RU2433842C1 - Method of surgical treatment of deep decubital wounds in patients with consequences of spinalcord injury - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to field of medicine, namely to neurosurgery, traumatology and surgery and is intended for surgical treatment of decubital wounds in case of separation of adjacent tissues in patients with consequences of spinal cord trauma. Cavity of decubital wound is densely tamponed with turunda preliminarily soaked in solution of methylene blue and 3% hydrogen peroxide with ratio of ingredients in solution 9:1. Entrance gate of decubital wound is tightly sewn with interrupted sutures. On skin, transversely to gluteal fold projection, marked is cut of ellipsoid shape sufficient for excision of bedsore capsule, with which sewn entrance gate of decubital wound are located inside excised skin section. Skin cut is performed. Pathologic focus is ablated in one block, guided by size of tamponed cavity and stained tissues. "Blind" draining of operation wound with further plasty of skin-muscular flap is performed. Antibacterial therapy is carried out for 5 days. Drainage is removed after 3 days. ^ EFFECT: method makes it possible to achieve complete and quality excision of decubital wound, reduce probability of recurrent surgery due to application of methylene blue and 3% hydrogen peroxide, extending narrow ways and slit recesses for complete staining and converting surgery from type of "purulent" into type of "clean" ones. ^ 1 ex

Description

The invention relates to medicine, in particular to neurosurgery, traumatology and surgery, and is intended for the surgical treatment of pressure sores in the presence of detachment of adjacent tissues in patients with consequences of a spinal cord injury.

Pressure ulcers, according to various authors, occur with a frequency of 28% to 90% of cases and are one of the main factors that impede the implementation of rehabilitation measures. In addition, decubitus sepsis is one of the main causes of death of patients in the long term after a spinal injury. According to foreign sources, the cost of treating pressure sores makes up a quarter of the total cost of treating patients with spinal cord injury.

Treatment of bedsore wounds, in most cases, is carried out by conservative methods. A superficial bedsore defect is epithelized for several weeks, and even a deep bedsore wound is scarred for several months. Nevertheless, often bedsore wounds have existed for years and do not tend to heal, despite topical treatment using modern dressings.

Currently, various classifications are used to characterize bedsore wounds. It should be noted that none of the proposed classifications has received universal recognition. The most commonly used recently is the Agency for Health Care Policy and Research (1992) scale: Stage 1 - persistent hyperemia of the skin that does not disappear after the cessation of pressure, the skin is not broken; Stage 2 - persistent hyperemia of the skin, epidermal detachment, superficial (superficial) violation of the integrity of the skin (necrosis) with spread to the subcutaneous tissue; Stage 3 - destruction (necrosis) of the skin up to the muscle layer with penetration into the muscle, there may be liquid discharge from the wound; Stage 4 - damage (necrosis) of all soft tissues, the presence of a cavity in which tendons and / or bone formations are visible.

Treatment of bedsores of I and II degrees usually does not require surgical treatment. Surgical treatment is indicated for bedsores of the III, IV degrees.

The following surgical procedures are mainly used for surgical treatment, aimed at closing the wound surface: 1) free skin plastic; 2) excision of the bedsore with subsequent plastic surgery by local tissues; 3) excision of the bedsore with subsequent plasty of the displaced skin, skin-fascial and musculocutaneous flaps; 4) excision of the bedsore with subsequent plastic surgery by a mixed skin or musculocutaneous flap on the leg.

The literature covers rather widely the technique of plastic closure of pressure sores (Baskov A.V. Bedsores surgery (To help a practical doctor) / A.V. Baskov. - M.: GEOTAR-MED, 2001. - 208 p.), Indications for selection one or another method of surgical treatment of pressure sores (Klimiashvili A.D. Prevention and treatment of pressure sores / A.D. Klimiashvili // Russian Medical Journal. - 2004. - T.12, No. 12). At the same time, in the available literature there is no clear data directly on the technique for excising a pathological lesion.

Directly the method of excising a purulent wound is described in various medical literature.

There is a method of excising fistulas and foci of osteomyelitis, which consists in the fact that the fistulous course and the foci of osteomyelitis were stained with methylene blue, when the fistula was revised, the latter was dissected directly to the foci of osteomyelitis. Subsequently, the fistula and foci of osteomyelitis were removed within the limits of healthy tissues (Selivanov VP, Voronyansky Yu.P. Pelvic osteomyelitis. - M .: Medicine, 1973. - 160 p.). The wound was sutured and a permanent flushing system was used in the postoperative period.

