RU2480169C1 - Preventive plasty of anterior abdominal wall in case of infected abdominal wound - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery for prevention of hernia. Subcutaneous adipose cellular tissue is separated from aponeurotic or fascial tissue on wound perimetre. On two sides from wound placed are two endoprostheses of rectangular shape, whose dimensions are 3 cm larger than wound length and width from each side and ensure 2 cm overlapping of endoprostheses on each other when wound ends are connected. Endoprosthese are fixed on perimetre and to each other, non-sewn section, which forms "lip-like" hole when edges of endoprostheses are brought apart. Tampon is installed into drainage channel through "lip-like" hole. Subcutaneous adipose cellular tissue and skin are sutured to draining tampon. Visible part of endoprosthesis is processed with preparations applied for wound treatment. In case of drainage channel reduction lower than endoprostheses to 1.5-2.0 cm and removal of draining tampon, "lip-like" hole is covered by application of endoprostheses on each other in form of duplicature without tension, with their suturing to each other. Wound treatment is carried out in open way until its epithelisation.

EFFECT: method prevents hernia in place of draining tampon installation.

1 ex, 4 dwg

Description

The invention relates to medicine, namely to surgery, and can be used to prevent the formation of postoperative ventral hernias.

Currently, factors of the occurrence of postoperative ventral hernias (POVH) are studied in detail. However, the proposed methods for their prevention: stimulation of reparative processes in the surgical wound, prophylaxis of suppuration of postoperative wounds, and strengthening of the surgical wound area with local tissues, were ineffective. A promising method for preventing the occurrence of POVH is preventive alloprosthetics. The results of preventive alloplasty are still not well understood and poorly covered in the medical literature. An increase in the number of surgical interventions on the abdominal organs is accompanied by a significant increase in the number of patients with postoperative hernias. The incidence of postoperative hernias is 5% in patients after uncomplicated glomeruli and 10% in patients after suppuration of postoperative wounds. These hernias take the second place after inguinal and make up 20-22% of the total number of hernias. Moreover, the absolute number can be much larger, since only 13-15% of patients seek medical help.

Given the steady growth of abdominal interventions, the prevention of postoperative ventral hernias is of particular relevance. And the problem of surgical treatment of patients with defects of the anterior abdominal wall under conditions of infection is one of the most serious in abdominal surgery.

A known method is when in experimental studies used implantation of cryoprecipitate in the deep layers of the wound in the phase of repair of the wound process for early induction of fibroblastic activity. RF patent for the invention No. 2236856, IPC A61K 35/14, publ. 09/27/2004

The use of cryoprecipitate as a means of stimulating reparative processes allows it to be used to form a durable connective tissue scar and prevent postoperative hernias. (Materials of the V Russian Scientific Forum “SURGERY 2004” Moscow 2004, November 1–4, Auto- and alloplasty of ventral hernias. Kolesnikov SA, Gorelik S.G., Myasnikov A.D., Duganova M.V., p. 80-81.)

However, the presented system for the prevention of postoperative hernias remains ineffective. One of the main reasons for their occurrence is not taken into account - a change in the anterior abdominal wall due to sagging, muscle atrophy and degenerative processes in aponeurotic tissues, cannot be used in infected conditions. Does not exclude repeated surgical intervention.

Today, in the world, tissue connections in the surgical intervention area are getting more widespread using adhesive compositions, by fixing the endoprosthesis with latex tissue sulfacrylate adhesive.

There is a method for the prevention and surgical treatment of postoperative hernias of small accesses, characterized in that after mini-accesses or laparoscopic surgical treatment of the underlying disease or after suturing of the hernial defect due to postoperative hernias of small accesses, an individual size implant pre-impregnated with the adhesive composition was placed on the aponeurosis. (O.V. Galimov, V.O. Khanov, A.V. Shkundin, E.Kh. Gaptrakipov, R.F. Fattakhov. The use of synthetic materials in the prevention and treatment of postoperative hernias of small accesses. Bulletin of the East Siberian Scientific Center SB RAMS, 2011, No. 4 (89), part 2, pp. 36-39.)

This method does not involve prolonged contact of the graft with infected edematous tissues, which can lead to rejection of the endoprosthesis in the early stages. In addition, with open wound management, periodic traction for the endoprosthesis during dressings is assumed, and the absence of rigid fixation with this method can lead to accidental removal of the endoprosthesis. Does not exclude the formation of seromas and fistulas.

