RU2511458C2 - Method for laparoscopic drainage of residual abscess cavity in localised and combined appendicular peritonitis in children - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely surgical management. What is involved is an optical controlled drainage with a double-lumen drain tube through an anterior abdominal wall puncture. The drain tube is placed into an abscess cavity using two endoscopic forceps. The drain tube is attached to a vacuum suction. At the completion of the surgical intervention, the drain tube position is adjusted while eliminating a pneumoperitoneum with underlying abdominal pressure reduction. An excessive length in the abdomen is eliminated by tightening an outer end of the drain tube. After the endoscopic instruments have been removed, the drain tube is fixed to the skin with a separate interrupted suture. The postoperative follow-up requires abdominal ultrasonography. The drain tube is removed if observing no free fluid and residual pus pockets in a projection of the drain tube.

EFFECT: method provides the active radical adequate drainage of the residual cavity, prevents early postoperative complications and potential peritonitis.

1 ex

Description

The invention relates to medicine, namely to pediatric surgery, and can be used in the surgical treatment of residual abscess cavity with delimited and combined forms of appendicular peritonitis using laparoscopic technologies.

Acute appendicitis is the main disease in the structure of emergency conditions of the abdominal organs in pediatric surgery. The frequency of occurrence of delimited and combined forms of appendicitis is, according to some authors, about 3.5-4% and 10-12%, respectively. Recently, surgical treatment of children with complicated appendicitis is carried out mainly using laparoscopic technologies. One of the components of the surgical treatment of patients with delimited and combined forms of appendicular peritonitis is the use of rational methods for drainage of the abdominal cavity, namely the residual abscess cavity. The latter serves as a source of continued infection in the early postoperative period, makes it possible to develop continued peritonitis in the early stages of hospital stay, which requires intensification of therapeutic measures. The effectiveness of the abdominal drainage methods used determines the frequency of complications in the form of continued delimited and diffuse peritonitis.

A known method of drainage of the residual cavity of the abscess with abscessed forms of appendicular peritonitis in children with laparoscopic surgical treatment (Karaseva O.V., Kapustin V.A., Bryantsev A.V. Laparoscopic surgery for abscessed forms of appendicular peritonitis in children // Pediatric Surgery. - Moscow. - 2005. - No. 3. - p.25-29).

The method consists in the fact that after the main stage of the operation is performed - destruction of the abscess cavity and appendectomy under the control of the telescope, one-lumen drainage is installed in the residual cavity of the destroyed abscess, as well as in the pelvic cavity. With a long duration of the disease and pronounced delimitation of the abscess, a single-lumen drainage is installed in the abscess cavity through the accesses used to set up working tools.

However, the method has significant disadvantages. Single-lumen drainage with passive drainage option, i.e. the spontaneous outflow of exudate along it is easily clogged and turns into a monolithic foreign body containing infected fibrin clots. In addition, the lack of the ability to wash the residual abscess cavity does not provide its adequate and radical sanitation in the early postoperative period, which entails the development of complications in the form of continued delimited and diffuse peritonitis.

There is also a method of draining the residual cavity of the abscess of the abdominal cavity in pediatric surgery (Dronov A.F., Poddubny I.V., Kotlobovsky V.I. Endoscopic surgery in children / Moscow, 2002.-P. 36), including drainage of the abscess cavity of silicone a tube with a diameter of about 10 mm, which is introduced into the abdominal cavity through a previously installed 11 mm trocar in the right iliac region under the control of a telescope after the main stage of the operation is performed - destruction of the abscess cavity and appendectomy.

A feature of the known method is the larger diameter of the used drainage, which is a risk factor for the development of postoperative hernia.

The disadvantage of the methods is the passive outflow of pathological contents from the abdominal cavity, which is insufficient for a complete and adequate rehabilitation and leading to continued infection in the early postoperative period with all the ensuing consequences.

The objective of the invention is the creation of a highly effective safe method for aparoscopic drainage of the residual cavity of the abscess with delimited and combined appendicular peritonitis in children, which prevents the development of intra- and postoperative complications with minimal trauma of the operation, and also improves the psycho-emotional adaptation of children in the postoperative period.

