RU2460552C2 - Method for preoperative preparation of patients suffering extensive peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, particularly to abdominal surgery, and may be applied for preoperative preparation of the patients suffering extensive peritonitis. That is ensured by abdominal paracentesis by the introduction of a catheter through a trocar into an abdominal cavity that is followed by aspiration of the pathological content. Immediately after aspiration of the pathological content, hyperosmolar 10% NaCl is introduced in the abdominal cavity in the amount twice exceeding that of the discharged pathological content. Thereafter, the catheter is clamped for 5-10 minutes, then opened, and the content is evacuated; antiseptic solutions are introduced in the abdominal cavity in the amount twice exceeding that of the hyperosmolar solution. Then the catheter is clamped for 5-10 minutes and opened, the content is evacuated; the abdominal cavity is irrigated with the antibacterial solution.

EFFECT: method provides reducing body intoxification, bacteremia and thereby enhancing the preoperative preparation for compensation of cardiovascular and pulmonary pathologies in somatically severe patients that enables reduced length of the operation and risk of postoperative complications.

5 ex

Description

The invention relates to medicine, namely to abdominal surgery, and can be used in the preoperative preparation of patients with widespread peritonitis.

Preoperative preparation includes activities consisting in specific tasks. The first of them is solved comprehensively - elimination of tissue dehydration, hypovolemia and electrolyte disturbances. This is achieved by infusion of isotonic (NaCl 0.9%, glucose solution 5%), polyionic solutions (Acesol, Disol, Trisol, Ringer-Locke) at a rate of 30-50 ml per 1 kg of body weight. The rate of infusion and its total volume are adjusted depending on the functional state of the cardiovascular system. With its stable state, therapy for detoxification is carried out in hemodilution mode. An extremely important task is to ensure early (preoperative) initiation of adequate antibiotic therapy (I. Yerukhin, Purulent Peritonitis Surgery, Consilium Medicum., Surgery No. 1, 2008).

Known methods for treating the abdominal cavity during surgery and the postoperative period in the treatment of peritonitis include:

- peritoneal dialysis by the flowing method, consisting in the introduction of fluid through the drainage in the hypochondria, with the assumption that, washing the abdominal cavity, it will be discharged through the drainage of the abdominal cavity in the small pelvis (Deryabin I.I., Lizonets M.N., Peritoneal dialysis, M., Medicine, 1991, 168 pp., Kanevich MD, Selivanov EA, Starokon PM Peritonitis, Infusion-transfusion and detoxification therapy, M., LLC MedExpertPress, 2004, 203 pp. );

- hypothermic perfusion, which consists in washing the abdominal cavity with a large amount of cold solution (up to 30 liters per day), the fluid, washing the abdominal cavity, is independently removed through the drainage from the small pelvis (Tatishvili G.G., Tamazashvili T.M., Tavdaradze I. D .., Abdominal hypothermia in the treatment of postoperative peritonitis, Herald of Surgery, 1985, No. 12, p.139-142);

- hyperthermic perfusion (Deryabin II, Lizonets M.N., Peritoneal dialysis, M., Medicine, 1991, p.168);

- using perfusants of various compositions (Bondarev V.I., Ablitsev N.G., Bazen A.P., Intra-abdominal lavage in the complex treatment of patients with diffuse peritonitis, Surgery, 1995, No. 2, p. 18-22).

The disadvantages of the above methods for treating the abdominal cavity include the following.

1. The low efficiency of peritoneal dialysis due to the rapid formation of channels in the abdominal cavity, due to prolapse of fibrin filaments and the formation of adhesions fragmenting it, which also limits the possibility of conducting the required number of sessions.

2. Prerequisites are created for additional infection of the abdominal cavity and the formation of abscesses with fibrous-purulent peritonitis due to the fact that not all fluid introduced into the abdominal cavity is removed through the drains (Kanevich MD, Selivanov EA, Starokon P .M. Peritonitis. Infusion-transfusion and detoxification therapy, M., LLC MedExpertPress, 2004, 203 pp.).

