RU2438716C1 - Method of treating diffuse fibrinous-purulent peritonitis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention relates to medicine, namely to abdominal surgery and can be used in treatment of patients with diffuse forms of fibrinous-purulent peritonitis in post-operative period. On 2-3 day after operation control laparoscopy is carried out. Under video control determined are places of fibrin overlay. Through trocar introduced is metal insufflator with thin outlet hole for supply of jet of antiseptic solution into abdominal cavity. Optimal frequency of pulsation for separation of friable overlays of fibrin is 8-10 Hz and pressure is 5-6 kg/sq.cm, for separation of densely fixed fibrin - 15-20 Hz and 7-8 kg/sq.cm. After step-by-step irrigation of required parts, washing liquid is aspirated. ^ EFFECT: method makes it possible to remove fibrinous overlay in abdominal cavity under visual control and reduces risk of commissural disease development. ^ 1 cl, 2 ex

Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the treatment of patients with common forms of fibrinous-purulent peritonitis.

There is a method of treating peritonitis, which consists in the fact that after laparotomy, elimination of the source of peritonitis and sanitation of the abdominal cavity, a large omentum is resected, a round and sickle ligament of the liver is dissected. Irrigators are installed in the sloping places of the abdomen along the right lateral canal and pelvis on the right, the mesentery root of the small intestine, along the left lateral canal into the subphrenic space. A pulsating stream of antiseptic in a mixture with air is fed through irrigators. Aspirate contents through median drainage. Median drainage is placed along the anterior abdominal wall over intestinal loops. After the intervention, a gas bubble is created between the abdominal organs and the anterior abdominal wall. For washing use a solution of sodium hypochlorite. Washing is carried out every 5-6 hours (Remizov I.V., Savchenko Yu.P., Tuzov S.T., Patent No. 2147444).

The main disadvantages of this method are:

1) unregulated pulsation frequency of the antiseptic stream, which does not allow to create the optimal compression-decompression mode, which prevents the ability to adequately remove fibrinous deposits;

2) the inability to control the quality of rehabilitation, which can lead to the prolongation of peritonitis;

3) high morbidity, in particular, resection of the greater omentum, dissection of the round and sickle-shaped ligaments of the liver, which negatively affects the effectiveness of treatment.

Object of the invention: optimization of laparoscopic sanitation of the abdominal cavity in patients with advanced purulent peritonitis by increasing the efficiency of removing fibrinous deposits from the visceral and parietal peritoneum with minimal trauma.

The problem is achieved by the fact that for laparoscopic sanitation of the abdominal cavity, irrigation with a pulsating fluid stream with an adjustable pulsation frequency and feed pressure is used. The frequency of the pulsation and the pressure of the supplied fluid depend on the strength of fixation of fibrin to the peritoneum. The stronger the fibrin is fixed, the higher the frequency and pressure. The processing effect is explained mainly by mechanical action. In the “microhydroshock” phase, the liquid jet releases weakly fixed portions of fibrin, blood clots and microbial bodies, penetrates into microcavities, destroying them. In the inter-pulse "decompression" phase, they depart with a fluid flow. Multiple repetition of pulsations allows more efficient removal of fibrin.

The method is as follows.

Under endotracheal anesthesia, a laparotomy is performed. The source of peritonitis is eliminated. The abdominal cavity is sanitized with an antiseptic solution. Drainage is carried out by tubular drains from the required number of points, depending on the prevalence of the process.

On the second, and if necessary, the next day, a rehabilitation laparoscopy is performed. Indications for its implementation are those cases when during the surgical aid it was not possible to completely remove fibrinous deposits, and in the postoperative period, the phenomena of non-stopping peritonitis persist: hyperthermia, bloating, intestinal paresis, purulent discharge through the drains. Intervention is performed under general anesthesia. Existing drains are pinched. Oxygenoperitoneum is applied through one of the drains.