The closest is a method of treating eventual purulent wound (Patent RU 2355321, MKI A61B 17/00, publ. 05/20/2009), which provides skeleton function of the abdominal wall, includes the location of the graft in the intra-abdominal position and its fixation to the anterior abdominal wall. As a transplant, a mesh endoprosthesis based on polypropylene is used, which is fixed with polypropylene monofilament through all layers of the anterior abdominal wall, with knots tied and immersed under the skin, the wound is loosely filled with ointment wipes, skin sutures are not applied, the wound is opened in the postoperative period, final closure the defect is produced as the wound cleanses when healthy granulations on the endoprosthesis appear. The prosthesis is fixed in the distant postoperative period, in the intra-abdominal position, through the entire thickness of the anterior abdominal wall, with a continuous sheet.

Fixation of the endoprosthesis with this method in the long-term postoperative period is a repeated surgical intervention (it is not simultaneous). The intra-abdominal position can lead to the formation of fistulas with hollow organs. With this method, there is no stock of endoprosthesis for the divergence of the edges of the wound due to degenerative processes in the aponeurotic tissues against the background of local inflammation, the plastic may be stretched. There is no way to monitor the wound in the subendoprosthetic space, since the endoprosthesis is sutured tightly. In case of infection and rejection of the endoprosthesis, repeated surgical treatment will be required to remove the endoprosthesis fixed through all layers with immersion in the tissue. Fixation through the entire thickness of the anterior abdominal wall increases the invasiveness of surgical intervention, creating additional entry gates for infection. Moreover, this method does not provide for the possibility of draining the abdominal cavity with a tampon.

The objective of the invention is to prevent the occurrence of hernias of the anterior abdominal wall and the exclusion of repeated surgical treatment by preventive plastic surgery of the anterior abdominal wall in infected conditions with the simultaneous treatment of the underlying disease.

The task is achieved by the method of preventive plastic surgery of the anterior abdominal wall in case of an infected abdominal wound, including the installation of a mesh polypropylene endoprosthesis, fixation with sutures, open wound management in the postoperative period, closing the defect during wound cleansing and the appearance of healthy granulations on the endoprosthesis. When performing an operation on the organs of the abdominal cavity, with the installation of a draining tampon, subcutaneous fat from aponeurotic or fascial tissue is separated along the wound perimeter. Two rectangular endoprostheses are placed on both sides of the wound, the dimensions of which exceed the length and width of the wound by 3 cm on each side and ensure that the endoprostheses approach each other when the edges of the wound are joined by 2 cm. Endoprostheses are fixed along the perimeter and between them with interrupted sutures, this leaves an unbroken portion in the center, which forms a “lip-shaped” hole when the edges of the endoprosthesis are diluted. Use the Esfil endoprosthesis. Through the "lip-shaped" hole, a draining swab is installed in the drainage channel. Subcutaneous fat and skin are sutured to a draining swab. In the process of wound management according to the program for the treatment of infected wounds, the visible part of the endoprosthesis is treated with drugs used to treat this wound. When the drainage channel is reduced below the endoprosthesis to 1.5-2.0 cm and the drainage swab is removed, the “lip-shaped” hole is closed by applying endoprostheses to each other in the form of a duplicature without tension and stitch them together with polyamide monofilament with interrupted sutures. Wound treatment is open until its epithelization.

Novelty of invention

- When performing an operation on the abdominal organs with the installation of a draining tampon, subcutaneous fat is separated from the aponeurotic or fascial tissue along the wound perimeter, two rectangular prostheses are placed on both sides of the wound, the dimensions of which exceed the length and width of the wound by 3 cm each sides and ensure the endoprostheses approach each other when connecting the edges of the wound by 2 cm. The endoprostheses are fixed along the perimeter and between them with interrupted sutures, while leaving in the center a section that forms when diluting the edge ev endoprosthesis "lip-shaped" hole. The use of two endoprostheses allows access to the drainage channel with open wound management.

- Use the Esfil endoprosthesis. The Esfil polypropylene mesh endoprosthesis used has mechanical strength, biological and chemical inertness, does not cause rejection and inflammation reactions, and is easily sterilized.

- Through a “lip-shaped” hole, a draining swab is installed in the drainage channel, subcutaneous fatty tissue and skin are sutured to a draining swab, which is convenient to change. Endoprostheses, performing a kind of frame function, due to the “lip-shaped” form, do not allow premature closure of the skin wound before the healing of the drainage canal.