3. The washing out of a large amount of protein from the body by flowing fluid, which leads to the development of hypoproteinemia.

4. The need for each session of peritoneal dialysis of a large number (13-15 to 30 liters per day) of expensive medicinal solutions (Karimov Sh.I., Tursunov KN, Asrarov AA, etc. The effectiveness of peritoneal dialysis, intestinal lavage and enteral tube feeding in the complex treatment of diffuse purulent peritonitis, Methodological recommendations, Tashkent, 1984, 14 pp.).

The introduction into the abdominal cavity of hyperosmolar solutions, antibacterial and antiseptic drugs as a preoperative preparation of patients with widespread peritonitis is not described in the available literature.

As a prototype for the closest technical essence, we have chosen a method for diagnostic laparocentesis to determine the nature of the contents of the abdominal cavity in acute and postoperative peritonitis. Laparocentesis is carried out in the operating room, dressing room or in the intensive care unit according to the technique, which is as follows. The patient is given a supine position. The surgeon is located to the right of the patient, and the assistant is opposite the surgeon. For 20-30 minutes before the start of laparocentesis, premedication is carried out by intramuscular injection of the mixture: promedol 1% 1 ml, diphenhydramine 1% 2 ml, atropine 0.1% 0.5 ml. The manipulation is carried out under local anesthesia: 0.25% solution of novocaine 50-100 ml. The introduction of a trocar with a stylet is performed along the midline of the abdomen 1-2 cm below the navel. After removing the stylet, the abdominal wall is gradually pressed with the palm of the hand in the epigastric and suprapubic right and left iliac regions. If during this compression pathological contents enter through the trocar, then the further study is stopped, the trocar is removed and proceeds to surgical treatment. In the absence of exudate, a transparent polyvinyl chloride catheter is inserted through the trocar, followed by aspiration of the pathological contents with a syringe. A similar technique in modern literature is called laparocentesis using a “rummaging” catheter. A catheter can be inserted into any part of the abdominal cavity (Khanevich MD, Bordakov VN, Zubritsky VF Postoperative intra-abdominal infection in emergency surgery, St. Petersburg, Agraf + LLC, 2009, 287 pp.).

The disadvantages of the method chosen by us as a prototype are the following.

- The likelihood of additional contamination of the abdominal cavity with pathogenic flora using the “catheter” catheter method, since the catheter inserted into the abdominal cavity, in contact with the pathological focus, is seeded with microorganisms and, with further manipulations, spreads the infection through the abdominal cavity, which can lead to progression of the underlying disease and intoxication of the body .

- Lack of dilution and removal of the remaining exudate in the abdominal cavity using solutions, which creates the prerequisites for its infection and the formation of abscesses.

- The absence of the introduction of solutions with bacteriostatic and bactericidal properties, which leads to an increase in the concentration of microorganisms and their waste products that form endotoxemia.

- The palpation method for the active extraction of exudate can lead to further seeding of the abdominal cavity due to increased blood flow to the palpable places, which is a prerequisite for more active absorption of microorganisms and toxins into the blood and lymphatic channels. The disadvantage of the method of palpation is also the resulting additional pain in the patient.

- When using diagnostic laparocentesis as a method of preoperative preparation of a patient for surgical treatment of acute and postoperative peritonitis, there is no possibility to increase the time of preoperative preparation in order to compensate for cardiovascular and pulmonary pathologies in somatically severe patients.

The technical result of the invention is to reduce intoxication of the body and bacteremia, increase the time of preoperative preparation in order to compensate for cardiovascular and pulmonary pathologies in somatically severe patients, reduce the risk of postoperative complications, as well as reduce the time of the operation itself and the duration of treatment in a hospital.

