RU2468739C1 - Method of preventing purulent-septic complications in laparoscopic operations - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used for prevention of purulent-septic complications in laparoscopic operations. For this purpose before beginning surgery ceftriaxon is introduced intravenously to create systemic antibacterial effect. After that, performed is targeted processing of patient's abdominal cavity with drug mixture, delivered to inflammation nidus through one or several trocars, used simultaneously to provide access to operation field. Used is drug mixture, which includes ceftriaxon and miramistin solution in weight ratio 1:8. Drug mixture is dispersed to fine-dispersive state and delivered within 16 minutes into abdominal cavity, to inflammation nidus, under excessive pressure by means of carbon dioxide or any other inert gas, simultaneously used to create pneumoperitineum.

EFFECT: method ensures increased efficiency of preventing purulent-septic complications after laparoscopic operations due to prevention of microbial contamination of those parts of abdominal cavity, which are not involved into inflammatory process, producing local antibacterial effect with increase of concentration of wide-spectrum antibiotic in inflammation nidus.

1 dwg, 3 ex

Description

The invention relates to medicine, namely to surgery and can be used for intraoperative prophylaxis of purulent-septic complications during laparoscopic operations. The use of the invention is most appropriate when performing laparoscopic appendectomy, cholecystectomy, laparoscopic surgery on the pelvic organs.

In an effort to reduce trauma and speedy postoperative rehabilitation of patients, minimally invasive interventions using laparoscopic techniques are increasingly used in surgical practice (Dolgushkin A.N. et al. 2007; Orekhov G.I., 2009). However, despite significant progress in the field of asepsis, antibiotic prophylaxis, and operating equipment, there is a tendency to increase purulent-septic complications due to the constant formation of pathogen resistance to antibiotics and antiseptics (Fomin S.A., 2008; Chan KW, 2010 ; Ming PC, 2009).

Purulent-septic complications that develop after surgery, create difficulties in the treatment of patients, because they require additional use of drugs, which leads to an increase in financial costs. Purulent-septic complications also lead to a lengthening of the postoperative period and increase the period of disability of patients, which has a certain socio-economic significance.

Therefore, the development and implementation of new methods for the prevention of purulent-septic complications is an urgent problem of modern laparoscopic surgery.

A study of patent and medical literature has revealed the following methods of both intraoperative and postoperative prophylaxis of purulent-septic complications in patients operated on with abdominal organs.

A known method for the prevention of purulent complications in acute destructive appendicitis (RF patent No. 2368330 dated 09/27/2009), in which, after performing an appendectomy in a traditional or laparoscopic manner, the right iliac fossa is drained with a polyethylene catheter through which an additional roncoleukin is introduced, incubated for 60 minutes at a temperature 37 ° C with plasmapheresis obtained by suspension of the patient, in the amount of 70-80 ml in 1, 3, 5 days of the postoperative period. The method allows to increase local immunity, to prevent the development of purulent complications in acute destructive appendicitis.

The disadvantages of this method are:

- the absence of a specific antibacterial effect aimed at reducing the bacterial contamination of the focus of inflammation;

- the application of the method does not provide for intraoperative rehabilitation of the focus of inflammation, which is a predisposing factor in the development of purulent-septic complications and causes a low efficiency of this method.

A known method of treatment of acute inflammatory diseases of the abdominal cavity and the prevention of their complications (patent application of the Russian Federation No. 97114906 published date of application: 07/20/1999), which is carried out as follows. Surgical interventions are performed in the area of pathological foci of inflammation and destruction of the abdominal organs, followed by irradiation of these pathological foci and postoperative wounds with pulsed laser light with the following parameters: wavelength 0.85-0.95 μm, power 2-4 W, frequency 80-100 Hz, exposure for 2 minutes on the field, the course of treatment 5-15 procedures.

The disadvantages of this method are:

- the complexity of expensive laser irradiation equipment and the need for specially trained personnel;

- the possibility of developing burns with a deviation from the exposure time, which not only does not contribute to the prevention of complications, but can also contribute to the spread of the inflammatory process to the burned surface;

- lack of intraoperative local antibacterial effects.

For a number of these reasons, the method cannot be widely implemented in clinical practice.

A known method for the prevention of purulent complications in acute destructive appendicitis in children (patent application of the Russian Federation No. 94030868, application publication date: July 10, 1997), including intramuscular antibiotic therapy, characterized in that the antibiotic therapy is carried out using three broad-spectrum antibiotic preparations from various groups, for example cephalosporins, semisynthetic penicillins and aminoglycosides, with the separate daily administration of each antibiotic alternating through their sequential use.