- In the process of wound management under the program for the treatment of infected wounds, the visible part of the endoprosthesis is treated with drugs used to treat this wound. This avoids rejection of the endoprosthesis and infection of adjacent tissues.

- When the drainage channel is reduced below the endoprosthesis to 1.5-2.0 cm and the drainage swab is removed, the “lip-shaped” hole is closed by applying endoprostheses to each other in the form of a duplicature without tension and stitch them together with polyamide monofilament with interrupted sutures. Wound treatment is open until its epithelization. At the same time, it is seen how the process of endoprosthesis germination by granulation and connective tissue, which allows you to fully control the course of the wound process, correctly determine the timing of the closure of the drainage channel, eliminating the possibility of a number of complications such as seromas, ligature fistulas and abscesses. Duplication of endoprostheses is a reliable preventive measure for the formation of hernias at the site of installation of the tampon. The proposed method allows to obtain a new technical result:

- Adapt the endoprosthesis to the divergence of the edges of the wound during the treatment of the underlying disease.

- Duplication of endoprostheses is a very reliable preventive measure to prevent the formation of postoperative hernia at the site of installation of the draining swab.

- The simplicity of plastic surgery allows novice surgeons to master and perform the operation.

- The method makes it possible to implant a mesh polypropylene prosthesis in the abdominal wall under infected conditions simultaneously with the treatment of the underlying disease, which prevents the occurrence of hernias of the anterior abdominal wall and excludes repeated surgical treatment of this category of patients.

- Exclude endoprosthesis tension.

- Allows you to visually control the course of the wound process.

The present invention meets the criterion of "inventive step", as there are no technical solutions with essential features of the proposed method.

The invention is illustrated Fig.1-4.

Figure 1 shows the endoprosthesis, suture, drainage channel.

Figure 2 shows the position of the endoprosthesis with a section without seams with the formation of a "lip-shaped" hole above the drainage channel.

Figure 3 shows the installation of a draining swab in the drainage channel through the "lip-shaped" hole.

Figure 4 shows the closure of the drainage channel stitched with each other in the form of a duplicate endoprosthesis.

In the figures: 1 - one endoprosthesis, 2 - the second endoprosthesis, 3 - a section of the duplicate endoprosthesis, 4 - a nodal suture, 5 - a section without seams for the formation of a “lip-shaped” hole, 6 - a drainage channel, 7 - a draining tampon, 8 - a suture for endoprosthesis joints in place of the “lip-shaped” hole.

The method is as follows. When performing operations for acute purulent diseases of the abdominal cavity, accompanied by drainage with a tampon (limiting, hemostatic, draining), aponeurotic or fascial tissue is separated from the subcutaneous fat from the subcutaneous fat, depending on the location of the wound, for 3 cm from its edges . On two sides of the wound, two rectangular mesh endoprostheses 1 and 2 are applied and fixed with a 2 cm approach to each other, with the formation of a duplicate 3 above the wound, Figure 1, Figure 2. In this case, Esfil polypropylene endoprostheses manufactured by Lintex LLC, St. Petersburg are used. The endoprostheses 1 and 2 are fixed with interrupted sutures 4 with polyamide monofilament or polypropylene thread to the drainage channel 6, leaving the area without sutures 5 for the formation of a “lip-shaped” hole, FIG. 2. The length and width of endoprostheses 1 and 2 are selected depending on the size of the wound and should exceed the length and width of the wound by 3 cm and ensure that the endoprostheses are set on top of each other by 2 cm to form a duplicate. Between the endoprostheses 1 and 2, a drainage tampon 7 is installed into the drainage channel 6 through the “lip-shaped” hole, FIG. 3. Subcutaneous fat and skin are sutured to a draining swab. The postoperative period is carried out according to the program for the treatment of infected wounds: dressings with aseptic solutions, before cleansing the wounds, replacement of ointment dressings that stimulate reparative processes. The visible part of the mesh of endoprostheses 1 and 2 is treated with drugs that are used to treat this wound. When reducing the drainage channel 6 below the endoprosthesis to 1.5-2.0 cm and removing the draining tampon 7, the seamless section in the form of a “lip-shaped” hole 5 between the endoprostheses is closed by applying endoprostheses to each other in the form of a duplicate 3 without tension and stitching them between a polyamide monofilament knotted seams 8, Figure 4. Further treatment of the wound is carried out openly, using a periodic change of dressings, until the epithelialization of the wound (30th day).

Clinical example

Patient N.S. 27 years old (medical history No. 13130). He entered the emergency surgery department with a diagnosis of Acute appendicitis. From the anamnesis: prescription of the disease 3 days, 4 degrees obese.