The essence of the invention lies in the fact that in the method of laparoscopic drainage of the residual cavity of the abscess with delimited and combined appendicular peritonitis in children, including performing laparoscopic appendectomy and subsequent drainage of the residual cavity, double-lumen drainage is used for drainage, an optic vascular zone is selected for its implementation, which is determined above the anteroposterior spine of the iliac wing by at least 2-3 cm on the right, an incision is made skin 1 cm long and a puncture of the anterior abdominal wall, through which a stroke is formed at an angle of 45 degrees to the anterior abdominal wall along the right lateral canal in the direction of the small pelvis with orientation to the correct installation of drainage in the residual cavity at its most optimal and functional position relative to the periappendicular organs and tissues of the abdominal cavity, drainage is introduced through the formed passage, it is installed in the abscess cavity with two endoscopic clamps, after which the drainage is connected to a vacuum suction, at before completing the surgical intervention in the process of eliminating pneumoperitoneum against the background of a decrease in intra-abdominal pressure, the drainage position is corrected relative to the main landmarks and structures of the abdominal cavity, its excess length in the abdominal cavity is eliminated by pulling at the external end, after extraction of endoscopic instruments, the drainage is fixed to the skin with a separate knotted suture, in the postoperative period, control ultrasound examinations of the abdominal cavity are performed, in the absence of In the case of standing drainage of free fluid and residual purulent cavity, the drainage is removed.

Using the invention allows to obtain the following technical result.

The method is highly effective and easily reproducible.

It provides active radical adequate drainage of the residual cavity of the periappendicular abscess with double-lumen drainage under the control of a telescope, which prevents continued infection in the early postoperative period and the possibility of the development of continued peritonitis.

At the same time, there is no need for intensive therapeutic measures, including the introduction of large doses of antibacterial and other drugs into the child's body, as well as the need to use additional expensive tools and supplies.

The proposed drainage option is safe for children of any age.

Intraoperative complications, such as damage to the vessels of the anterior abdominal wall at the point of drainage with the subsequent development of bleeding due to visual inspection by the telescope from the abdominal cavity when performing a skin incision and creating a special passage for drainage in the anterior abdominal wall, are excluded.

The correct installation of drainage into the residual purulent cavity is visually controlled with respect to the main landmarks and structures of the periappendicular organs and tissues, which excludes their trauma.

The effectiveness of the drainage is evaluated intra-operatively under visual control, the likelihood of squeezing and kinking of the drainage tube in the structures of the anterior abdominal wall during drainage, the possibility of obstruction by adjacent intestinal loops and stuffing box with pneumoperitoneum is prevented.

The position of drainage in the abdominal cavity is adjusted relative to the main landmarks and structures of the abdominal cavity when pneumoperitoneum is eliminated at the stage of completion of surgical intervention by eliminating its excess length in the abdominal cavity.

Reliable fixation of drainage by the structures of the anterior abdominal wall and individual knotted sutures on the skin is carried out, which prevents the loss of the latter from the abdominal cavity.

The method allows to prevent the development of complications in the postoperative period: hernias and events.

Using the method contributes to the rapid psycho-emotional adaptation of children in the early and long-term postoperative period.

The technical result is achieved due to the new technology developed by the authors for active drainage of the residual cavity of the periappendicular abscess, which provides for the complete ablation of the pathological contents of the cavity using double-lumen drainage under the control of a telescope, the installation of which is carried out through a specially formed passage at an angle of 45 degrees to the anterior abdominal wall along the right lateral canal, which provides the correct direction and orientation of the drain Ms. in the abdominal cavity and accurate installation in the cavity.

The authors first used double-lumen drainage for drainage of the residual cavity during surgical treatment of delimited and combined forms of appendicular peritonitis in children after laparoscopic appendectomy, which provides its adequate and radical sanitation by aspiration with simultaneous washing of the cavity, which prevents the development of life-threatening complications in the form of prolonged delimited and .

The effectiveness of drainage is explained by its design feature. The presence of two channels makes it possible to actively aspirate the pathological contents from the drained cavity while washing the latter. The non-absorbable properties of the tube are achieved by connecting the suction system to an internal channel that does not have side openings. During aspiration, atmospheric air is sucked into the external channel. The vacuum created on the internal channel aspirates the liquid content entering through the side openings of the external channel, which, together with the suction air, enters the sump.