The disadvantages of this method are:

- The possible development of resistance to antibacterial drugs, since the widespread use of various groups of antibacterial drugs with a wide spectrum of activity contributes to the subsequent adaptation of microorganisms and a decrease in sensitivity to the antibacterial effect.

- Insufficient antibacterial effect in the focus of inflammation, because with a high concentration of antibacterial drugs in the patient's blood, an effective concentration is not always created in the focus of inflammation.

Closest to the claimed invention is a method for the prevention of purulent-septic complications after laparoscopic surgery (A. F. Dronov, I. V. Poddubny, V. I. Kotlobovsky. “Endoscopic surgery in children” Geotar-honey. Page 74.), carried out intraoperatively and based on targeted treatment of the patient’s abdominal cavity with an antiseptic solution delivered to the site of inflammation through one or more trocars simultaneously used to access the operative field. In accordance with the prototype method, a solution of furatsilin or sterile physiological solution in a volume of 0.5-1.0 l is delivered to the abdominal cavity to the focus of inflammation in liquid form.

The disadvantages of the prototype method are:

- The possibility of developing separated purulent-septic complications due to microbial contamination of the intact abdominal cavity through the transfer of microorganisms with antiseptic solutions that wash the abdominal cavity.

- Lack of antibacterial effect on the microbial flora in the focus of inflammation.

The objective of the invention is to increase the effectiveness of prevention of purulent-septic complications during laparoscopic operations by preventing microbial contamination of the abdominal regions not involved in the inflammatory process, providing a local antibacterial effect by increasing the concentration of a broad-spectrum antibiotic in the focus of inflammation.

The problem is solved due to the fact that intraoperatively targeted treatment of the patient’s abdominal cavity with a drug mixture delivered to the site of inflammation through one or more trocars simultaneously used to access the operative field, the drug mixture, which is a solution of the antibiotic ceftriaxone and antiseptic miramistin in a mass ratio of 1: 8 sprayed to a finely divided state and delivered to the abdominal cavity to the site of inflammation under excessive pressure using w carbon dioxide or any other inert gas, at the same time used to create a pneumoperitoneum for 16 minutes while before surgical intervention the same antibiotic administered intravenously to create a systemic antibacterial effect.

The invention differs from the prototype in that the drug mixture, which is a solution of an antibiotic - ceftriaxone and antiseptic - miramistin in a mass ratio of 1: 8, is sprayed to a finely divided state and delivered into the abdominal cavity to the site of inflammation under excessive pressure using carbon dioxide or any other inert gas , simultaneously used to create pneumoperitoneum, for 16 minutes, while the same antibiotic is administered intravenously before surgery to create a systemic wow antibacterial effect.

The use of the drug mixture according to the claimed method in a finely divided form promotes better penetration and absorption of the antibiotic and antiseptic in the focus of inflammation. In this case, spraying and targeted delivery of the drug solution to the site of inflammation is carried out according to the claimed method by means of a flow of carbon dioxide (or inert) gas, a priori used in laparoscopic operations to create pneumoperitoneum. Thus, it is essential that the implementation of the proposed method of prevention does not require the use of additional sophisticated equipment and tools.

The simultaneous intravenous and local intraoperative use of the same antibiotic according to the claimed method creates both a systemic and local antibacterial effect.

Figure 1 shows a device by which the inventive method for the prevention of purulent-septic complications after laparoscopic operations is implemented.

The device is a hollow cylindrical body 1 made of steel grade 08x18H10, which inside is a spray chamber and two tubes of steel of the same grade. Tube 2 is designed to connect the hose from the insufflator, which supplies carbon dioxide under a pressure of 20 mm RT. Art. and at a speed of 8 liters per minute. By means of a tube 3 coming from the spray chamber, a finely divided aerosol of the antibiotic solution is delivered to the site of inflammation located in any hard-to-reach section of the abdominal cavity. From below, a spray cup is attached to the housing 1, the bottom of which is a round piezoceramic element 4 connected to the electronic unit of the Monsoon-2 inhaler via a cable 2 meters long. The electronic unit, connected to an alternating voltage of 220 V, contains a high-frequency generator that generates a high-frequency voltage, exciting a piezoceramic element, which in turn splits the antibiotic and antiseptic solution into fine particles, the average diameter of which is about 4 μm.

The inventive method for the prevention of purulent-septic complications after laparoscopic surgery is implemented as follows (for example, appendectomy).