The technical result of the invention is achieved by the fact that laparocentesis is carried out, including the introduction of a catheter through a trocar into the abdominal cavity, followed by aspiration of the pathological contents contained therein. Immediately after aspiration of the pathological contents, a hyperosmolar 10% NaCl solution is injected into the abdominal cavity in a volume exceeding the amount of the obtained pathological contents by 2 times. After this, the catheter is clamped for 5-10 minutes, then open it and evacuate the contents. Then, antiseptic solutions are introduced into the abdominal cavity in a volume exceeding the volume of the hyperosmolar solution by 2 times. Then the catheter is squeezed for 5-10 minutes, after which it is opened, the contents are evacuated and the abdominal cavity is irrigated with an antibacterial solution.

The method is as follows.

Upon admission to the hospital against the background of preoperative preparation (infusion-detoxification therapy) in the operating room, dressing room or in the intensive care unit, laparocentesis is performed for a patient with advanced peritonitis. The patient is given a supine position. For 20-30 minutes before the start of the operation, premedication is carried out by intramuscular injection of the mixture: promedol 1% 1 ml, diphenhydramine 1% 2 ml. Manipulation is carried out under local anesthesia with a 0.5% solution of novocaine 20-40 ml. The introduction of a trocar with a stylet is performed along the midline of the abdomen 1-2 cm below the navel. Removing the stylet from the trocar, the presence or absence of exudate is noted. In the presence of exudate, its passive expiration occurs. Then a polyvinyl chloride catheter is inserted through the trocar and the trocar is removed. In the absence of effusion, it is necessary to change the position of the patient's body for the active flow of exudate. After the effusion and the contents of the hollow organs poured into the abdominal cavity, a hyperosmolar solution (10% NaCl) is introduced through the catheter in a volume exceeding the amount of exudate obtained by 2 times. Then the catheter is squeezed for 5-10 minutes to expose the solution in the abdominal cavity. Then, depending on the prevalence of the process, which is determined by the symptom of Shchetkin-Blumberg, a change in the position of the patient’s body is carried out depending on the alleged source of peritonitis or the Fauler position is attached. Then the catheter is opened and the contents are evacuated to the maximum in a passive and / or active (change of body position) way. Then, antiseptic solutions (furatsilina solution 0.02%, aqueous chlorhexidine solution 0.02%) are introduced into the abdominal cavity in a volume 2 times higher than the hyperosmolar solution. Then the catheter is clamped for 5-10 minutes. Then the catheter is opened and the contents are maximally evacuated in a passive and / or active (change of body position) way. At the final stage, an irrigation of the abdominal cavity with antibacterial drugs is carried out through the catheter.

Distinctive essential features of the claimed invention are the following.

- Insertion of a catheter through a trocar into the abdominal cavity, followed by aspiration of the pathological contents contained therein.

- Immediately after aspiration of the pathological contents, a hyperosmolar 10% NaCl solution is injected into the abdominal cavity in a volume exceeding the amount of the obtained pathological content by 2 times.

- After that, the catheter is squeezed for 5-10 minutes, then open it and evacuate the contents. Then, antiseptic solutions are introduced into the abdominal cavity in a volume exceeding the volume of the hyperosmolar solution by 2 times.

- Then the catheter is squeezed for 5-10 minutes, after which it is opened, the contents are evacuated and the abdominal cavity is irrigated with an antibacterial solution.

A causal relationship between the salient features and the effect achieved.

- The introduction of a catheter through a trocar into the abdominal cavity, followed by aspiration of the pathological contents located in it, allows you to clean the exudate and contents that have poured from the hollow organs into the abdominal cavity, which at the stage of preoperative preparation reduces the body's intoxication and bacteremia and allows you to extend the preoperative period in somatically severe patients with diseases of the cardiovascular and pulmonary systems, and also reduces the time of rehabilitation of the abdominal cavity during the main surgical intervention.

- The introduction into the abdominal cavity of a hyperosmolar 10% NaCl solution increases the volume of fluid in the abdominal cavity and thereby helps to reduce the concentration of toxins and microorganisms in it, and also prevents their penetration into the blood and lymphatic channels. A hyperosmolar 10% NaCl solution is injected in a volume exceeding the amount of exudate obtained by 2 times, since after aspiration of the exudate in the abdominal cavity there may be exudate, which when mixed with a hyperosmolar solution weakens its osmolarity, thereby leading to a decrease in efficiency.