The disadvantages of this method is the infection of tissues during surgery, a high probability of microbial contamination of the surgical field.

In particular, there is a known method for excision of bedsores (Baskov A.V. Surgery of bedsores (To help a practical doctor) / A.V. Baskov. - M.: GEOTAR-MED, 2001. - 208 p.). The technique consists in staining the wound with methylene blue, excising the granulation and capsule of the bedsore wound and subsequent plastic closure of the surgical defect. For the prevention of suppuration of the postoperative wound, through drains were installed and then for 6-8 days the wound was washed through the drains with antiseptics.

The disadvantages of this method are also infection of the surgical wound, constant microbial seeding of the surgical field, which in some cases causes suppuration of the postoperative wound and leads to relapse of the bedsore. Prolonged use of the flushing system also increases the risk of infection in the postoperative period.

There is a method of surgical treatment of deep bedsore - bursitis of the area of the sciatic tubercle in patients with combined spinal injury (Lurin I.A., Gerasimenko V.N., Paray A.E., Pendrakovsky K.V. Method of surgical treatment of deep bedsore - bursitis of the sciatic area mound in patients with combined spinal injury [electronic resource], // http: stmu.at.ua/blog/2009-08-19-4). The method consists in preliminary staining of the sciatic bursa with methylene blue and 3% hydrogen peroxide, then the bursa is removed in a single block, the intervention ends with through drainage and plastic surgery of the wound with a skin-fat flap. Subsequently, the drainage was washed twice a day with antiseptics, the drainage was removed on the 5th day. When using this method, preoperative antibiotic prophylaxis, antibiotic therapy for 5 days were used.

In our opinion, the disadvantages of this method, despite the excision of the pathological focus even as a single block, but with an open sore entrance gate, is a high probability of infection of the surgical wound that is separated from the pressure sore wound. Periodic use of drainage to wash the wound, even if all the rules of asepsis are followed, increases the risk of infection of the wound. The number of postoperative complications when using this method is very small (3.8%), but with the total number of patients operated on - 26 people - it is premature to talk about the reliability of the results.

The closest is a method for excising pressure sores with detachment of adjacent tissues (Savchenko P.A. Plastic surgery of pressure sores / P.A.Savchenko, E.V. Filatov // Questions of reconstructive and plastic surgery - 2003. - No. 3. - p. 16-20). The essence of the method was to excise the edges and bottom of the bedsore wound within apparently healthy tissues. Granulations lining the wound must be carefully dissected. During the preparation and excision of bedsores with a significant detachment of the edges and a small inlet, tamponade of the cavity with gauze turunda, previously moistened with methylene blue for staining the cavity, was used. All this made it possible to facilitate the excision of a pressure sore wound in a single unit. Subsequently, the surgical wound and its plastic were drained with a musculocutaneous flap. The leg flexors, part of the gluteus maximus, are used as the muscle leg for plastics in the sciatic region, and the tailor muscle and the lateral head of the quadriceps femoris muscle are used for the trochanteric region; gluteus muscles were used in the sacral region for plastics. The wound capitulation should be maximum, but without any immersion seams. This is achieved by the addition of removable "polyspast" seams or seams of the Donati type. The drainage system was constantly flushed with aseptics, the average drainage removal time was 8 days. Antibacterial therapy for 7-10 days. Sutures from the wound were removed on the 18th day.

The disadvantages of this method are an open infected wound, the possibility of seeding the surgical field, the staining of narrow and slit-like pockets is often not achieved, and as a result, when a pressure sore capsule is excised, it is highly likely to open it and a long-running rinsing system.

The objective of the invention is a high-quality and complete excision of a pressure sore wound, reducing the risk of infection of an operating wound.

The task is achieved by the following method of surgical treatment of deep bedsore wounds with the presence of a cavity in patients with consequences of a spinal cord injury. The method includes tamponade of the cavity with turunda with methylene blue for staining the cavity, excision of the pressure sore, drainage, plastic surgery with a musculocutaneous flap with removable "polyspast" sutures, antibiotic therapy. For staining, a solution of methylene blue in a mixture with hydrogen peroxide 3% in a ratio of 9: 1 is used. Before the bedsore is excised, its entrance gate is sutured tightly. Wound drainage is carried out by "blind" drainage for 3 days.