Under intubation anesthesia, 1.0 g of ceftriaxone is administered intravenously before the incision, after which a small 1 cm long skin incision is made in the umbilical region, through which pneumoperitoneum is applied to the patient using a Veress needle attached to the insufflator hose (carbon dioxide is injected into the abdominal cavity under with a pressure of 20 mm Hg and a feed rate of 8 l / min), after percussion of the anterior abdominal wall is carried out and convinced that there is no dullness of sound (with applied pneumoperitoneum, tympus is percussion anite - the sound of a drum), that the organs are not attached to it, remove the Veress needle, after which 3 trocars are inserted into the patient through 1 centimeter sections (hollow cylindrical tubes with a diameter of 10 mm with a stylet inside for puncture of the anterior abdominal wall, stiletto is removed after a puncture of the abdominal wall) by a standard technique providing convenient access for viewing and manipulating an endoscopic video camera and tools. After installing the trocars, a hose from an insufflator is connected to one of them to maintain pneumoperitoneum, which creates a space inside the abdominal cavity, and an inflammatory focus is identified that causes the disease, for example, an inflamed catarrhal, phlegmonous or gangrenous changed appendix. A typical appendectomy is performed, and an inflammatory effusion from the abdominal cavity is removed by an electric suction pump. Then, in one of the lateral trocars under the control of a video camera of a laparoscope inserted into an adjacent trocar, the inventive device is introduced, connected to a glass containing a solution of ceftriaxone antibiotic and miramistin antiseptic in a mass ratio of 1: 8, the glass, in turn, is connected to the ultrasound electronic unit inhaler (for example, "Monsoon-2", connected to an AC network with a voltage of 220 V), then disconnect the carbon dioxide (inert) gas insufflator hose from the trocar and connect to the device. Under the control of the video camera of the laparoscope, the peritoneum in the focus of inflammation is irrigated with a finely divided solution of antibiotic and antiseptic, thereby increasing the concentration of the antibacterial drug in the focus of inflammation (the same drug is also administered intravenously during surgery) and has a local antiseptic effect.

The method was tested in 10 patients of the surgical department of the clinic of the Rostov State Medical University and the surgical department of MLPUZ BSMP-2, Rostov-on-Don.

Example 1

Patient G.N., 29 years old, medical history No. 015472/130, was admitted on 02.02.2011 to the surgical department of the Rostov State Medical University with complaints of acute pain in the right iliac region, giving to the suprapubic region and to the inner surface of the right thigh. An objective examination: the tongue is dry, coated with a white coating. The abdomen is involved in the act of breathing, the correct form, moderately swollen. On palpation, it is tense in the right iliac region, and soreness is determined there and above the bosom. Symptoms of Obraztsov, Rowzing, Sitkovsky are positive. The symptom of Shchetkin-Blumberg is weakly positive in the right iliac region and above the bosom. Ultrasound of the pelvic organs from 02/10/2011 - ultrasound signs of uterine lateral flexion to the right, cystic formation of the right ovary, small cystic formation of the left ovary. In the general analysis of blood leukocytosis is noted - 13.6 × 10 ^{9 /} / l, stab neutrophils - 3%; segmented neutrophils - 77%; lymphocytes - 15%; monocytes - 5%; basophils - 0%; eosinophils - 0%. Operation 02.10.2011. In the patient’s supine position after treatment of the surgical field with antiseptic solutions and intravenous administration of 1.0 g of ceftriaxone, a Veress needle was inserted through an incision in the umbilical region. Carboxyperitoneum 20 mmHg laid A laparoscope has been introduced. During the audit, the vermiform appendix, hyperemic, somewhat edematous, 8 × 1.5 cm in size, was visualized in the abdominal cavity, the appendage was bent in the form of a hook, an injection of the vessels of the serous membrane was noted. In the small pelvis, up to 30 ml of serous effusion is noted. A further audit of the pelvic organs revealed the formation of a right ovary, macroscopically cyst, 6 × 5 cm in size. Additional trocars were introduced through additional incisions according to the standard method under the control of a laparoscopy. A puncture of the cyst of the right ovary was performed, and up to 20 ml of a turbid detachable dark brown color was obtained. The walls of the cyst are excised using an En-Seal apparatus within healthy ovarian tissue. The mobilization of the appendix in the bipolar coagulation mode was carried out. After mobilization of the appendix, two catgut loops were superimposed. The appendix is cut off, its stump is treated with a solution of iodopyrone, the mucous membrane is coagulated. Control of hemostasis. The abdominal cavity is drained using an electric suction pump. Given the pronounced inflammatory changes in the appendix and the dome of the cecum, indications for the prevention of purulent-septic complications are determined (by local dosing of a gas-liquid dispersion consisting of a solution of ceftriaxone and miramistin in a mass ratio of 1: 8). The working part of the original device was inserted through a 10 mm trocar in the right iliac region of the abdomen, aerosol solution of 1.0 g ceftriaxone and 8.0 g miramistin antiseptic was insufflated under the control of a video camera of a laparoscope. Performed local treatment of foci of inflammation in the area of surgical intervention. Installed drainage from the silicone tube into the pelvis. The postoperative period was uneventful. Peristalsis recovered on the first day after surgery. The wounds healed by first intention, the sutures were removed on the 7th day, the drains were removed on the 2nd day. The patient on the 10th day after the operation was discharged to work. In the analyzes: white blood cells - 8 × 10 ⁹ / l; stab neutrophils - 3%; segmented neutrophils - 66%; lymphocytes - 18%; monocytes - 8%; eosinophils - 5%, basophils - 0%.