Large volumes of solutions (both a hyperosmolar 10% NaCl solution and an antiseptic solution) are not used to prevent the spread of exudate to other parts of the abdominal cavity at the stage of preoperative preparation. The results of our clinical trials have demonstrated insufficiently high efficiency when using smaller volumes of solutions. The chosen volumes of the introduction of solutions are due to the fact that it is in such volumes that the medicinal solutions reduce the concentration of bacteria and toxins in the abdominal cavity, which is proved by clinical trials.

- Given that after the removal of toxins and microorganisms by the hyperosmolar solution in the abdominal cavity, microorganisms and their toxins can remain, the abdominal cavity is sanitized with an antiseptic solution, the volume of which is 2 times the volume of the hyperosmolar solution.

- The introduction of antibacterial and antiseptic drugs provides bacteriostatic and bactericidal action directly in the focus of inflammation.

- Squeezing the catheter for 5-10 minutes after introducing a hyperosmolar 10% NaCl solution into the abdominal cavity is necessary for the solution to distribute throughout the abdominal cavity, exerting a hyperosmolar effect, while reducing the concentration of microorganisms and their metabolic products in the abdominal cavity.

With an exposure of a hyperosmolar 10% NaCl solution equal to 15 minutes, that is, with an exposure of more than 5-10 minutes, pain was observed in some patients, and, given the exudative properties of the peritoneum, with an exposure of 15 minutes, the effectiveness of the hyperosmolar effect of this solution decreases . When exposed for less than 5 minutes, a hyperosmolar solution does not have a clinically significant effect.

When the antiseptic solutions are exposed for less than 5-10 minutes, these solutions do not exhibit significant antiseptic properties. The most significant clinical effect was obtained with exposure to antiseptic solutions in 5-10 minutes. The increase in temporary exposure did not increase a significant clinical effect.

The combination of essential distinguishing features allows

- reduce body intoxication and bacteremia, which, in turn, reduces the risk of postoperative complications, which is expressed in the initial healing of the wound without signs of inflammation, reducing the formation of intra-abdominal abscesses and reducing the risk of pneumonia;

- increase the time of preoperative preparation, which allows compensation of concomitant diseases in somatically severe patients;

- reduce the time of the operation itself and the duration of treatment in a hospital.

Examples of clinical performance of the method.

Example No. 1.

I / B No. 1960. Patient S., 79 years old.

She was hospitalized in the clinic of surgical diseases No. 2 on an emergency basis, with a diagnosis of exacerbation of chronic pancreatitis. Examination and drug treatment were carried out. On the fourth day, the patient showed signs of intoxication, abdominal pain intensified, peritoneal symptoms appeared in the lower abdomen. According to a clinical blood test: an increase in the level of leukocytes to 15.9 × 10 ⁹ / l, stab neutrophils - 37.

Objectively: moderate state, heart rate - 104 bpm.

For diagnostic purposes, the patient underwent laparocentesis, which confirmed the diagnosis of acute peritonitis.

For the purpose of preoperative preparation, laparocentesis was used as a method of detoxification and preliminary sanitation of the abdominal cavity.

In the dressing room under local anesthesia, a 0.5% novocaine solution, a cut along the midline of the anterior abdominal wall 2.0 cm below the navel, was punctured with an abdominal cavity using a trocar with a stylet. A polyvinyl chloride catheter with a thickness of 0.5 cm was inserted into the abdominal cavity. No discharge was obtained. 100 ml of a 0.5% solution of novocaine were introduced into the abdominal cavity. Within 1 hour, a cloudy effusion compartment appeared along the drainage tube. About 150 ml of turbid exudate was evacuated from the abdominal cavity. Through a drainage tube, 100 ml of a hyperosmolar 10% NaCl solution was introduced into the abdominal cavity. The catheter was pinched for 5 minutes to expose the solution in the abdominal cavity. The patient's body position changed (right, left side), then the patient was in the Fowler position. After that, the catheter was opened and 100 ml of turbid exudate was evacuated from the abdominal cavity. The abdominal cavity is washed with 200 ml of physiological solution of 0.9% and 200 ml of furatsilin solution of 0.02%. The catheter was pinched for 5 minutes to expose the solution in the abdominal cavity, after which the catheter was opened, the exudate was evacuated by gravity through the installed drainage tube. Then, 100 ml of ciprofloxacin solution was introduced into the abdominal cavity.