An optical laparoport is introduced through the postoperative scar - a trocar with an inner diameter of 7 mm, a laparoscope with a diameter of 6 mm is inserted through it. An examination and assessment of the condition of the abdominal cavity is carried out, fibrin overlay sites are determined.

Then, under the control of vision, an instrumental laparoport, a trocar with an inner diameter of 6 mm, is introduced into the most involved part of the abdominal cavity through the drainage position or into an additionally superimposed hole, and through it a long metal aquapurator with a diameter of 5 mm with a thin outlet with a diameter of 1, 5 mm. The tube is 30 cm long. To prevent organ trauma, an elastic cambric is worn at its end, which is inserted into the abdominal cavity. The pulsating jet is created by the Letell doctor Aquajet LD-A7 insufflator. The aquapurator and insufflator are connected by an inelastic catheter. The liquid was a 0.2% solution of furatsilina or 0.06% sodium hypochlorite. The ripple frequency is regulated by the handle of the device. A pulsating fluid stream removes fibrin, detritus, and blood clots. The optimal pulsation frequency for separation of loose overlays of fibrin 8-10 Hz and a pressure of 5-6 kg / cm ² . In the case of tight fixation of fibrin to the peritoneum, the optimal parameters are 15-20 Hz and 7-8 kg / cm ² . In the first case, 400-500 ml of liquid is consumed per minute of continuous operation of the device, in the second - 600-800 ml. Pressure within the range of 5-8 kg / cm ² at the outlet does not damage the tissue. The jet is directed to fibrinous deposits immediately at the place of their fixation to the peritoneum, gradually exfoliating and rinsing them from a distance of about 1-2 cm.Then, the jet is sent to the intestinal loops from a distance of 4-6 cm in a circular motion for better sanitation and hydromassage.

Then the aquapurator is changed to suction and the contents of the abdominal cavity are aspirated. The last two manipulations are repeated until the fibrin is adequately cleaned from the abdominal cavity. If there is no longer a need for rehabilitation, tools, gas and drainage are removed, the wounds are sutured. If such a need remains, then thin drainage conductors are left for the next rehabilitation.

Clinical example No. 1

Patient K., 30 years old (source of illness No. 4273), was admitted on an emergency basis to the surgical department of the Municipal Clinical Hospital GKB SMP 03/31/10. Preliminary diagnosis: pelvioperitonitis. After lower middle laparotomy, it was found: purulent salpingitis, acute catarrhal appendicitis, fibrinous-purulent pelviopertonitis. In the small pelvis, the application of fibrin on the peritoneum in a large volume, pus is secreted from the right fallopian tube. Appendectomy performed. After consultation with a gynecologist, surgical treatment was completed with rehabilitation and drainage of the abdominal cavity. It was not possible to completely remove fibrinous overlays on the visceral and parietal peritoneum. Conservative treatment in full in accordance with the standards of treatment of peritonitis.

In the postoperative period, febrile condition, soreness in the lower abdomen, intestinal paresis, and serous-purulent discharge through the drains remained.

04/02/10 under intravenous anesthesia through drainage in the right iliac region, oxygenoperitoneum was applied. Drainage was removed from the left iliac region, an optical laparoport was inserted. Peritoneal cavity revision performed. In the pelvis, single loose adhesions between the small intestine and the parietal peritoneum, about 150 ml of serous-purulent effusion with loose overlays of fibrin on the visceral and parietal peritoneum. Loops of the intestine are not pneumotized, do not peristaltize, are slightly hyperemic in the pelvic area. The fallopian tubes are hyperemic, there is no purulent discharge, the ovaries are without signs of inflammation. Under the control of vision, a manipulative laparoport was installed at the drainage position in the right iliac region. Performed separation of adhesions, sanitation of the abdominal cavity with a pulsating jet of furatsilin solution with a frequency of 8-10 Hz and a pressure of 5-6 kg / cm ² with targeted removal of fibrin films. Pneumo-hydromassage bowel loops. Removed gas and tools. Delivered drainage, hemmed. Aseptic dressing.