Histological analysis No. 2486-99: 1) Acute simple catarrhal appendicitis; 2) In the resected ovary, a smooth-walled cyst without epithelial lining with sclerosis, hemosiderosis in the cyst wall.

Example 2

Patient G.A., 63 years old, medical history No. 020026/710, was admitted on June 10, 2011 to the surgical department of the Rostov State Medical University with complaints of acute pain in the right iliac region, giving to the inner surface of the right thigh. An objective examination: the tongue is dry, coated with a white coating. The abdomen is involved in the act of breathing, the correct form, moderately swollen. On palpation, it is tense in the right iliac region, where severe pain is noted. Symptoms of Obraztsov, Rowzing, Sitkovsky are positive. The symptom of Shchetkin-Blumberg is positive in the right iliac region. In the general analysis of blood leukocytosis is noted - 10 × 10 ⁹ / l, stab neutrophils - 8%; segmented neutrophils - 68%; lymphocytes - 19%; monocytes - 5%; basophils - 0%; eosinophils - 0%. Operation June 10, 2011. In the patient’s supine position after treatment of the surgical field with antiseptic solutions and intravenous administration of 1.0 g of ceftriaxone, a Veress needle was inserted through an incision in the umbilical region. Carboxyperitoneum 20 mmHg laid A laparoscope has been introduced. During the audit in the abdominal cavity, the vermiform appendix was visualized - hyperemic, edematous, rigid, club-shaped, 10 × 2.5 cm in size, injection of vessels of the serous membrane was noted. In the small pelvis, up to 50 ml of turbid effusion is noted. With a further audit of the pathology of the small, large intestine, liver, gall bladder, pancreas, and pelvic organs were not detected. Additional trocars were introduced through additional incisions according to the standard method under the control of a laparoscope. The vermiform appendix was mobilized, the mesentery of the latter was crossed using the Liga Sure apparatus. After mobilization of the appendix, two catgut loops were superimposed according to the method of F. Gotz. The appendix is also dissected between the ligatures using the Liga Sure apparatus. Control of hemostasis. The abdominal cavity is drained. Given the pronounced inflammatory changes in the appendix and peritoneum of the anterior abdominal wall, indications for the implementation of measures for the prevention of purulent-septic complications (by local dosed administration of a gas-liquid dispersion consisting of 8 g of miramistin antiseptic and 1.0 g of ceftriaxone) are determined. The working part of the original device was introduced through a 10 mm trocar in the right iliac region of the abdomen, aerosol insufflation was performed under the control of the video camera of the laparoscope. Performed local treatment of the focus of inflammation in the area of surgical intervention. Installed drainage from the silicone tube into the pelvis. The postoperative period was uneventful. Peristalsis recovered on the first day after surgery. The wounds healed by first intention, the sutures were removed on the 7th day, the drainage was removed on the 2nd day. The patient on the 10th day after the operation was discharged to work. In the analyzes, white blood cells - 4.2 × 10 ⁹ / l; stab neutrophils - 4%; segmented neutrophils - 60%; lymphocytes - 33%; monocytes - 3%; eosinophils - 0%, basophils - 0%.

Histological analysis No. 11195-96: Acute appendicitis, phlegmonous and ulcerative appendicitis, periappendicitis, mesentery.