The state of moderate severity. Concerned about constant pain in the right iliac region, fever up to 38 ° C, dry mouth.

The diagnosis at admission was not in doubt.

On an emergency basis, on November 17, 2011, after the preoperative preparation, an operation was performed: under ETN access by Volkovich-Dyakonov, gangrenous-perforated appendicitis, appendectomy were isolated from the infiltrate, and the process stump was not submerged due to the severity of tiflitis. Bacteriological material was taken from the wound (No. 925 E. Coli). Wound size: 10x5 cm. A glove-gauze draining swab of 5 cm diameter was brought to the bed of the appendix. Two endoprostheses from the Esphil polypropylene mesh were fixed to the aponeurosis of the external oblique muscle, according to the previously described method, each 16x5 cm in size. A "lip-shaped" hole between the endoprostheses the diameter of the draining swab is 5 cm. The subcutaneous fatty tissue and skin are sutured to the draining swab.

Diagnosis after surgery: Acute gangrenous-perforated appendicitis in loose infiltrate. Typhlitis.

Further treatment in an emergency surgery department: antibiotic therapy, dressings, endoprosthesis treatment.

On the 6th day a channel of 12 cm was formed, with purulent discharge. Mesh endoprostheses without signs of rejection and infection of adjacent tissues are tightly fixed around the perimeter, without deformations. Dressing with an antiseptic solution was performed under dressing conditions, without restricting access to the drainage canal and good visualization. Subsequent dressings showed an active germination of the endoprosthesis with granulation and connective tissue along the perimeter of the drainage channel. The postoperative period is smooth. On the 17-18th day against the background of treatment, the wound channel below the endoprosthesis from 12 cm decreased to 1.5 cm, the edges of the wound on the skin also narrowed to 3.0 cm.

Under the conditions of the dressing, the draining swab is removed, after the wound is treated, the edges of the “lip-shaped” opening are closed by applying endoprostheses to each other in the form of a duplicature and stitched together by interrupted sutures with polyamide thread without the use of anesthetics because they are not necessary. Subsequently, on dressings, granulations covered the central part of the endoprostheses in the area of duplication, the wound on the skin narrowed. The patient was discharged on the 21st day in satisfactory condition, for outpatient aftercare. Subsequently, the patient was observed on an outpatient basis in the surgical department of the hospital until epithelialization of the wound on day 30.

The developed method for carrying out preventive plastic surgery of the anterior abdominal wall and the technology of endoprosthetics for purulent diseases of the abdominal cavity organs can be used in the work of the surgical department when draining the abdominal cavity with a tampon to treat the following nosology: acute gangrenous appendicitis (cholecystitis) in the infiltrate with abscessing (diffuse bleeding), with pancreas -Necrosis complicated by purulent omentobursitis (omentobursostomy).

Thus, the use of the proposed method prevents the formation of postoperative ventral hernias in the area of drainage wounds of the anterior abdominal wall, and their open management allows monitoring and influencing the course of the wound process.

Claims (1)

Preventive plastic surgery of the anterior abdominal wall in an infected abdominal wound, including the installation of a mesh polypropylene endoprosthesis, fixation with sutures, open wound management in the postoperative period, closing the defect during wound cleansing and the appearance of healthy granulations on the endoprosthesis, characterized in that when performing surgery on the abdominal organs with the installation of a draining tampon, subcutaneous fat from aponeurotic or fascial tissue is separated along the perimeter of the wound, on both sides of the ra we place two endoprostheses of a rectangular shape, the dimensions of which exceed the length and width of the wound by 3 cm on each side and ensure that the endoprostheses approach each other, when connecting the edges of the wound by 2 cm, fix the endoprostheses around the perimeter and between them with interrupted sutures, while leaving In the center, an unbroken portion, which forms a “lip-shaped” hole when the edges of the endoprostheses are diluted, use the Esfil endoprosthesis, a drainage swab is inserted into the drainage channel through the “lip-shaped” hole, subcutaneous fat and skin are sutured o drainage swab, in the course of wound management according to the program for the treatment of infected wounds, the visible part of the endoprosthesis is treated with drugs used to treat this wound, with a decrease in the drainage channel below the endoprosthesis to 1.5-2.0 cm and the removal of the drainage swab, the lip-shaped hole is closed by applying endoprostheses to each other in the form of a duplicature without tension and stitching them together with polyamide monofilament with interrupted sutures, the wound is treated openly until its epithelization.

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