in suture inconsistency of low colorectal anastomoses, as well as in cases when anastomosis exteriorisation is not obviously possible. Substance of the method consists in drug aspiration and irrigation. In the presence of intestinal anastomoses, an incision of the length of 8-10 cm is made in an iliac region to place a truncated cone tube with an oval lower end over the anastomosis towards a bottom of an iliac fossa. On an external surface of the cone, there are fixed drainage tubes at a level of a preperitoneal subcutaneous fat and subcutaneous fat with their ends delivered on an anterior abdominal wall through additional incisions, and a two-lumen drainage is delivered through the cone aperture to the anastomosis and fixed to skin from the outside.

EFFECT: use of said invention allows eliminating wound closure within a suture inconsistency region and execution of such manipulations, improving abdominal cavity and abdominal wall wound drainage due to permanent pumpdown through all drainages, preventing peritonitis distribution and avoiding abdominal wall wound abscess within laparostoma.

1 ex, 1 dwg

Description

The present invention relates to medicine, namely to surgery, and can be applied in case of failure of the sutures of low colorectal anastomoses, as well as in other cases when it is not possible to bring out the anastomosis.

It is known that the application of low colorectal anastomoses is always accompanied by great technical difficulties, which in some cases leads to inconsistency of the sutures, the development of peritonitis, accompanied by high mortality (45-92.8%, Karimov Sh.I. et al., 1998; Isaev G. .B., 2002; Wang A., 2000). Various methods of treatment are used to combat such complications. In particular, many authors use laparostomy in various modifications. They differ in both certain advantages and significant disadvantages. So, a good outflow of pus from the abdominal cavity is not always ensured, the possibility of eventing, suppuration of the wound of the abdominal wall, and the development of deformation in the anastomotic region is not eliminated. All this dictates the need for further improvement of treatment methods with the help of various modifications of laparostomy.

A known method of controlled laparostomy with peritonitis. After laparotomy and elimination of the source of infection, drainage of the iliac regions is carried out. Then, a laparostomy apparatus is placed on the abdominal wall, consisting of 2-curved detachable plates, which are metered together using studs and nuts. The intestines are protected with a bandage of perforated plastic film and gauze. A microirrigator for irrigation is placed under the dressing. After the operation, manual sanitation of the abdominal cavity is performed, during which the condition of the intestinal sutures is monitored, drainage function is checked, newly diagnosed pathological changes are corrected, etc., that is, a programmed laparotomy is performed / E.I. Brekhov, M.M.Shaferman, N. I. Izimbergenov, V. M. Chegin, A. N. Severtsev “Controlled laparostomy in peritonitis surgery”. The journal "Surgery", Moscow, 1988, No. 12, pp. 23-28 /.

After opening the abdominal cavity, the source of infection is eliminated and sanitation with chlorhexidine or furacilin solutions is performed. The iliac regions drain. Then, a laparostomy apparatus is placed on the abdominal wall at a distance of 1.5-2 cm from the edges of the surgical wound. The plates of the apparatus are fixed with thick synthetic threads, which are passed through all layers of the abdominal wall, except for the peritoneum, parallel to the edges of the surgical wound. Then the threads are threaded into the grooves of the horizontal plates of the apparatus and knotted. The intestines are protected with a bandage consisting of a perforated plastic film and a single-layer napkin, which are brought under the edges of the surgical wound. A microirrigator is left under the dressing for constant irrigation of the underlying intestinal loops. With the help of studs and bolts, the edges of the surgical wound are extra-focally drawn together and fixed. The width of the laparostomy during the treatment is regulated with bolts within 2-8 cm, depending on the degree of intestinal paresis, respiratory failure, fluid loss through the wound. In the postoperative period carry out manual sanitation of the abdominal cavity. They sought to carry out the latest reorganization with minimal trauma, subjecting only dubious sites to audit. The bandage covering the intestines is removed, drainages in the iliac regions are left, rare sutures are placed on the aponeurosis and the plates of the device are completely reduced to close contact of the wound edges with each other. Wounds heal by soft tissue compression. During suppuration, the compression was temporarily weakened and only the wound of the abdominal wall was sanitized additionally.