Example 3

Patient M.G., 63 years old. Case history No. 002199/108, was received on 02/27/2010 in the surgical department of the Rostov State Medical University with complaints of acute pain in the right hypochondrium, a feeling of heaviness in the epigastric region, general weakness, fever up to 38 ° C. An objective examination: the tongue is dry. The abdomen is involved in the act of breathing, the correct form, moderately swollen. On palpation, tense in the right hypochondrium and epigastrium. Symptoms of Kera, Murphy are positive, there are no peritoneal symptoms. Peristalsis is sluggish. Ultrasound of the abdominal cavity determines the gallbladder 9.0 × 3.5 cm, the cavity is filled with echo-positive structures up to 1.0 cm in diameter. In the general analysis of blood leukocytosis is noted - 9.6 × 10 ^{9 /} / l, stab neutrophils - 9%; segmented neutrophils - 73%; lymphocytes - 15%; monocytes - 3%; basophils - 0%; eosinophils - 0%. Operation 03/01/2010. In the patient’s supine position after treatment of the surgical field with antiseptic solutions and intravenous administration of 1.0 g of ceftriaxone, a Veress needle was inserted through an incision in the umbilical region. Carboxyperitoneum 20 mmHg laid A laparoscope has been introduced. During revision in the abdominal cavity, a pronounced adhesive process in the gallbladder is determined. Pathology of the pancreas, small and large intestine, pelvic organs was not detected. According to the standard method, additional trocars are introduced through additional incisions at the points of Kalk under the control of a laparoscope. Using a coagulation hook, the gallbladder was isolated from friable infiltrate in a blunt and sharp way, and up to 20 ml of a turbid serous effusion was released. The gallbladder 90 × 35 mm in size is pulled up by Hartmann’s pocket, after which the elements of the Kahlo triangle are highlighted. A typical cervical cholecystectomy was performed. There is moderate bleeding from the gallbladder bed, hemostasis is produced by electrocoagulation. The abdominal cavity is drained. Given the pronounced inflammatory changes in the walls of the gallbladder, the presence of a loose infiltrate of inflammatory changes in the peritoneum of the anterior abdominal wall, indications for the implementation of measures for the prevention of purulent-septic complications (by local dosing of a gas-liquid dispersion consisting of 8.0 g of Miramistin antiseptic and 1.0 g of ceftriaxone). The working part of the original device was introduced through a 10 mm trocar in the left hypochondrium, aerosol insufflation was performed under the control of a laparoscope video camera. Performed local treatment of foci of inflammation in the area of surgical intervention. Installed drainage from a silicone tube into the subhepatic space. The postoperative period was uneventful. Peristalsis recovered on the first day after surgery. The wounds healed by first intention, the sutures were removed on the 7th day, the drainage was removed on the 2nd day. The patient on the 11th day after the operation was discharged to work. In the analyzes, white blood cells - 6.9 × 10 ⁹ / l; stab neutrophils - 2%; segmented neutrophils - 78%; lymphocytes - 13%; monocytes - 5%; eosinophils - 2%, basophils - 0%.

Histological analysis No. 4367-68: Acute calculous cholecystitis with total atrophy of the mucosa, sclerosis of the gallbladder wall.

The use of the claimed technical solution will improve the effectiveness of the method for the prevention of purulent-septic complications after laparoscopic operations.

Bibliography

1. Dolgushkin A.N., Zhuravlev P.A. Laparoscopy as a method of choice in the diagnosis and treatment of acute appendicitis. // Almanac of clinical medicine. - 2007. - No. 16. - S. 61-62.

2. Orekhov G.I. The place of endovideo surgical technology in the treatment of patients with acute appendicitis. // Endoscopic surgery. - 2009. - T.15, No. 3. - S. 35-38.

3. Fomin S.A. Comprehensive prevention of purulent-inflammatory and cosmetic defects in appendectomy. // Bulletin of Siberian medicine. 2008.V. 7. Number 4. S.82-89.

4. Chan KW, Evidence-based adjustment of antibiotic in pediatric complicated appendicitis in the era of antibiotic resistance // Pediatric Surgery Internanacional. 2010 Feb; 26 (2): 157-60.

5. Ming PC, Risk factors of postoperative infections in adults with complicated appendicitis // Surgical Laparoscopy Endoscopy Percutaneous Techniques. 2009 Jun; 19 (3): 244-8.

Claims (1)

A method for the prevention of purulent-septic complications during laparoscopic operations, carried out intraoperatively and based on targeted treatment of the patient’s abdominal cavity with a drug mixture delivered to the site of inflammation through one or more trocars simultaneously used to access the operative field, characterized in that said drug mixture representing a solution of an antibiotic - Ceftriaxone and antiseptic - Miramistin in a mass ratio of 1: 8 is sprayed to a finely dispersed state and delivered They are injected into the abdominal cavity, to the focus of inflammation, under excess pressure using carbon dioxide or any other inert gas simultaneously used to create pneumoperitoneum for 16 minutes, while the same antibiotic is administered intravenously before surgery to create a systemic antibacterial effect.

Images