Creating a drainage stroke at an angle of 45 degrees relative to the anterior abdominal wall ensures reliable fixation of the drainage by the structures of the anterior abdominal wall, eliminates kinks and squeezes of the drainage tube, provides easy correction of the drainage position and the length of the intraperitoneal segment by pulling the outer segment of the drainage, and prevents complications such as postoperative hernias and events.

The use of a telescope when choosing a skin incision and puncture of the anterior abdominal wall for drainage in the avascular zone in the right lateral canal eliminates the possibility of damage and bleeding from the vessels of the anterior abdominal wall.

Visual control and the ability to manipulate the abdominal organs with endoscopic instruments when creating a channel for draining with pointed instruments excludes the possibility of iatrogenic damage to the abdominal organs when performing this manipulation.

Visual installation of drainage in the cavity of the periappendicular abscess allows you to position the drainage in the most favorable and functional position relative to the periappendicular organs and tissues, and also immediately assess the adequacy of drainage intraoperatively.

The introduction of washing liquid and aspiration directly during the operation under visual control with a significant amount and density of pathological contents prevents the possibility of obstruction of the drainage tube.

Visual control when eliminating pneumoperitoneum behind adjacent organs and tissues, the ability to fix the latter with endoscopic instruments exclude the possibility of suction of intestinal loops and omentum at the end of the operation, and also prevents the possibility of omentum events when removing drainage in the postoperative period.

Traction for the outer section of the drainage and correction of its position under conditions of decreasing intra-abdominal pressure allow maintaining the correct position of the drainage at the final stage of surgical treatment.

External fixation with a separate knotted suture to the skin of the anterior abdominal wall during oblique drainage provides the functional position of the drainage for the entire period of operation.

The method is as follows.

The patient is placed on the operating table, anesthesia is performed, the operating surgeon performs abdominal palpation to determine the size and localization of the inflammatory volumetric formation and to choose a safe puncture site for the application of pneumaperitoneum. Catheterize the bladder, installs a probe into the stomach. They treat the surgical field, pierce the anterior abdominal wall with a Veress needle, apply pneumoperitoneum, establish working 5 mm trocars in the umbilical region and the left iliac region. When revising the abdominal cavity, the severity of peritonitis, the stage of the delimited and diffuse process are assessed, determines the possibility of performing the operation by laparoscopic access. After that, a 5 mm trocar is inserted to clamp over the midline along the bosom. An optical telescope is installed in the abdominal cavity through a 5 mm trocar in the left iliac region. Under the control of optics, the periappendicular abscess is opened with working tools, the purulent contents are aspirated by suction, the resulting pathological contents are sent for bacteriological examination, the destructively changed appendix is isolated from the periappendicular abscess. The appendix is grasped by the grasper by the mesentery, which is coagulated by mono- or bipolar coagulation and crossed. Appendectomy is performed in a ligature manner with the application of 2 Raeder loops and the intersection of the appendix between them. The appendix is removed from the abdominal cavity.

After that, the residual abscess cavity is drained using double-lumen drainage (Kanshin NN Unformed intestinal fistulas and purulent peritonitis. 2008, p. 160).

An optical telescope is installed in the paraumbilical region through an adapter of 11 mm trocar into the abdominal cavity.

Under the control of optics, a place is chosen for double-lumen drainage based on the localization of the periappendicular abscess. The point of drainage is determined 2-3 cm above the anterior-superior spine of the iliac wing on the right. With a higher location of the periappendicular abscess, the drainage installation point is shifted higher, up to the subhepatic space.

Under the control of optics, an avascular zone is selected, a skin incision is made up to 1 cm with a scalpel, a pointed mosquito-type clip under the control of a telescope (if necessary, intestinal loops are removed with a working tool), the anterior abdominal wall is punctured.

With a straight tool, a stroke is created at an angle of 45 degrees to the anterior abdominal wall into the abdominal cavity along the right lateral canal in the direction of the pelvis to ensure the correct direction of drainage with orientation to the correct accurate installation in the residual cavity at the most optimal and functional position of the drainage tube relative to the periappendicular organs and abdominal tissues.

By clamping under visual control, a drainage is introduced into the abdominal cavity through the formed passage, which is captured with an endoscopic clamp and carried out in the direction of the small pelvis. In the abdominal cavity with two endoscopic clamps, the drainage is installed in the abscess cavity. After that, the drainage is connected to the vacuum suction of the suction device, which is turned on for subsequent suction of the contents of the residual cavity.