After 2 hours, the patient was taken to the operating room. An emergency median laparotomy was performed. In the abdominal cavity - purulent-fibrinous exudate. During the surgical intervention revealed the presence of a paracolar abscess of the sigmoid colon, the presence of creamy pus in the pelvic cavity. Loops of the intestine with edematous hypermerized serous membrane, secondary changes in the appendix. The main changes were in the lower floor of the abdominal cavity.

During intraoperative rehabilitation, the evacuation of purulent discharge from the pelvic cavity. The abdominal cavity was washed with 2 l of a solution of chlorhexidine 0.02% and 1.5 l of a NaCl solution of 0.9%. The source of peritonitis is perforation of the sigmoid colon diverticulum. A resection of the sigmoid colon was performed, with a colostomy on the anterior abdominal wall. Appendectomy. Sanitation and drainage of the abdominal cavity.

Postoperative diagnosis: Diverticular disease. Diverticulosis of the sigmoid colon, with diverticulitis. Perforation of the diverticulum. Paracolar abscess. Common purulent-fibrinous peritonitis.

Concomitant diagnosis: IHD. Angina pectoris 2 f. Atherosclerotic cardiosclerosis. Hypertension 2 tbsp., Risk 3. Atrial ventricular extrasystole. DUNZ.

The postoperative period was uneventful. Drainage from the abdominal cavity was removed on the 4th day after surgery. Intestinal motility appeared on the 3rd day, independent stool on the 4th day. The patient was discharged for outpatient treatment in satisfactory condition on the 20th day after surgery.

Example No. 2.

I / B No. 48. Patient S., 64 years old.

He was hospitalized in the hospital on an emergency basis, with a diagnosis of exacerbation of chronic pancreatitis.

Examination of the patient revealed a pancreatic cyst. Metastatic changes in the liver. Surgical treatment was performed: puncture of the pancreatic cyst, external drainage of the cyst cavity.

In the postoperative period, on the 3rd day, the patient experienced a sharp deterioration, peritoneal symptoms, signs of perforation of the hollow organ appeared. A laparocentesis technique was carried out for diagnostic and therapeutic purposes.

In the ICU of the surgical department under local anesthesia, a 0.5% novocaine solution, an incision along the midline of the anterior abdominal wall 2.0 cm below the navel, was punctured with an abdominal cavity with a stylet. Received 150 ml of turbid effusion with an admixture of intestinal contents. A 0.5 cm thick polyvinyl chloride catheter was left in the abdominal cavity. 100 ml of a hyperosmolar 10% NaCl solution was introduced through the catheter into the abdominal cavity, after which the catheter was pinched for 10 minutes. The patient was given the Fowler position of the body. 100 ml of turbid effusion with an admixture of intestinal discharge was evacuated by catheter. Subsequently, the abdominal cavity was rinsed with 200 ml of 0.02% chlorhexidine solution and 200 ml of 0.02% furacilin solution. The catheter was pinched for 10 minutes to expose the solution in the abdominal cavity, after which the catheter was opened, the exudate was evacuated by gravity through the installed drainage tube. Then, 100 ml of ciprofloxacin solution was introduced into the abdominal cavity.

Surgical treatment was performed 2 hours after the diagnosis of acute peritonitis. Intraoperatively revealed signs of a common tumor process, peritoneal carcinomatosis, metastases to the lymph nodes of the intestine, omentum, liver, loops of the small intestine. In the abdominal cavity turbid exudate, with an admixture of intestinal contents. The loops of the small intestine are swollen, the serous membranes are hyperemic, injected. Perforation of the small intestine, in the area of metastatic lesion. Common peritonitis.