The novelty of the invention:

- For staining using a solution of methylene blue in a mixture with hydrogen peroxide 3% in a ratio of 9: 1. This ratio allows the capsule of the bedsore wound to be stained quite well, including narrow and slit-like pockets, due to the fact that the resulting foam expands the narrow passages and facilitates the penetration of methylene blue into them. At the same time, the use of a small amount of 3% hydrogen peroxide does not reduce the staining properties of methylene blue and allows to minimize the discharge of wound discharge from the pressure sore cavity when it comes in contact with hydrogen peroxide and thus minimize the risk of infection of the surgical field.

- Before the bedsore is excised, its entrance gate is sutured tightly. The surgical field is treated with aseptics according to a standard technique. An ellipsoidal incision is sufficient to excise the bedsore capsule, the sutured entrance gate of the pressure sore wound remains intact inside the excised skin area, which also eliminates the risk of infection of the surgical field.

- Wound drainage is carried out by “blind” drainage for 3 days, the drainage is on active aspiration. Since when using this method, in fact, a clean operation is performed and there is no constant or periodic washing of the drainage, the drainage performs only the functions of evacuating the liquid contents from the wound, which reduces the risk of infection of the wound in the postoperative period.

The set of essential features of the proposed method allows to obtain a new technical result:

- verify all the nodules and pockets of the pressure sore wound, at the same time reduce the likelihood of wound contents leaving the pressure sore cavity when it interacts with hydrogen peroxide;

- allows you to transfer surgery from the category of "purulent" to "clean";

- significantly reduced economic costs both by reducing the duration of antibiotic therapy by 3-4 days, and by eliminating aseptics from the arsenal for washing drainages;

- A high percentage of healing of pressure sores is achieved, which reduces the likelihood of repeated surgery.

The method is as follows.

Conducted standard processing of the surgical field. Further, the cavity of the decubitus wound is tightly plugged with turunda, previously moistened in a solution of methylene blue and 3% hydrogen peroxide. The ratio of ingredients in the solution is 9: 1, we came to this ratio in a practical way. In our opinion, this ratio makes it possible to stain a capsule of a pressure sore wound, including narrow and slit-like pockets, due to the fact that the resulting foam expands the narrow passages and facilitates the penetration of methylene blue into them. At the same time, the use of a small amount of 3% hydrogen peroxide allows preserving the staining properties of methylene blue and minimizing the discharge of wound discharge from the pressure sore cavity when it comes in contact with hydrogen peroxide. Treatment of the surgical field with aseptics. Then the entrance gate of the bedsore wound is sutured tightly with interrupted sutures. The surgical field is again treated with aseptics according to a standard technique. An ellipsoidal incision is sufficient to excise the bedsore capsule, the sutured entrance gate of the pressure sore wound remains intact inside the excised skin area. Using an electric knife, guided by the size of the plugged cavity and stained tissues, the pathological lesion is removed in a single block, which eliminates the possibility of microbial contamination of the surgical wound. A wound toilet, thorough hemostasis. The operation ended with "blind" drainage of the surgical wound and its plastic surgery with a skin-muscle flap according to the previously developed technique (Savchenko P.A. Plastic surgery of bedsores / P.A.Savchenko, E.V. Filatov // Problems of reconstructive and plastic surgery. - 2003. - No. 3. - S.16-20). In the postoperative period, drainage is placed on active aspiration; a device for active drainage of single-use wounds is used (Medpolymer, St. Petersburg, TU 64-2-114-82). Since when using this method, in fact, a clean operation is performed, we did not use antibiotic prophylaxis, antibiotics, taking into account the sensitivity of microflora to them, were prescribed in therapeutic dosages for 5 days. When using this method, permanent or periodic washing of the drainage is not carried out, the drainage performs only the functions of evacuating the liquid contents from the wound. The average drainage removal time is 3 days. “Polyvascular” sutures are removed on the 12-14th day, stitches from the skin - on the 18-20th day. We believe that such a long time is necessary for the formation of the primary scar, and also because of the threat of divergence of the edges of the wound against a background of high spastic syndrome.