Properly installed drainage begins to function immediately, which is visually manifested by the entry of pathological contents into the drainage tube and discharge of effusion from the abdominal cavity.

In the process of actively aspirating the pathological contents from the residual cavity while washing the latter, atmospheric air is sucked into the outer channel of the drainage tube.

The liquid content entering through the side openings of the external channel, together with the suction air, enters the sump.

At the stage of completion of surgical intervention, pneumoperitoneum is removed under the control of optics, in some cases, the adjacent intestinal loops and gland are fixed with a manipulator to prevent the latter from sticking to the drainage holes.

In the process of eliminating pneumoperitoneum due to a decrease in the volume of the abdominal cavity against the background of a decrease in intra-abdominal pressure, the drainage position is corrected relative to the main landmarks and structures of the abdominal cavity, its excess length in the abdominal cavity is eliminated by pulling at the outer end.

Endoscopic instruments are removed from the abdominal cavity. Outside, the drainage is fixed to the skin with a separate knotted suture, in some cases, additionally with adhesive tape. Punctures of the anterior abdominal wall are sutured with knotted intradermal sutures.

In the postoperative period, starting from the third day, a control ultrasound examination of the abdominal cavity is performed. If there is no free fluid drainage and residual purulent cavity in the projection, the drainage is removed. They conduct a course of antibacterial therapy and physiotherapy.

Example (medical history No. 9315/012).

Patient M., 10 years old, was admitted to the hospital on April 8, 2012 at 11 o’clock with a directing diagnosis: acute appendicitis. From the anamnesis it is known that the child is sick for 2.5 days. The pains in the lower abdomen were constant, repeated vomiting, weakness, malaise, and loose stools were noted.

Upon admission, the condition is serious, conscious, complaints of pain in the lower abdomen. The skin is clear and pale. In the lungs, breathing is carried out in the fields, no wheezing. Heart tones are clear, rhythmic. The abdomen is not swollen, participates in the act of breathing, painful on palpation in the right iliac region, here a significant volume formation is determined up to 15 cm from the womb to the right iliac region, passive muscle tension is expressed, the symptoms of peritoneal irritation are positive. The chair is frequent, liquefied. Urination is painful. In a general blood test, inflammatory changes were noted. When performing an ultrasound examination of the abdominal cavity: echographic signs of a periappendicular abscess of the II-III stage, diffuse peritonitis of the I-II stage.

After performing preoperative preparation, the patient underwent laparoscopic appendectomy and drainage of the abdominal cavity. Under endotracheal anesthesia. A skin incision of up to 5 mm was made in the left iliac region through a Veress needle inserted through the resulting incision, pneumoperitoneum was applied. The second skin incision up to 10 mm was made in the paraumbilical region, along which a 5 mm trocar was inserted into the abdominal cavity, and an optical telescope was introduced. The Veress needle is removed from the abdominal cavity, a working 5 mm manipulator tool is inserted. A skin incision was made up to 5 mm above the bosom along the midline, under the control of a telescope, a second working tool, a clamp, was introduced into the abdominal cavity. Instruments are located at an angle of 45 degrees relative to the right iliac fossa. When revising the abdominal cavity, it was found that there is an accumulation of pus along the right lateral canal, in the pelvic cavity, and the left lateral canal. Pus is aspirated by suction. The appendix is located in the direction of the small pelvis, with the parietal peritoneum of the right lateral canal, loops of the small intestine and the dome of the cecum ulcer up to 100 ml with fecal crumb.

The periappendicular abscess after opening with endoscopic instruments and aspiration of the contents partially decreases, the residual purulent cavity at the entrance to the small pelvis is lined with fibrin overlays. Pus from the abscess is aspirated by suction, the material is sent for bacteriological examination. The appendix is isolated from the periappendicular abscess, the mesentery is mobilized, cut off. After mobilization of the appendix, 2 ligatures are superimposed on its base. The appendix is crossed by scissors. Given the pronounced macroscopic changes in the appendix and the extension of the latter to 12 mm in the transumbilical region, a 5 mm trocar was replaced by 11 mm to extract the appendix from the abdominal cavity. The telescope is inserted into the abdominal cavity through a 5 mm trocar in the left iliac region, a clamp is inserted into the abdominal cavity through the 11 mm trocar adapter in the paraumbilical region, the appendix is captured and removed from the abdominal cavity.