The operation was performed: resection of the small intestine, omentum, with the application of the small-intestinal anastomosis “side to side”. Appendectomy.

In the postoperative period, the patient's condition remained severe, the postoperative period was uneventful. The amount of discharge through the drains decreased to 20-30 ml on the 2nd day, the drainage was removed on the 3rd day after the operation. Intestinal motility appeared on the 3rd day. Independent stool on the 4th day. The wound healed by primary intention. The patient was discharged for outpatient treatment on the 20th day after surgery.

Example No. 3.

And / B No. 19149. Patient K., 22 years old.

Hospitalized in a clinic of surgical diseases in an emergency with a diagnosis of acute appendicitis? acute gastritis?

The state of moderate severity. Concerned expressed pain in the epigastric region, peritoneal symptoms were determined, there were signs of perforation of the hollow organ. The diagnosis is confirmed by x-ray examination.

In a dressing room under local anesthesia, a 0.5% novocaine solution, a 2.0 cm incision along the midline of the anterior abdominal wall below the navel was punctured by an abdominal cavity using a trocar with a stylet. A polyvinyl chloride catheter with a thickness of 0.5 cm was inserted into the abdominal cavity. No discharge was obtained. 100 ml of a hyperosmolar 10% NaCl solution was introduced into the abdominal cavity, after which the catheter was pinched for 10 minutes. The patient was given the Fowler position of the body. A catheter evacuated 100 ml of cloudy effusion mixed with hemorrhagic discharge. Subsequently, the abdominal cavity was washed with 200 ml of furatsilina solution of 0.02% and 200 ml of physiological saline. The catheter was pinched for 10 minutes to expose the solution in the abdominal cavity, after which the catheter was opened, the exudate was evacuated by gravity through the installed drainage tube. Then, 100 ml of ciprofloxacin solution was introduced into the abdominal cavity.

Surgical treatment was carried out 1.5 hours after diagnosis. Under endotracheal anesthesia, a laparotomy was performed. When auditing in the upper floor of the abdominal cavity, about 200 ml of turbid effusion with an admixture of gastric contents. In the outlet of the stomach along the front wall there is a perforated hole with a diameter of 0.5 cm. The serous membranes of the stomach, loops of the small intestine are hyperemic, with a touch of fibrin.

Operation: suturing the perforated opening of the anterior wall of the stomach. Sanitation and drainage of the abdominal cavity. Intraoperative rehabilitation was carried out with two l of a solution of furatsilina of 0.02% and 1 l of a solution of NaCl of 0.9%, 4 drainage tubes were installed.

The postoperative period was uneventful. Separated by 2 drains, standing in the pelvic cavity on the left and in the left lateral canal, stopped on the 2nd day after the operation, the drains were removed. On the drains in the right hypochondrium, the discharge ceased on the 3rd day, the drains were removed. Peristalsis on the 3rd day, an independent chair on the 4th day.

The patient was discharged on the 8th day after surgery for outpatient treatment in satisfactory condition.

Example No. 4.

I / B No. 19153. Patient V., 28 years old.

Hospitalized in a clinic of surgical diseases in an emergency with a diagnosis of acute appendicitis?

The state of moderate severity. Concerned expressed pains in the epigastric region, nausea, single vomiting, peritoneal symptoms were determined, there were signs of perforation of the hollow organ. The diagnosis is confirmed by x-ray examination.

In a dressing room under local anesthesia, a 0.5% novocaine solution, a 2.0 cm incision along the midline of the anterior abdominal wall below the navel was punctured by an abdominal cavity using a trocar with a stylet. A 0.5 cm thick polyvinyl chloride catheter was inserted into the abdominal cavity. The discharge is a cloudy character, in a volume of 100 ml. 200 ml of a hyperosmolar 10% NaCl solution were introduced into the abdominal cavity, after which the catheter was pinched for 5 minutes. The patient was given the Fowler position of the body. 250 ml of turbid effusion were evacuated by catheter. Subsequently, the abdominal cavity was washed with 400 ml of 0.02% furatsilin solution and 200 ml of physiological saline. The catheter was pinched for 5 minutes to expose the solution in the abdominal cavity, after which the catheter was opened, the exudate was evacuated by gravity through the installed drainage tube. Then, 100 ml of metronidozole solution was introduced into the abdominal cavity.