The described method is one of many controlled laparostomies and has the following disadvantages:

a) does not allow for an effective constant outflow of pus from the abdominal cavity;

b) the fibrin film does not exclude the possibility of the formation of intestinal adhesions and fistulas;

c) the method is quite traumatic, as it provides for programmed laparotomy, and in cases of insolvency of the sutures of the anastomosis does not illuminate the issue of combating this complication.

The closest analogue is the method of programmed laparoscopic debridement and peritoneal lavage under endoscopic control using a modified Fedorov fistula, through which laparoscopic control is carried out using various laparolifting options. At the same time, the abdominal cavity is drained with 4-6 PVC tubes / See appendix: copy from the abstract for the degree of candidate of medical sciences. Visually controlled abdominal sanitation in the complex treatment of common peritonitis - A. Bondarenko 2003 year.

Disadvantages:

1. Fistula Fedorov does not allow manual examinations due to the small diameter and limits visual inspection and instrumental examinations, in particular, it is not possible to repair the bowel wall defect.

2. Impossible preventive measures to eliminate suppuration of the wound of the abdominal wall in the fistula. The objectives of this method are:

1) to ensure effective and continuous removal of pus and intestinal contents from the abdominal cavity;

2) provide visual, and if necessary endoscopic control of the adjacent areas of the abdominal cavity and the healing process of the wound of the intestinal wall in the area of the anastomosis;

3) partially isolate the abdominal cavity from the pathological focus;

4) create the conditions for the least traumatic suturing of the defect of the anastomosis while maintaining its shape and lumen, exclude re-operation in the area of the anastomosis while restoring the continuity of the gastrointestinal tract;

5) protect the laparotomy wound as much as possible from suppuration.

The objectives are achieved in that the method of combined drainage of the abdominal cavity and wounds of the abdominal wall, including aspiration and irrigation of drugs, provides for an 8-10 cm incision in the left iliac region, in which a tube in the form of a truncated truncated tube above the anastomosis is placed cone and drainage tubes at the level of preperitoneal fiber and subcutaneous fat, while drainage tubes are placed on the outer surface of the cone, and the ends of these drainage tubes on the anterior abdominal wall through additional incisions.

The technical result.

The risk of complications in patients is reduced, since wound closure in the area of suture failure and the performance of operations such as the treatment of paracolostomy abscesses when they occur are not required. Processing is performed through a laparostomy cone. The drainage of the abdominal cavity and the wound of the abdominal wall is improved due to the constant evacuation through all drainages, which prevents the spread of peritonitis and prevents suppuration of the wound of the abdominal wall in the laparostomy area.

The method was tested on 42 patients in the purulent department of the Krasnodar Regional Clinical Hospital No. 1 (KKB) named after Professor Ochapovsky S.V. and showed good results. All patients succeeded in eliminating local or diffuse peritonitis in a short time (10-14 days), avoiding the development of diffuse peritonitis and preventing suppuration of the surgical wound, and 40 patients also sutured the wound in the intestine, in the area of suture failure through a laparostomy cone, without relaparotomy. In addition, the opportunity was created to visually monitor the course of the inflammatory process in the abdomen by monitoring the functioning of the drainage and the regeneration of the intestinal wall wound. The hospital stay of patients was reduced by an average of 2 weeks. A fatal outcome was observed in only one patient who was late diagnosed with anastomotic suture failure and developed diffuse peritonitis.

The method is additionally demonstrated in the drawing, where 1 is the failure of the anastomotic sutures, 2 is a cone, 3 is four interrupted sutures, 4 are drainage tubes, 5 is double-lumen drainage, 6 is a laparotomy wound.

The treatment method is as follows.