The telescope is mounted in the paraumbilical region through an adapter of 11 mm trocar into the abdominal cavity. In the left iliac region, a working tool clamp was inserted into the abdominal cavity through a 5 mm trocar.

The point of drainage was determined: 2-3 cm above the anteroposterior spine of the iliac wing on the right.

Under the control of the telescope, an avascular zone was selected where a skin incision of up to 1 cm was made with a scalpel.

A pointed clip type mosquito and a direct clip created a stroke at an angle of 45 degrees in the anterior abdominal wall into the abdominal cavity.

The drainage tube is captured and fixed by the previously used clamp over the distal segment, from the outside, under the visual control of the telescope, is inserted into the abdominal cavity.

The inserted drainage segment is captured by an endoscopic clamp and held in the direction of the small pelvis.

In the abdominal cavity with two endoscopic clamps, the drainage is installed in the pelvic cavity through the abscess along the right lateral canal.

Visually determined: the drainage is installed correctly, it began to function immediately, which was visually manifested with the entry of pathological contents into the drainage tube and discharge of effusion from the abdominal cavity.

Pneumoperitoneum eliminated under visual control. Correction of the position of the drainage by endoscopic instruments was carried out and its excess length in the abdominal cavity was eliminated by pulling the outer end.

Endoscopic instruments removed from the abdominal cavity. Outside, the drainage is fixed to the skin with 1 knotted suture and adhesive tape. Punctures of the anterior abdominal wall are sutured with knotted intradermal sutures.

The operation went without complications.

The course of the early postoperative period is smooth, without features. On the 3rd day of the postoperative period, a control ultrasound examination of the abdominal cavity was performed, on which no projection of free fluid drainage and residual purulent cavity was detected. Drainage removed on the 3rd day. A course of antibacterial therapy and physiotherapy. The child was discharged home on the 15th day with recovery in satisfactory condition.

Rapid emotional and psychological adaptation in the early postoperative period was noted.

Clinical application of the proposed laparoscopic method of active drainage of delimited and combined appendicular peritonitis in children was carried out at the Department of Pediatric Surgery of the Russian Academy of Medical Education in the Department of Emergency Surgery of the Tushino Children's City Hospital in the treatment of 272 patients from 2005 to the present. There were no cases of inefficiency of the proposed method. The results are traced from 1 month to 5 years.

Thus, the use of the laparoscopic method of active drainage of delimited and combined forms of appendicular peritonitis in children allows to achieve a good clinical effect. One of the main stages of surgical treatment of children with delimited and combined forms of appendicular peritonitis is ensured - rational complete drainage of the residual cavity with minimal trauma of the operation. In this case, the development of intra- and postoperative complications is excluded. Achieves rapid emotional and psychological adaptation in the early postoperative period.

Claims (1)

A method of laparoscopic drainage of the residual abscess cavity with delimited and combined appendicular peritonitis in children, including performing laparoscopic appendectomy and subsequent drainage of the residual cavity, characterized in that double-lumen drainage is used for drainage, and the vascular zone is selected under optics control, which is determined above the anterior region the upper spine of the iliac wing on the right at least 2-3 cm, perform a skin incision 1 cm long and about count of the anterior abdominal wall, through which a stroke is formed at an angle of 45 degrees to the anterior abdominal wall along the right lateral canal in the direction of the pelvis with an orientation to the correct installation of drainage in the residual cavity at its most optimal and functional position relative to the periappendicular organs and tissues of the abdominal cavity, through the formed passage is introduced drainage, set it into the abscess cavity with two endoscopic clamps, after which the drainage is connected to the vacuum suction, at the stage of completion of the operation If there is an intervention in the process of eliminating pneumoperitoneum against the background of a decrease in intra-abdominal pressure, the drainage position is corrected relative to the main landmarks and structures of the abdominal cavity, its excessive length is eliminated in the abdominal cavity by pulling to the external end, after extraction of endoscopic instruments, the drainage is fixed to the skin with a separate knotted suture, in the postoperative period, control ultrasound examinations of the abdominal cavity are performed, in the absence of drainage in the projection free fluid and residual purulent cavity drainage is removed.