Surgical treatment was performed 2 hours after diagnosis. Under endotracheal anesthesia, a laparotomy was performed. When auditing in the upper floor of the abdominal cavity, about 100 ml of turbid effusion with an admixture of gastric contents. In the outlet of the stomach along the front wall there is a perforated hole with a diameter of 1.5 cm. The serous membranes of the stomach, loops of the small intestine are hyperemic, with a touch of fibrin.

Operation: suturing the perforated opening of the anterior wall of the stomach. Sanitation and drainage of the abdominal cavity. Intraoperative sanitation was carried out with 2.5 L of a solution of furatsilina 0.02% and 1 L of a NaCl solution of 0.9%, 4 drainage tubes were installed.

The postoperative period was uneventful. Separated by two drains, standing in the pelvic cavity on the left and in the left lateral canal, stopped on the 3rd day after the operation, the drains were removed. On the drainage in the right hypochondrium, the discharge also stopped on the 3rd day, the drainage was removed. Peristalsis - on the 3rd day, an independent chair - on the 4th day.

The patient was discharged on the 9th day after surgery for outpatient treatment in satisfactory condition.

Example No. 5.

I / B No. 19172. Patient S., 30 years old.

Hospitalized in a clinic of surgical diseases in an emergency with a diagnosis of acute gastritis?

The state of moderate severity. Concerned expressed pain in the epigastric region, peritoneal symptoms were determined, there were signs of perforation of the hollow organ. The diagnosis is confirmed by x-ray examination.

In a dressing room under local anesthesia, a 0.5% novocaine solution, a 2.0 cm incision along the midline of the anterior abdominal wall below the navel was punctured by an abdominal cavity using a trocar with a stylet. A 0.5 cm thick polyvinyl chloride catheter was inserted into the abdominal cavity. Detachable - 200 ml of a cloudy character mixed with bile. 400 ml of a hyperosmolar 10% NaCl solution was introduced into the abdominal cavity, after which the catheter was pinched for 5 minutes. The patient was given the Fowler position of the body. 200 ml of turbid effusion mixed with hemorrhagic discharge was evacuated by catheter. Subsequently, the abdominal cavity was washed with 800 ml of furatsilina solution of 0.02% and 200 ml of physiological saline. The catheter was pinched for 5 minutes to expose the solution in the abdominal cavity, after which the catheter was opened. The contents were evacuated from the abdominal cavity in a passive way. After evacuation of the contents, 100 ml of ceftriaxone solution was injected into the abdominal cavity.

Surgical treatment was carried out 1.5 hours after diagnosis. Under endotracheal anesthesia, a laparotomy was performed. When auditing in the upper floor of the abdominal cavity, about 200 ml of turbid effusion with an admixture of gastric contents. In the bulb of the duodenum along its front wall there is a perforated hole with a diameter of 1.0 cm. The serous membranes of the stomach, loops of the small intestine are hyperemic, with a touch of fibrin.

Operation: suturing the perforated opening of the anterior wall of the stomach. Sanitation and drainage of the abdominal cavity. Intraoperative sanitation was carried out with 1.5 L of furatsilin solution of 0.02% and 1 L of NaCl solution of 0.9%, 4 drainage tubes were installed.

The postoperative period was uneventful. Separated by 2 drains, standing in the pelvic cavity on the left and in the left lateral canal, stopped on the 2nd day after the operation, the drains were removed. On the drains in the right hypochondrium, the discharge ceased on the 3rd day, the drains were removed. Peristalsis on the 3rd day, an independent chair on the 4th day. The patient was discharged on the 8th day after surgery for outpatient treatment in satisfactory condition.

According to the claimed method, the abdominal cavity was treated in 9 patients - group 1. The comparison group was 9 patients (prototype method) - group 2.