After diagnosing the failure of the sutures of the anastomosis (1), a median laparotomy (6) and an audit of the abdominal cavity are urgently performed. Assess the prevalence of peritonitis. An unloading colostomy is applied according to the generally accepted method, then an additional incision is made 8-10 cm long over the anastomosis region, through which the cone (2) is inserted strictly above the anastomosis. The upper edge of the cone is fixed with 4 interrupted sutures (3) to the skin, the lower edge of the cone is fixed with 2 sutures to the parietal peritoneum of the left iliac fossa in case of failure of the colorectal anastomosis (1), which partially isolates the abdominal cavity from the pathological focus. Carry out the washing of the contents in the area of discharge colostomy and colorectal anastomosis. The cone (2) is introduced into the wound with the drainage tubes (4) pre-fixed around it and the lower edge of the cone is worn for atraumaticity. The ends of the tubes (4) are discharged through additional cuts along the edges of the cone (2). A 2-lumen drainage (5) with a diameter of a thick tube of 1.0-1.2 cm is inserted through the lumen of the cone (2), the lumen of which is set 0.5 cm above the wound of the anastomosis (1). Outside, this drainage is fixed to the skin, after which the lower end of this drainage is finally installed in the correct position and limited in mobility by a swab inserted into the lumen of the cone (2). The abdominal cavity is sanitized, drainages are introduced into the lateral canals of the abdomen and into the small pelvis, depending on the prevalence of peritonitis, and suturing of the mid-laparotomic wound (6). They control the correct location of the laparostomy cone (2) and drainages in this area, loose laying a large napkin in the cone lumen, dressings on wounds.

Example.

Patient T., 58 years old, was admitted to the colopractology department on March 3, 2007, and was diagnosed with 8 cm rectal cancer. An anterior resection of the rectum was performed with a low hardware rectosigmoid anastomosis, and anastomosis was diagnosed on the 4th day. With relaparotomy, the diagnosis is confirmed. Insolvency was noted on the anteroposterior wall of the intestine due to the divergence of one suture. An unloading transversostom is imposed. An additional oblique incision was made in the left inguinal-iliac region 10 cm long over the projection of the anastomosis. Through the hole in the anastomosis, liquid is released, the stinking contents of the intestine in a small amount and individual fragments of the formed feces. It was not possible to thoroughly wash the contents from the segment of the intestine between the colostomy and the anastomosis due to the presence of fecal blockage due to poor preparation in the preoperative period. A cone with 2 drainage tube systems fixed on its body is inserted into the wound. The ends of these tubes are brought out through separate skin incisions in the left iliac region. In the abdominal cavity, the edge of the cone is hemmed with 2 interrupted sutures to the parietal peritoneum of the iliac fossa. The upper edge of the cone is attached to the skin with 4 interrupted sutures. Through the lumen of the cone, a 2-lumen drainage with a diameter of 1.0 cm is installed strictly above the anastomotic opening. It is fixed to the skin. Sanitation of the abdominal cavity. Due to the fact that the patient had diffuse peritonitis, a typical drainage of the left lateral canal and pelvis was made only on one side. Suturing of the mid-laparotomic wound. A gauze napkin was loosely inserted into the laparostomy cone in such a way that it surrounded the 2-lumen tube on all sides, fixing its lower edge strictly above the hole in the anastomosis. Dressings for wounds.

In the postoperative period, the patient's condition remained moderate. Through all the drains continuous aspiration was carried out. During the dressings, tampons in the cone were changed and several times the formed stool fragments that could not stand out through the drains were removed with the final clamp or tweezers. On the 16th day, the wound in the anastomosis area was completely cleansed of pus and was sutured with 2 rows of nodal sutures. At the same time, it was possible to avoid deformation of the anastomosis and, in general, to maintain the shape and lumen of the intestine. The cone was removed on the 23rd day, and the wound in this area was sutured with rare sutures to a 2-lumen drainage, which was initially brought to the anastomosis. It was deleted last. The wound healed by type of primary tension. The unloading colostomy was closed locally according to generally accepted methods. At the same time, a revision of the colorectal anastomosis was not performed, and its good patency was confirmed by control irreography and colonoscopy. 04/10/2007 in satisfactory condition the patient was discharged under the supervision of an oncologist at the place of residence.

Claims (1)

A method of combined drainage of the abdominal cavity and abdominal wall wounds, including aspiration and irrigation of drugs, characterized in that in the presence of intestinal anastomoses, an 8-10 cm length incision is performed in the iliac region, in which a tube in the form of a truncated truncated tube is placed over the anastomosis cone with a zavovanny bottom edge, drainage tubes are fixed on the outer surface of the cone at the level of preperitoneal tissue and subcutaneous fat, the ends of which lead to the anterior abdominal wall through additional incisions, and through the lumen of the cone, a double-lumen drainage is brought to the anastomosis, fixing it externally to the skin.

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