By 15:00 on 04/03/10 there is no discharge through the drains, the general condition is satisfactory, the body temperature is normal, palpation of the lower abdomen is moderately painful. Drainage removed.

04/12/10 discharged in satisfactory condition. Turnout in a month.

05/14/10 no complaints, deep palpation of all parts of the abdomen is painless.

Clinical example No. 2

Patient Shch., 79 years old, was admitted to the surgical department of the Municipal Clinical Hospital GKB SMP in an emergency order 02.25.10 with a diagnosis of gangrenous-perforated cholecystitis, common fibrinous-purulent peritonitis. After median laparotomy found: in all parts of the abdominal cavity gall-purulent contents. On the hyperemic visceral peritoneum, fibrin overlay. In the subhepatic space, a loose infiltrate, upon separation of which a gangrenous changed gall bladder with impaired integrity was found. Performed cholecystectomy, sanitation of the abdominal cavity with a solution of furatsilina, drainage from four points, layered suturing of the laparotomy wound. It was not possible to completely clear the abdominal cavity from the application of fibrin. Conservative treatment in full in accordance with the standards of treatment of peritonitis.

In the postoperative period, febrile condition persists, pain on palpation in all parts of the abdomen, peristalsis is not heard, the gases do not go away, scanty serous-purulent discharge through the drains.

04/26/10 under intravenous anesthesia through drainage in the right iliac region, oxygenoperitoneum was applied. One seam was removed from the laparotomy scar 2 cm below the navel, an optical laparoport was inserted. The abdominal cavity was examined. In all parts of the abdominal cavity, the visceral and parietal peritoneum is moderately hyperemic, purulent contents in the interlobular spaces. Between the loops of the intestine and the anterior abdominal wall there are many loose fibrinous adhesions in the form of threads. In the upper right quadrant of the abdominal cavity, dense fibrinous deposits in a large volume on the walls of the intestine and the surface of the liver. The intestinal loops are pneumotized, without visible peristalsis. Under the control of vision, a manipulative laparoport was installed at the drainage position in the right iliac region. Adhesive separation completed. To remove loose fibrin films, a pulsating jet of furatsilin solution with parameters of 8-10 Hz and a pressure of 5-6 kg / cm ^{2 was used} . To remove dense fibrinous deposits, a jet with parameters of 15-20 Hz and a pressure of 7-8 kg / cm ^{2 was used} . The release of fibrin drainage, replaced the drainage in the right hypochondrium. Pneumo-hydromassage bowel loops. Removed gas and tools. Aseptic dressing.

By 2 p.m. on 2/27/10, there is no discharge through the drains, the general condition is closer to satisfactory, body temperature is 37.0 ° C, palpation of the abdomen is moderately painful. Gases depart. Peristalsis is heard.

By 11:00 on 02/28/10, the drains were removed, and enteral nutrition was started.

03/12/10 discharged in satisfactory condition. Turnout in a month.

05/14/10 no complaints, deep palpation of all parts of the abdomen is painless.

Thus, the improvement of the results of surgical treatment of fibrinous-purulent peritonitis can be achieved by more complete removal of fibrinous deposits by means of a pulsating fluid stream with adjustable frequency and pressure parameters under visual control, reducing trauma and reducing the likelihood of adhesive disease.

Claims (1)

A method of treating widespread purulent-purulent peritonitis, including laparotomy, eliminating the source of peritonitis, sanitation of the abdominal cavity, characterized in that on the second, and if necessary the next day postoperative period, irrigation of the abdominal cavity with a pulsating liquid jet with frequency regulation is used during laparoscopic sanitation pulsation and supply pressure, the optimum parameters of frequency and pressure for separating unconsolidated fibrin overlay are 8-10 Hz and a pressure of 5-6 kg / cm ^2, and in case n otnoy fibrin fixation to the peritoneum optimal parameters are 15-20 Hz and 7-8 kg / cm ^2.