In group 1 - 6 women, 3 men aged 35 to 87 years. The cause of peritonitis was acute appendicitis, acute cholecystitis, perforated gastric ulcer, acute intestinal obstruction, perforation of the sigmoid colon diverticulum, strangulated inguinal hernia. According to the claimed method, the restoration of peristalsis in patients was observed for 2-3 days, in patients without preoperative preparation for 3-5 days. The treatment period according to the claimed method in 8 patients was 8 days, in 2 patients was 9 days and in 2 patients 13 days, in 1 patient was 10 days, in 1 patient 14 days and 1 patient 23 days. The average treatment time is 9 days.

Intestinal motility is restored on the 2nd day. The amount of exudate separated is reduced to 20-30 ml for 3 days.

In a group of 2 out of 9 patients who did not undergo preoperative rehabilitation, the treatment period in 1 patient was 54 days, in 2 patients - 18 days, in 1 patient - 11 days, in 1 patient - 12 days, in 1 patient - 19 days, in 1 patient - 16 days, in 1 patient - 15 days, in 1 patient - 33 days. The average treatment time is 20 days.

Thus, the treatment time for the claimed method is reduced, compared with the prototype method, by 11 days.

The inventive method, compared with the prototype method, allows

- reduce intoxication of the body and reduce bacteremia, which, in turn, reduces the risk of postoperative complications, which is expressed in the initial healing of the wound without signs of inflammation, reducing the formation of intra-abdominal abscesses and reducing the risk of pneumonia;

- increase the time of preoperative preparation up to 2 hours, which allows compensation of concomitant diseases in somatically severe patients;

- reduce the time of the operation by reducing the period of intraoperative rehabilitation and saving time by introducing a smaller number of solutions by 3-4 liters;

- reduce the time of treatment in the hospital by 11 days.

Literature taken into account when preparing the application:

1. Deryabin II, Lizonets MN, Peritoneal dialysis, M., Medicine, 1991, 168 p.

2. Tatishvili GG, Tamazashvili TM, Tavdaradze ID, Abdominal hypothermia in the treatment of postoperative peritonitis, Bulletin of Surgery, 1985, No. 12, p.139-142.

3. Deryabin I.I., Lizonets M.N., Peritoneal dialysis, M., Medicine, 1991, p.168.

4. Bondarev V.I., Ablitsev N.G., Bazen A.P., Intra-abdominal lavage in the complex treatment of patients with diffuse peritonitis, Surgery, 1995, No. 2, p. 18-22.

5. Kanevich M.D., Selivanov E.A., Starokon P.M. Peritonitis. Infusion-transfusion and detoxification therapy, M., LLC MedExpertPress, 2004, 203 pp.

6. Karimov Sh.I., Tursunov K.N., Asrarov A.A. et al. The effectiveness of peritoneal dialysis, intestinal lavage and enteral tube feeding in the complex treatment of diffuse purulent peritonitis, Methodological recommendations, Tashkent, 1984, 14 pp.

7. Hanevich M.D., Bordakov V.N., Zubritsky V.F. Postoperative Intraabdominal Infection in Emergency Surgery, St. Petersburg, Agraf + LLC, 2009, 287 pp.

8. Eryukhin I.A., Consilium Medicum., Surgery No. 1, 2008.

Claims (1)

A method of preoperative preparation of patients with widespread peritonitis, characterized in that laparocentesis is performed by introducing a catheter through a trocar into the abdominal cavity followed by aspiration of the pathological contents located therein, immediately after aspiration of the pathological contents, a hyperosmolar 10% NaCl solution is introduced into the abdominal cavity in a volume exceeding the amount of pathological contents obtained is 2 times, after which the catheter is squeezed for 5-10 minutes, then the contents are opened and evacuated and Antiseptic solutions are brought into the abdominal cavity in a volume exceeding the volume of the hyperosmolar solution by 2 times, then the catheter is squeezed for 5-10 minutes, after which the catheter is opened, the contents are evacuated and the abdominal cavity is irrigated with an antibacterial solution.