This method operated on more than 200 bedsore wounds, primary healing was achieved in 97.4% of cases, relapse of pressure sores in 2.6%, respectively. Relapse of wounds in no case was due to suppuration. The reasons for the discrepancy of the sutures were the high spastic syndrome and errors of the operative technique, when the skin-muscle flaps were not well selected and the wound was sutured with excessive tension, which led to the eruption of the sutures.

Example. Patient F., 52 years old, was admitted to the department with a diagnosis of a late period of TBSM, as a result of a fracture of the Th11 vertebral body. Type A (ASIA). Pressure ulcer of the IV degree of the left sciatic area. The duration of the disease is 6 years. A pressure sore wound exists for 8 months. On examination, the entrance gate of the wound is 2 × 1 cm in the projection of the gluteal fold, the underlying cavity is up to 5 cm in diameter. According to fistulography, the cavity in the soft tissues does not come into contact with the tubercle of the ischium. After preoperative preparation under endotracheal anesthesia, surgery was performed. The patient's position on the abdomen with a roller under the pelvis. Conducted standard processing of the surgical field aseptics. Further, the cavity of the pressure sore wound is tightly plugged with turunda, previously moistened in a solution of methylene blue and 3% hydrogen peroxide, in a ratio of 9: 1. After tamponade, the size of the decubitus wound cavity visually increased to 8 cm in diameter. Treatment of the surgical field with aseptics. The entrance gate of the bedsore wound is tightly sutured with interrupted sutures. The surgical field is again treated with aseptics according to a standard technique. On the skin, transversely in the projection of the gluteal fold, is marked the incision, ellipsoid in shape, up to 12 cm long, the sutured entrance gate of the pressure sore wound is inside the excised skin area. A skin incision has been performed. Next, using an electric knife, focusing on the size of the plugged cavity and stained tissues, the pathological lesion was removed in a single block. Conducted toilet wounds, hemostasis. The lower part of the gluteal muscle, which was used for plastic surgery of the wound defect, was isolated and mobilized. “Blind” drainage is installed in the wound through the contra-hole, the drainage is fixed by a ligature to the skin. The gluteal muscle, fixed with "polyspast" sutures to the lower edge of the surgical wound, completely covered the wound defect after removing the pressure sore capsule, drainage remains at the bottom of the wound, under the muscle. Stitches are applied to the skin. The drainage is placed on active aspiration. Antibacterial therapy for 5 days, drainage removed on 3 days. The wound healed first. Sutures were removed on the 18th day. The load on the operated area is allowed 2 weeks after the removal of sutures. Dynamic observation of the patient for 4 years, recurrence of a pressure sore wound was not.

The invention allows using a new technical result.

The use of a staining solution - methylene blue and 3% hydrogen peroxide in a ratio of 9: 1 - allows you to verify all streaks and pockets of pressure sore wounds, at the same time, this ratio reduces the likelihood of wound contents leaving the pressure sore cavity when it interacts with hydrogen peroxide.

The closure of the entrance gate of the decubitus wound after its tamponade and staining, performed before the surgical incision, allows you to transfer the surgical intervention from the category of “purulent” to “clean”.

As a result of the proposed surgical treatment technique, economic costs are significantly reduced both by reducing the duration of antibiotic therapy by 3-4 days, and by eliminating aseptics from the arsenal for washing drainages.

A high percentage of primary healing of pressure sores reduces the likelihood of repeated surgery.

Thus, the method is effective, affordable, when used does not require large economic costs and further reduces the cost of postoperative treatment of patients with bedsore wounds. The medical and clinical significance of the proposed method consists in the rehabilitation of the most severe contingent of patients with TBSM.

Claims (1)

A method for the surgical treatment of deep bedsores with a cavity in patients with consequences of a spinal cord injury, including tamponade of the cavity with turunda with methylene blue for staining the bedsore, excision of the bedsore, drainage, plastic-muscular skin grafting with removable "multispast" sutures, antibacterial therapy characterized in that for staining use a solution of methylene blue in a mixture with hydrogen peroxide 3% in a ratio of 9: 1, before excision of the bedsore, its entrance gate is tight at they sew, drainage of the wound is carried out by “blind” drainage for 3 days.